Clinical Topics

Hypoactive sexual desire disorder: How do you identify it and treat it?

Approximately 1 in 10 women has distressing low sex drive, otherwise known as hypoactive sexual desire disorder (HSDD). How do healthcare providers determine whether a given patient has HSDD? And how should they treat it? The authors address these challenges in this article.

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NPWH 2018 Conference Podium Presentation Abstracts

   This issue of Women’s Healthcare: A Clinical Journal for NPs features the podium presentation abstracts that were introduced at the 21st annual NPWH conference in San Antonio in October 2018. Abstracts of the first- and second-place poster award winners and the first- and second-place student poster award winners appeared in the September 2019 issue of the journal.

My heartiest congratulations to all! Each year the NPWH conference is enriched by these podium presentations. 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 2020.

–Lorraine Byrnes, PhD, FNP-BC, PMHNP-BC, CNM (ret.), FAANP
2018 NPWH Research Committee Chair

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Low-risk pregnancies may result in fewer interventions with midwives

A new study from Obstetrics & Gynecology indicates that women with low-risk pregnancies, who delivered in a hospital setting with a midwife, may need fewer interventions and cesarean sections (C-sections) than women who saw obstetricians. However, these results may reveal more questions than answers.

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NPWH 2018 Conference Poster Abstracts

This issue of Women’s Healthcare: A Clinical Journal for NPs features poster abstracts presented at the 21st annual NPWH conference in San Antonio in October 2018. These abstracts include those of the first- and second-place poster award winners and the first- and second-place student poster award winners. Abstracts of the podium presenters will appear in the December 2019 issue of the journal. My heartiest congratulations to all! Each year the NPWH conference is enriched by these 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 2020!

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How the opioid epidemic affects women

Opioid use disorder (OUD) has become such a prominent topic in today’s society that it’s hard to go one day without hearing news about new death statistics or pending litigation issues, but one aspect of this ever-growing tragedy that may be overlooked is how OUD affects women specifically.

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The history of secnidazole

In September 2017, the FDA approved secnidazole for the treatment of bacterial vaginosis. Although new to the United States, secnidazole is a well-established anti-infective agent utilized worldwide for the treatment of various bacterial and parasitic infections. Published studies on secnidazole date back to the late 1960s, yet many U.S. healthcare providers remain unaware of the existence of this medication. This column details the history of secnidazole.

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Contraceptive and reproductive care in patients with systemic lupus erythematosus

The purpose of this article is to describe reproductive healthcare needs for patients with systemic lupus erythematosus (SLE), a condition that often affects females of reproductive age, and to describe a retrospective study conducted at Texas Children’s Hospital on contraceptive and reproductive care in female patients with SLE. Continue reading »

Improving prenatal health behaviors: Implementing a blended model of prenatal care

A key measure of the efficacy of prenatal care and childbirth education is whether or not they have a positive effect on health-promoting behaviors during and following pregnancy. The purpose of this study was to measure the performance of positive health behaviors prior to and following participation in a blended prenatal care (BPC) model (individual visits plus three group visits) versus traditional prenatal care (TPC) and to compare pregnancy outcomes between the BPC and TPC groups. 
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Preventing Postpartum Depression Closer to Home

About one out of every nine expectant mothers in the United States experiences symptoms of postpartum depression, according to the Centers for Disease Control and Prevention. The impact not only can affect the mother, but also the health of her child. In a PCORI-funded study, Darius Tandon, PhD, and his team are examining the Mothers and Babies Program, a cognitive behavioral therapy intervention focused on preventing postpartum depression. The study is comparing the program’s effectiveness when it’s led by mental health professionals versus lay home visitors, who do not possess advanced mental health training but often have previously established relationships with clients.     
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Focus on sexual health | Bacterial vaginosis: Impact of sexual activity, implications for sexual health

Brooke Professional 2011
Brooke M. Faught

Bacterial vaginosis (BV) is the most prevalent vaginal infection. Although BV is not classified as a sexually transmitted infection, it is considered a sexually associated infection. As such, it may be possible to reduce the chance of developing it or at least reduce the rate of recurrences. Both acute and recurrent BV can have a direct impact on a woman’s perceptions about her body and her sexual health, which can then have an adverse effect on her sexual activities and quality of life. What can healthcare providers do to help?

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Making the diagnosis: Vaginal infections

Most women experience at least one vaginal infection characterized by vaginal discharge, itching, and/or odor during their lives. In women who present with these vaginal symptoms, the three most common conditions are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. In some cases, more than one vaginal infection is present. A problem-focused history, physical examination, and laboratory evaluation are necessary for accurate diagnosis. The author describes characteristic findings for these vaginal infections and discusses currently available diagnostic tests.

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Considerations for partner therapy in patients with bacterial vaginosis

The author describes the relatively increased prevalence of bacterial vaginosis (BV) among women who have sex with women (WSW) and the concordance of vaginal flora between monogamous sexual partners. She suggests that these findings may represent sexual transmission of BV from one woman to another, not merely an association. She reports on the evidence for BV as a sexually transmitted infection, and suggests that more research is needed to determine whether treatment of asymptomatic but affected female partners might reduce BV recurrence in WSW.

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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 »

Using simulation to practice IUD insertion and removal techniques

Statement of Retraction of Article

The article and video, “Using Simulation to Practice IUD Insertion and Removal Techniques,” by Aimee Chism Holland, DNP, WHNP-BC, FNP-C, FAANP, have been retracted by the editorial staff and on request of the author after concerns about accuracy were expressed by some readers.  The article and video should not be used or relied upon for IUD insertion and removal instruction.  The article and video are under review and may be revised and republished at a later date. 
Beth Kelsey, EdD, APRN, WHNP-BC, FAANP,
Editor-in-Chief, Women’s Healthcare: A Clinical Journal for NPs

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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 »

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 »

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 »

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 »

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 »

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.

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 »

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

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 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 »

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.

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.

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 »

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 »

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

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.

Financials

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.

Conclusion

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.

References

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  gingermanley.com. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

 

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.

References

1. National Cancer Institute. SEER Stat Fact Sheets: Lung and Bronchus Cancer. 2015. http://seer.cancer.gov/statfacts/html/lungb.html

2. American Cancer Society. Cancer Facts & Figures: 2015. www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2015/index

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. www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/lung-cancer-screening

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. http://journal.publications.chestnet.org/article.aspx?articleid=1685837

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. www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf

9. HealthCare.gov. Preventive Health Services for Adults. https://www.healthcare.gov/preventive-care-benefits/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. www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

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. www.nccn.org/patients/guidelines/lung_screening/index.html

13. Agency for Healthcare Research and Quality. Treating Tobacco Use and Dependence: 2008 Update. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

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

FSH_Table

#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.

Conclusion

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.

References
1. Laumann, EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;
281(6):537-544.

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. fda.gov/News
Events/Newsroom/PressAnnouncements/ucm458734.htm

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.

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

Assessment

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

Management

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.

Conclusion

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.

Resources

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References
1. Centers for Disease Control and Prevention. CDC Vital Signs: New Hope for Stopping HIV. 2011. cdc.gov/vitalsigns/HIVtesting/index.html

2. Centers for Disease Control and Prevention. Fact Sheets: HIV/AIDS. 2013. cdc.gov/hiv/library/factsheets/index.html

3. Centers for Disease Control and Prevention. HIV among Pregnant Women, Infants, and Children. 2015. cdc.gov/hiv/
group/gender/pregnantwomen/index.html

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. cdc.gov/hiv/prevention/
research/prep

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. cdc.gov/STD/treatment/
SexualHistory.pdf

Billable coding for female sexual dysfunction disorders*

Billable coding for general medical diagnoses and procedures is a complicated process. Within a subspecialty such as female sexual health, which lacks a clear consensus regarding diagnostic coding for sexual dysfunctions, the process can be even more challenging and frustrating. As such, some women’s healthcare providers do not even treat patients with sexual dysfunction in their practices. The purpose of this very first article in the “Focus on sexual health” department is to shed light on the billable coding process for female sexual dysfunction disorders in order to clarify, if not simplify, this process.

DSM-5 categories

The World Health Organization’s International Classification of Diseases (ICD) is utilized in the United States for diagnostic coding for most diseases and other health problems. However, female sexual dysfunction (FSD) diagnoses were developed through the American Psychiatric Association and are listed in the Diagnostic and Statistical Manual (DSM). A text revision of the fourth edition, the DSM-IV-TR,1 published in 2000, included five categories of FSD: hypoactive sexual desire disorder (HSDD), female sexual arousal disorder, female orgasmic disorder, dyspareunia, and vaginismus. With release of the fifth edition, the DSM-5,2 desire and arousal disorders were merged into one unified diagnostic category—female sexual interest/arousal disorder—and vaginismus and dyspareunia were merged into genito-pelvic pain/penetration disorder (Table 1).1,2 A subcategory of HSDD, sexual aversion disorder, was removed.2

According to the DSM-5, in order to meet diagnostic criteria, a person must experience the FSD condition 75%-100% of the time for at least 6 months.2 In addition, the condition must result in significant distress. The disorder must not better be explained by a nonsexual mental disorder, a consequence of severe relationship distress such as domestic violence, or other significant stressors. Also, a new severity scale, which designates a condition as mild, moderate, or severe, was added to allow for more diagnostic specificity.

Current and future ICD diagnostic codes

With regard to the complicated matter of translating these definitions into billable coding, women’s healthcare providers must consider the landscape of the ninth edition, clinical modification, of the ICD (ICD-9-CM).3 Diagnostic codes are categorized into chapters of different body systems, symptoms, and conditions. One of the chapters is mental and behavioral disorders, which coincides with DSM definitions. This chap­ter includes the FSD diagnostic codes. When billing for patient care specific to FSD diagnoses, providers will find that these disorders are typically covered through a separate division of a patient’s healthcare plan or that they are not covered at all. To overcome this challenge, providers can find codes in other areas of the ICD-9-CM that cover symptoms of FSD such as low libido and dyspareunia (Table 2).3

To complicate matters further, the tenth edition of the ICD (ICD-10) is slated to be released in October 2015. Whereas previous revisions to the ICD were fairly easy to follow, ICD-10 coding will not resemble the familiar ICD-9 terrain at all. To begin, the first character of each code is a letter of the alphabet, not a number.4 F codes will cover mental, behavioral, and neuro­developmental disorders. Other chapters of relevance to women’s healthcare providers are E codes for endocrine, nutritional, and metabolic diseases; L codes for diseases of the skin and subcutaneous tissue; M codes for diseases of the musculo­skeletal system and connective tissue; N codes for diseases of the genitourinary system; and R codes for symptoms, signs, and abnormal clinical and laboratory findings.4Table 3 compares ICD-9-CM and ICD-10 codes related to FSD (with the latter codes still subject to change) and Table 4 lists additional codes that may apply to female sexual complaints.

CPT codes

Table 5 lists Current Procedural Terminology® (CPT) codes for procedures commonly performed in a sexual health practice. In many cases, though, time spent with female patients reporting sexual complaints can surpass that spent performing hands-on examinations and procedures. In these circumstances, providers should bill based on time spent, assuming that more than 50% of the time spent with the patient was face to face and for counseling. If a procedure is performed on the same day as an evaluation and management visit for a separately identifiable complaint, providers should use modifier 25 so that each element can be billed at 100%.

Conclusion

Although navigating the complicated billable coding process for FSD can be confusing and frustrating, treatment for these conditions is frequently reimbursable. General understanding of ICD and DSM terms and codes is critical to smart billable coding. If uncertain about a particular situation, women’s healthcare providers should consult with a billing and coding specialist.

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.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA; 2000.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC; APA; 2013.

3. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) Professional Edition. USA: Elsevier/American Medical Association; 2013.

4. ICD-10-CM: The Complete Official Draft Code Set. USA: American Medical Association; 2014.

Genitourinary syndrome of menopause: The new vulvovaginal atrophy

Menopause affects many areas of a woman’s body, including vulvar and vaginal tissue. Most women present with some degree of atrophic vulvovaginal tissue changes in the years following menopause, and up to nearly half of all menopausal women are symptomatic. In 2014, a name change was proposed to include the entire genitourinary tract, not just the vulva and vagina, with regard to all the changes that occur in this area of the body as a result of menopause: genitourinary syndrome of menopause (GSM). Women’s healthcare providers have a variety of FDA-approved options to treat women presenting with symptomatic GSM, including local hormonal therapies, a nonhormonal oral tablet, and an intravaginal CO2 laser device.

For years, the terms vulvovaginal atrophy (VVA) and atrophic vaginitis have been used to describe menopause-related changes to the vulvovaginal tissue.These terms have been used despite the negative connotation of the word atrophy and the specificity to vulvar and vaginal tissue. In May 2013, two organizations, the International Society for the Study of Women’s Sexual Health (ISSWSH) and The North American Menopause Society (NAMS), came together to develop more appropriate nomenclature through a terminology consensus conference. Late last year, the more appropriate and all-encompassing term genitourinary syndrome of menopause was adopted to replace the terms vulvovaginal atrophy and atrophic vaginitis. 1 The term genitourinary syndrome of menopause, or GSM, acknowledges the full spectrum of menopause-related atrophic changes that occur within the entire genitourinary tract. 1

The terms VVA, atrophic vaginitis, and GSM are used interchangeably throughout this column. Readers will continue to see the terms vulvovaginal atrophy and atrophic vaginitis in the literature for some time because these terms were used in research completed before adoption of the term GSM.

During perimenopause and the years following, the drastic decline in circulating sex hormones, including estrogen, progesterone, and testosterone, results in changes to multiple areas of the body. Some of the more widely recognized symptoms of menopause, including hot flashes, weight gain, and mood changes, diminish over time as the body acclimates to functioning without cyclical changes in hormone levels. By contrast, the effects of the ongoing hypoestrogenic state of menopause on genitourinary tissue intensify, at least in women who do not receive any type of treatment for them. 2 Objective findings related to this hypoestrogenic state include vaginal tissue thinning, diminished elasticity, and increased friability, which can result in petechiae, fissuring, erosions, and, in severe cases, stenosis. Symptoms related to these physical changes—hat is, the symptoms of GSM—include vulvovaginal dryness, itching and burning, painful intercourse, dysuria, urinary urgency and frequency, and recurrent urinary tract infections.1

The average age of menopause in the United States is 51 years. Because life expectancy in this country continues to climb, 4 the population of menopausal women is steadily rising, and women may expect to live up to 40% of their lives in a postmenopausal state.5 Of the millions of women who spend years or decades in a perimenopausal and then a postmenopausal state, nearly half will experience bothersome symptoms of GSM/VVA. 6 Given these numbers, GSM is an area that warrants major interest in the healthcare community.

Despite the widespread prevalence of GSM, healthcare providers (HCPs) must keep in mind that many women are not comfortable discussing symptoms of GSM with their HCP, and vice versa. According to the Women’s Voices in the Menopause international survey, nearly 80% of online respondents felt that women were not comfortable discussing vaginal atrophy.7 The Real Women’s Views of Treatment Options for Menopausal Vaginal Changes (REVIVE) survey reported that only 56% of women had ever discussed their VVA symptoms with an HCP.8 In the VIVA (Vaginal Health: Insights, Views & Attitudes) survey, 80% of respondents stated that vaginal discomfort adversely affected their lives, and 75% of respondents reported adverse consequences on their sex lives. 9

In the recent past, nonhormonal lubricants and local hormonal therapies were the only treatment options for women with GSM. To date, six FDA-approved therapies for GSM/VV are available (Box). Intravaginal CO2 laser therapy, approved in late 2014, offers a unique, nonpharmacologic option for women, including breast cancer survivors, who are not candidates for hormonal treatment.

Regardless of the treatment chosen, HCPs caring for women must encourage open communication regarding symptoms of GSM with patients who may be otherwise unlikely to initiate conversation on such sensitive matters. With healthcare advances, many treatment options are available for all degrees of GSM severity and all circumstances. =

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’ Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she serves on the speakers’ bureau for Actavis Pharma, Inc., and Shionogi Inc.

References

  1. Portman D, Gass M. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and The North American Menopause Society. Menopause.  2014;21(10):1063-1068.
  2. North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013  position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902.
  3. Tan O, Bradshaw K, Bruce RC. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012;19(1):109-117.
  4. U.S. Census Bureau. Statistical Abstract of the United States. 2012. https://www.census.gov/prod/2011pubs/12statab/pop.pdf
  5. Parish SJ, Nappi RE, Krychman ML, et al. Imapct of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy. Int J Womens Health. 2013;5:437-446.
  6. Santoro N, Komi J. Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med. 2009;6(8):2133-2142.
  7. Nappi RE, Kokot-Kierepa M. Women’s voices in the menopause: results from an international survey on vaginal atrophy. Maturitas. 2010;67(3):233-238.
  8. Kingsberg SA, Wysocki S, Magnus L, et al. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013;10(7):1790-1799.
  9. Simon JA, Kokot-Kierepa M, Goldstein J, Nappi RE. Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey.  Menopause.  2013;20(10):1043-1048.

Persistent genital arousal disorder: The uninvited guest (Part 1)

Persistent genital arousal disorder (PGAD) is a per- plexing and elusive health condition of unknown prevalence. Until recently, little was known about its etiology or amenability to treatment. However, re- cent advances in sexual medicine research provide a better understanding of PGAD, enhancing health- care providers’ ability to properly diagnose and manage it. In part 1 of this two-part series, diagno- sis and management of PGAD are discussed; in part 2, the focus is on the patient experience of PGAD.

Medical models of sexual response represent arousal as a desirable and pleasurable experience.1-3 In some women, however, genital arousal occurs in the absence of sexual interest or desire. First described in the literature by Leiblum and Nathan,4 persistent genital arousal disorder (PGAD), previously referred to as persistent genital arousal syndrome, is manifested by intrusive and unwanted symptoms such as persistent genital arousal, vulvar congestion, discomfort, and even pain.5 In such cases, orgasm provides little or only short-lived relief. Markos and Dinsmore6 liken the presentation of PGAD to that of vulvodynia. Of note, although cases of male PGAD have been reported as well,7 this article focuses on female PGAD.

Many healthcare providers (HCPs) are unaware of the existence of PGAD, leaving many women who have this condition without a timely diagnosis or treatment. Even if some HCPs are aware of PGAD, their patients may hesitate to mention their symptoms because the condition is so highly stigmatized. In fact, approximately 25% of women with PGAD wait more than 10 years to report symptoms to their HCP or they never report their symptoms.8

Prevalence and etiology

Little is known about PGAD prevalence. Most research on PGAD is in the form of case studies or surveys of limited populations.9,10 PGAD is likely under-reported because of patient embarrassment and fear of being labeled as hypersexual.11 A survey of a sexual health practice in the United Kingdom identified a PGAD prevalence of approximately 1% with all the diagnostic characteristics of the condition, although 33% of participants reported at least one identifying characteristic of PGAD.12 PGAD appears to affect women of all ages.4 A recent survey of more than 100 women with PGAD indicated an age range of 18-79 years (mean age, 47 years).10

No consensus exists regarding the etiology of PGAD, although it is thought that symptoms may arise as a result of dysregulation at central and peripheral levels.11 In addition, psychological conditions and external factors such as diet and pharmacologic agents may elicit symptoms of persistent arousal.11 Antidepressant use is cited as a trigger in 20% of women with PGAD.13 Vascular anomalies of the pelvis and compression of the pudendal nerve, as with Tarlov cysts, may play a role in some cases.14-16

Diagnosis

Women vary in terms of the presentation and experience of PGAD (Box).9 Because women may hesitate to disclose information about PGAD, HCPs should consider asking those presenting for annual checkups about whether they experience any genital pain, discomfort, persistent arousal, numbness, tingling, or throbbing.13,17 If PGAD is suspected, HCPs should review the patient’s health history, with a focus on potential co-morbidities and past/ current medication use, supplement use, and illicit drug use. Diet and exercise are important factors when assessing for PGAD.17 In addition, women should be asked about past and current sexual practices and partner(s), as well as a possible history of sexual abuse or trauma.

A comprehensive vulvovaginal and pelvic examination, including a neurologic and musculoskeletal assessment, can identify or exclude overt structural defects. In some cases, laboratory testing (e.g., thyroid panel, prolactin level, testosterone panel) and imaging studies (e.g., pelvic ultrasonography, magnetic resonance imaging) may provide useful diagnostic information.15 Women with PGAD should be screened for symptoms of restless leg syndrome (RLS) and overactive bladder (OAB). If symptoms of RLS and/or OAB co-exist with those of PGAD, a diagnosis of restless genital syndrome should be considered.5,18

Treatment

No medications are currently indicated specifically for the treatment of PGAD. All pharmacologic interventions for PGAD discussed in this article are investigational. Of note, HCPs should address potentially reversible causes of PGAD before pursuing further intervention.4 As with many complex and poorly understood health conditions, the treatment for PGAD necessitates an interdisciplinary approach, with consideration of all potential biopsychosocial causes.4 Further supporting the multifactorial causation of PGAD is the fact that clitoridectomy does not appear to benefit patient outcomes.19

Dysregulation of sensory excitation remains the focus of pharmacologic intervention for PGAD.20 Off-label use of medications such as selective serotonin reuptake inhibitors, varenicline, zolpidem, and tramadol appears to reduce PGAD symptoms in some cases, although further research is needed.17,20 Of interest, withdrawal from the aforementioned medications has been implicated in the onset of PGAD.17 Surgical correction of Tarlov cysts may effectively treat PGAD, whereas periclitoral injections of botulinum toxin do not appear to improve symptoms long term.14,16,21 Electroconvulsive therapy may ameliorate PGAD symptoms in patients with co-morbid bipolar disorder.22

Recommendations

Persistent genital arousal disorder is a legitimate health condition that warrants increased HCP awareness.10 Although PGAD is often represented in a comedic light, it is no laughing matter to women who carry the daily burden of the embarrassing and debilitating symptoms that accompany it. Women with PGAD report insensitive comments from their HCPs such as “You should be a porn star” or “Your symptoms are every husband’s dream.”10 Comments from a trusted HCP that embarrass, insult, or ridicule an already vulnerable woman can have devastating consequences. Compared with the general population, patients with PGAD have a two-fold increase in suicidal ideation.13 Care of patients with PGAD begins by providing a safe and nonjudgmental atmosphere in which to facilitate an open and honest discussion. If PGAD is suspected, HCPs can consider referral to a sexual medicine provider or visit the International Society for the Study of Women’s Sexual Health (ISSWSH) website for more resources.

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. She is an ISSWSH Fellow. The author states that she serves as a speaker and advisory board member for Shionogi and Valeant and an advisory board member for the Female Health Company.

References

  1. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little Brown; 1966.
  2. Kaplan HS. The New Sex Therapy. New York, NY: Brunner/Mazel; 1974.
  3. Basson R. Using a different model for female sexual response to address women’s problematic low sexual desire. J Sex Marital Ther. 2001;27(5):395-403.
  4. Leiblum SR, Nathan SG. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther. 2001;27(4):365-380.
  5. Waldinger MD, Schweitzer DH. Persistent genital arousal disorder in 18 Dutch women: part II. A syndrome clustered with restless legs and overactive bladder. J Sex Med. 2009;6(2):482-487.
  6. Markos AR, Dinsmore W. Persistent genital arousal and restless genitalia: sexual dysfunction or subtype of vulvodynia? Int J STD AIDS. 2013;24(11):852-858.
  7. Waldinger MD, Venema PL, van Gils AP, et al. Stronger evidence for small fiber sensory neuropathy in restless genital syndrome: two case reports in males. J Sex Med. 2011;8(1):325-330.
  8. Jackowich R, Pink L, Gordon A, Pukall C. Prevalence of persistent genital arousal disorder criteria in a sample of Canadian undergraduate students. Poster session presented at: Annual Meeting of the International Society for the Study of Women’s Sexual Health; February 23-26, 2017; Atlanta, GA.
  9. Parish S, Goldstein A, Goldstein S, et al. Toward a more evidence-based nosology and nomenclature for female sexual dysfunction-part II. J Sex Med. 2016;13(12):1888-1906.
  10. Jackowich R, Pink L, Gordon A, Pukall C. Health care experiences of women with symptoms of persistent genital arousal. Poster session presented at: Annual Meeting of the International Society for the Study of Women’s Sexual Health; February 23-26, 2017; Atlanta, GA.
  11. Jackowich R, Pink L, Gordon A, Pukall C. Persistent genital arousal disorder: a review of its conceptualizations, potential origins, impact and treatment. Sex Med Rev. 2016;4(4);329-342.
  12. Garvey LJ, West C, Latch N, et al. Report of spontaneous and persistent genital arousal in women attending a sexual health clinic. Int J STD AIDS. 2009;20(8):519-521.
  13. Pukall CF, Jackowich R. Persistent genital arousal disorder: when is pain assessment relevant? Presented at: International Society for the Study of Women’s Sexual Health Annual Meeting. February 23-26, 2017; Atlanta, GA.
  14. Komisaruk BR, Lee HJ. Prevalence of sacral spinal (Tarlov) cysts in persistent genital arousal disorder. J Sex Med. 2012;9(8):2047-2056.
  15. Pink L, Rancourt V, Gordon A. Persistent genital arousal disorder in women with pelvic and genital pain. J Obstet Gynaecol Can. 2014;36(4):324-330.
  16. Feigenbaum F, Boone K. Persistent genital arousal disorder caused by spinal meningeal cysts in the sacrum. Obstet Gynecol. 2015;126(4):839-843.
  17. Facelle TM, Sadeghi-Nejad H, Goldmeier D. Persistent genital arousal disorder: characterization, etiology, and management. J Sex Med. 2013;10(2):439-450.
  18. Aquino CC, Mestre T, Lang AE. Restless genital syndrome in Parkinson disease. JAMA Neurol. 2014;71(12):1559-1561.
  19. Waldinger MD, Venema PL, van Gils AP, et al. Restless genital syndrome before and after clitoridectomy for spontaneous orgasms: a case report. J Sex Med. 2010;7(2 pt 2):1029-1034.
  20. Pfaus JG. Persistent genital arousal disorder-fact or fiction? J Sex Med. 2017;14(3):318-319.
  21. Rubin R, Winter A, Minton J, et al. Peri-clitoral botulinum toxin as a treatment for persistent genital arousal disorder (PGAD). Poster session presented: Annual Meeting of the International Society for the Study of Women’s Sexual Health. February 23-26, 2017; Atlanta, GA.
  22. Yero SA, McKinney T, Petrides G, et al. Successful use of electroconvulsive therapy in 2 cases of persistent sexual arousal syndrome and bipolar disorder. J ECT. 2006;22(4):274-275.

AHA Guidelines: Time to Revisit Thinking on Pregnancy in Women with Complex Congenital Heart Disease

In a notable twist on conventional wisdom, a new American Heart Association scientific statement on managing pregnancy in patients with complex congenital heart disease (CHD) supports the notion that most women with complex CHD can have a successful pregnancy and normal vaginal delivery. To optimize outcomes, the statement notes, care should be collaborative and involve both a high-risk obstetrician and a cardiologist versed in CHD.

The new guidelines alter the idea that patients with complex CHD should avoid pregnancy out of concern about potential risks to the mother and child.

A stepped plan for complex pregnancies

“This is an excellent statement that provides a much-needed framework for caring for these patients, covering everything from pre-pregnancy counseling to pregnancy care to post-delivery care,” says obstetrician Jeff Chapa, MD, Head of Maternal-Fetal Medicine at Cleveland Clinic.

The guidelines provide a stepped assessment plan for general cardiologists to follow.

“The process makes it easy to assess risk prior to pregnancy, determine the frequency of follow-up needed once the patient becomes pregnant and identify the level of disease that warrants tertiary care,” says Dr. Chapa. “Knowing the changes that will occur can help with risk stratification and provide an idea of how well a patient is likely to do.”

Cardiologist David Majdalany, MD, Director of Cleveland Clinic’s Adult Congenital Heart Disease Center, trained under several members of the writing group behind the AHA guidelines, so he found no surprises in the document. But he’s delighted that a summary of the latest recommendations is finally at the disposal of all providers.

“Until now, we had only bits and pieces of information from various papers primarily written on individual defects,” Dr. Majdalany explains. “These guidelines coalesce what we know in a detailed document that discusses the pros and cons of pregnancy by every class of congenital lesion. This is very helpful.”

Validated by experience

The new guidelines’ recommendations align with the experience of Drs. Chapa and Majdalany in Cleveland Clinic’s Cardio-Obstetrics Clinic, where a high-risk obstetrician and a CHD cardiologist co-manage patients, with support from colleagues in virtually every subspecialty available when needed.

The decision of whether to proceed with a vaginal delivery is made jointly. “For example, with defects such as aortic root dilation, the patient is at risk for aortic dissection, so we would suggest avoiding natural delivery in such a case,” Dr. Majdalany notes.

Read more at Cleveland Clinic

 

Duke Team Reaches Milestone with Portable Cervical Cancer Screening Device

January was Cervical Health Awareness Month, and this year, that designation held special significance for Nimmi Ramanujam, professor of biomedical engineering and global health and director of the Center for Global Women’s Health Technologies.

Since 2012, she and her research team have been developing and testing a portable colposcope, called the “Pocket Colposcope,” to increase access to cervical cancer screening in primary care settings. Last month, 20 of these devices were produced for distribution to international partners.

SCREENING IS KEY TO EARLY DETECTION AND EFFECTIVE TREATMENT

According to the World Health Organization (WHO), more than 85 percent of the more than 270,000 annual deaths from cervical cancer occur in low and middle income countries. The disease is easily treatable if identified early, but because access to effective screening is limited in low-resource settings, early detection is often not possible.

And even if access to screening is available, for example via human papilloma virus (HPV) testing, a confirmatory test is needed before a woman can receive treatment. In the United States, this test is performed through colposcopy. However, a clinical colposcope is typically not available in a primary care setting, and in many low and middle income countries, often the alternative is to visualize the cervix with only the naked eye—a method that often results in missed diagnoses. The cost of a clinical colposcope—upwards of $20,000—presents yet another barrier.

The Pocket Colposcope is designed to address these barriers. It brings that secondary test—traditionally performed using a clinical colposcope by physicians at referral centers—to the primary care setting. In addition, it’s easy for a broad range of health care providers with different levels of training to use.

ABOUT THE POCKET COLPOSCOPE

After four generations of development, the team has created a beta prototype of the Pocket Colposcope in collaboration with product design and development company 3rd Stone Design, Inc.

The Pocket Colposcope is significantly less expensive, smaller and lighter than a traditional clinical colposcope. Weighing less than two pounds, it fits inside a pocket (hence the name). The device enables healthcare providers to zoom and capture images by pressing a button with their thumb. Images taken with the Pocket Colposcope are transmitted instantly to a smartphone, tablet or laptop.

Read more at Duke Global Health Institute

Impact of early sexuality education on adult sexuality

I am pleased to introduce Emi Canahuati, a sexuality educator and trainer who owns Talk and Thrive Education, LLC, which provides workshops, educational videos, and private coaching sessions so that parents can obtain the tools they need to have open, honest, and age-appropriate conversations with their children about sexuality. In this column, Emi discusses her experience working with parents of young children, as well as the impact of childhood experiences on adult sexuality. —Brooke

Talk and Thrive Education

Most of my professional work focuses on helping parents raise sexually healthy children by facilitating age-appropriate discussions about sexuality. Many parents have difficulty talking about healthy sexuality with their children—in some cases because they feel ill equipped to educate their children about this topic, in other cases because of embarrassment, and in still other cases because they have sexual problems of their own, which may inhibit them from holding an open and honest discussion. In addition, parents may not fully appreciate the importance of addressing sexual health when their children are young. Regardless, most parents with whom I work want their children to become sexually healthy adults who enjoy their sexuality in a responsible and ethical way.

Sexuality education

Self-reflection

When I speak with adult clients about challenges they face in their sexual lives, including difficulties with desire, arousal, orgasm, and intimate relationships, I sometimes identify a correlation between these difficulties and various negative attitudes and values they acquired during childhood. Few adults recognize the impact of childhood experiences on their current sexual health. Although many factors underlie sexual dysfunction in adulthood, I am focusing this column on the impact of sexuality education—or the lack thereof—in childhood.

Introduction to the concept of sexuality

Sexuality encompasses more than just intercourse and sexual orientation. Sexuality is affected by childhood experiences such as physical touch, messages received about the body, emotional closeness and relationships, and gender identity. When I ask adults to think about the messages they received about sexuality as children, many of them report that their parents did not talk about sexuality at all; the subject was taboo. Or if the topic of sexuality was addressed, they, as children, were told Just don’t do it. Many of these adults said that, as children, they didn’t even know what was meant by it, but they subsequently developed a negative perception of sexuality.

Sexuality behaviors and milestone

One of the exercises I conduct with parents is to ask them to tell me at what age they think a healthy child starts to display certain sexual behaviors and reach certain sexual milestones. These behaviors and milestones include:

having crushes;

masturbation or self-pleasuring;

physiologic sexual arousal (i.e., penile/clitoral erections, vaginal lubrication);

growing independence;

reaching puberty;

awareness of their gender identity;

playing “doctor”;

development of body image (including genitals);

having questions about pregnancy and childbirth;

having interest in other people’s bodies; and

engaging in relationships, both romantic and non-romantic.

Many parents believe these behaviors and milestones occur much later than they actually occur; all of these behaviors/milestones can start before children are 8 years old.1 As a result, many children do not receive the support and resources they need at the appropriate time. It’s as if parents were to wait until their children are 6 years old before helping them walk! Children are sexual beings from birth, and they benefit from age- and developmentally-appropriate sexuality education starting when they are very young.2

Childhood introduction of sexual education

We in the United States do not have a systematic process for providing scientifically accurate, comprehensive sexuality education.3 Therefore, children may or may not receive information about sexual anatomy, birth control, sexually transmitted infections, sexual decision-making skills, pregnancy prevention, puberty education, or healthy relationships during their most formative years. Sexuality education, if provided at all, tends to vary widely from school to school in terms of instructional technique and content. If sexuality education is not provided by a school system, then parents are responsible for imparting to their children not only their values about sexuality, but also basic facts.

Many children receive mixed or negative messages about sexuality. Girls in particular tend to receive negative messages from both their families and the culture at large that can inhibit their sexual growth. In this country, girls are encouraged to meet rather narrow definitions of femininity and beauty, laying the foundation for a negative body image. Having a negative body image can then lead girls to make unhealthy choices with regard to their sexual partner(s) and the sexual behaviors in which they engage.

To make matters worse, in U.S. society, girls’ bodies are sexualized from an early age. For example, much of the clothing available for young girls in major department stores is not really age appropriate. Girls then receive unwanted sexual attention, for which they are made to feel responsible. Many of these girls react by shutting down their sexual selves, which feels safer. Women are then expected, as if by magic, to feel sexual in an appropriate setting after years of intentional sexual suppression. This concept is not realistic. Many of my female clients report problems in their adult relationships that are due to previous suppression of their sexuality.

Challenges with adult sexuality

For many people, the message about sexuality that is gleaned during childhood is Don’t talk about it because It’s bad. This message translates into difficulty discussing sexuality as an adult. Adults then have difficulty expressing or even recognizing their sexual needs, negotiating for what they want/don’t want sexually from partners, and talking about sexual difficulties in relationships. I also have adult clients whose parents told them Don’t touch yourself down there. This message, when disregarded, translates into I’m bad, That’s dirty, or even I’m dirty, but it feels so good. I often identify a connection between childhood shaming related to masturbatory behavior and difficulties with desire, arousal, orgasm, sexual pleasure, and relationships in general.

Other messages about sex that are often sent by parents or society, particularly to girls, are You should not want it  because Nice girls do not do things like that and It’s your responsibility to say “no,”  regardless of how you feel or what you might want. So, as women, they inhibit their sexual desires for fear of adverse repercussions. They feel that if a sexual encounter occurs, they must have wanted it  and male partners will feel they were asking for it . Some of my clients state that they avoid sexual encounters because they do not want to be held accountable for the experience. Subsequently, they never learn about their sexual desires and true responsibilities.

Methods for supporting healthy sexuality

I suggest that healthcare providers promote healthy sexuality education in these three main ways:

1. Support comprehensive sexuality education in schools. According to the Sexuality Information and Education Council of the United States (SIECUS), comprehensive sexuality education includes the provision of age-appropriate, scientifically accurate information on a broad set of topics related to sexuality, including human development, relationships, decision making, abstinence, contraception, and disease prevention.4 Under ideal circumstances, this education is available in grades K-12. This education can help systematically address the gaps in students’ knowledge about anatomy, healthy relationships, and overall sexual health. For younger children in particular, this education can provide a foundation to discuss their family; their feelings; the correct names for all body parts, including genitals; and topics such as boundaries and consent.

2. Encourage and support communication between parents and children in an age- and developmentally- appropriate manner that embraces sexuality in a positive way. The communication should not be shame based or an attempt to control their sexuality. Instead, the communication should help empower children to “own” their sexuality—that is, to acknowledge and balance the potential beauty of their sexuality with the responsibilities that come with it.

3. Encourage, seek out, and support media that present a broad range of bodies and gender expressions in a positive light, not just the narrow ways we are trained to see beauty in our society—as being feminine, thin, white, tall, and able bodied.

Conclusion

In the past, women’s sexuality was not considered a relevant topic of study. Modern healthcare in this country now supports the importance of human sexuality, both male and female. There are ways to dismantle some of the psychosocial barriers that prevent women from thriving sexually. Regardless of our diverse backgrounds and training, we all have an opportunity to support the next generation of women in their quest for sexuality that is healthy and satisfying.

Emi Canahuati is certifi ed as a sexuality educator by the American Association of Sexuality Educators, Counselors and Therapists (AASECT). She owns Talk and Thrive Education, LLC, and has been working for more than 18 years with thousands of parents, conducting workshops on parent-child communication about sexuality. She is passionate about helping parents have age-appropriate conversations with their children because she believes that these conversations help produce children who become sexually healthy adults. 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.

References

1. Wurtele K, Kenny MC. Normative sexuality development in childhood: implications for developmental guidance and prevention of childhood sexual abuse. Couns Human Devel. 2011;43(9).

2. National Sexuality Education Standards: Core Content and Skills, K–12. 2012.

3. Guttmacher Institute. American Teens’ Sources of Sexual Health Education. 2016.

4. Sexuality Information and Education Council of the United States. Comprehensive Sex Education. 2009.

Irregular Sleep During Menopause May be Hard for Older Women’s Hearts

The sleep woes that many women suffer during menopause may be more than a nuisance: New research suggests a link between lost sleep and an increase in risk factors for heart disease and stroke.

When loss of sleep was measured both objectively and subjectively, the researchers found it correlated with a higher risk of plaque buildup in blood vessels and a thickening of artery walls. Continue reading »

The elusive vulva

This article reviews some of the more common vulvar dermatoses that healthcare providers may encounter in their practice. Many of these conditions warrant vulvoscopy and, in some cases, biopsy, in order to facilitate proper diagnosis and treatment.

In June 2016, the third annual Women’s Sexual Health Course for NPs, sponsored by NPWH and the International Society for the Study of Women’s Sexual Health (ISSWSH), offered the firstever dedicated vulvoscopy training course for healthcare providers (HCPs). And for good reason. It is impossible to properly care for women presenting with vulvar dermatologic conditions without some form of advanced magnification and a biopsy skill set. Many anomalies can affect vulvar tissue. Without use of the vulvoscope, identifying characteristics of various dermatoses can be missed, thereby delaying treatment.

The vulva is often an overlooked area of assessment during routine pelvic examinations. When time is limited and the ultimate goal of an exam is the collection of cells from the depths of the vaginal canal, it is easy to understand why many HCPs bypass the scenic route and dash directly to the final destination. In doing so, however, pertinent details of a women’s vulvovaginal health may be missed and potentially serious conditions may go undiagnosed and untreated. As detailed in this article, some vulvar dermatologic conditions are benign and fairly simple to treat. However, other conditions are more serious, necessitating long-term treatment and/or surgical intervention. Although vulvar carcinoma and similar neoplasia are outside the scope of this article, proper evaluation, including biopsy when warranted, will identify or exclude such concerning diagnoses.

Contact dermatitis and lichen simplex chronicus

One of the most common vulvar skin disorders is contact dermatitis, which includes both irritant contact dermatitis and the more severe presentation, allergic contact dermatitis. Fifty-four percent of cases referred to one dermatologic practice for chronic vulvovaginitis resulted in a diagnosis of contact dermatitis.The well-demarcated outline of inflammation consistent with the shape of pads and pantiliners is a common sight in women who consistently wear such products. This reaction occurs in response to the chlorine and bleach used in the manufacturing of feminine hygiene goods. In such circumstances, many women turn to over-the-counter anti-itch creams that can actually exacerbate symptoms because of the preservatives and other constituents within product bases. Some of the more common exogenous vulvar irritants include benzocaine, glycerin, parabens, alcohol, latex, and adhesives.

Readers might be surprised to learn that in the early and mid-1900s, Lysol® was commonly marketed for use as a contraceptive and vaginal health douche. Even today, some women continue such practices, thinking they are maintaining proper personal hygiene. As such, HCPs need to ask patients about their vulvovaginal hygiene practices.

If contact dermatitis is strongly suspected based on a generalized pattern of inflammation consistent with a known vulvar irritant, vulvoscopy and biopsy are not necessarily warranted. In this case, avoidance of the irritant is the primary treatment. Additional options include oral antihistamines, sitz baths with Epsom salts, and local application of coconut oil and/or vegetable shortening. If symptoms persist despite these efforts, further investigation is appropriate.

Whereas contact dermatitis develops from an exogenous source, atopic dermatitis, also known as eczema, is triggered by an endogenous culprit.Atopic dermatitis, which is commonly associated with a genetic predisposition, is manifested by erythema, edema, and fissuring and is typically generalized and in a symmetric pattern.

When any of these aforementioned conditions result in a perpetual itch–scratch cycle, lichen simplex chronicus (LSC), also known as neurodermatitis, often becomes the primary diagnosis for the vulvar dermatosis. Instead of the generalized erythema and edema that occurs with contact and atopic dermatitis, LSC results in lichenification and excoriations of vulvar tissue because of persistent rubbing and scratching. In this case, breaking the itch–scratch cycle is of utmost importance. Sedatives, including high-potency antihistamines, can prove beneficial, particularly because many women do not realize that they are rubbing and scratching themselves at night during sleep. Some women find comfort in using direct application of ice to distract them from the sensation of itching. In severe cases, use of topical corticosteroids is warranted. However, HCPs must be aware that use of steroids masks presentation of pathology on biopsy. Also, HCPs must be alert to the potential for secondary infection with any inflammatory vulvar skin disorder. Vaginal cultures and PCR swabs are considered when appropriate.

Lichen sclerosus and lichen planus

Although the terms lichen sclerosus and lichen planus resemble one another, they are quite different pathologic processes. Lichen sclerosus (LS) presents as chronic and severe vulvovaginal and perianal itching. Changes to the tissue lead to vulvar scarring and significant loss of vulvar architecture, resulting in dysuria, dyspareunia, and dyschezia. Prevalence of LS has been reported at 1.7% of patients presenting to a gynecology practice.Of note, patients with LS have an increased incidence of squamous cell carcinoma (SCC).4 Findings occur in a figure 8 pattern to the vulvar and perianal tissue.

Women with lichen planus (LP) typically present with severe vulvar burning and rawness and, like those with LS, report dyspareunia. In many cases, LP appears throughout the vaginal canal, as well as on external vulvar structures. In addition, LP affects other mucous membranes, including the oral mucosa. Erosive LP (ELP), a more severe form of the disease, can result in severe scarring and stenosis of the vaginal canal. LP constitutes about 1% of new dermatology referrals.5

Unlike LS, LP does not appear to be associated with an increased incidence of SCC, although LP can coexist with LS. Vulvoscopy and biopsy are essential to properly diagnose and treat both conditions. When ELP is suspect, biopsy of both the erosive and lichenified tissue can aid the dermatologist in a proper diagnosis. In addition, collaboration with a dermato-pathologist familiar with vulvar dermatoses is strongly advised. Preferred treatment for both LS and LP entails high-potency topical steroids.

Seborrheic dermatitis

Seborrheic dermatitis (SD) is a common inflammatory disease of the skin characterized by scaly lesions that usually appear on sebacious gland-rich areas. Upwards of 5% of adults are afflicted with SD, which most commonly affects the scalp, eyebrows, nose, ears, groin, buttocks, skin folds, navel, and vulva.Vulvar presentation of SD can be particularly bothersome because of the sensitive nature of its location. Symptoms include itching and burning that coincides with splotchy erythema, oily skin, and white/yellow scales. If symptoms and examination findings are consistent with SD and the patient already has an established diagnosis of SD from a systemic presentation, vulvar biopsy is not always warranted. Topical corticosteroids and ketoconazole are often used to treat vulvar SD.

Psoriasis

Vulvar psoriasis is another condition that can be presumed based on systemic presentation. One percent to 3% of the general population have the chronic, relapsing symptoms associated with psoriasis,with the most common complaint being pruritus. The red, silvery/scaly, well-demarcated plaques of psoriasis often affect the mons pubis, groin folds, inner thighs, and buttocks in a symmetric pattern. Inverse psoriasis, otherwise known as intertriginous psoriasis, is the most common form of psoriasis in the genital region.If the diagnosis is not clear, biopsy of the outer border of a suspected psoriatic lesion is recommended. Once again, mid- to high-potency topical steroids are preferred for vulvar psoriasis. Dapsone is occasionally used for cases of inverse psoriasis refractory to topical steroids.8

Genitourinary syndrome of menopause

Women who have reached menopause, either naturally or surgically, are likely to experience genitourinary syndrome of menopause (GSM). This syndrome is characterized by changes in the vulvovaginal tissue that can cause burning, dryness, irritation, dyspareunia, and vaginal discharge. (Of note, women who are in a prolonged hypoestrogenic state as a result of long-term use of oral contraceptives or breastfeeding can experience vulvovaginal tissue changes and symptoms similar to those of women with GSM.) Many women with GSM also experience urinary urgency/frequency, recurrent urinary tract infections, and dysuria. In 2014, precisely because of the urinary symptoms that frequently accompany vulvovaginal symptoms in menopausal women, The North American Menopause Society and ISSWSH endorsed a name chance from vulvovaginal atrophy to genitourinary syndrome of menopause for this symptom complex.9

On examination, many women with GSM present with tissue thinning, pallor, erythema, petechiae, vaginal stenosis, generalized mucosal dryness, loss of vulvovaginal architecture, clitoral phimosis, and urethral caruncle. In addition, vaginal pH rises above the normal acidic range of 3.5-4.5 and wet prep reveals an increase in parabasal cells and white blood cells. Although vulvoscopy can prove helpful in identifying the severity of GSM, biopsy is not required to diagnose the condition when the clinical presentation supports this diagnosis.

Current FDA-approved treatments for GSM include local estrogen products (two cream options, a vaginal ring, and a vaginal tablet) and an oral selective estrogen receptor modulator with tissue-selective effects on the vulvovaginal tissue. If symptoms persist or specific lesions remain refractory to treatment, then biopsy is warranted.

Conclusion

Vulvar dermatoses and dermatitis can be elusive and difficult to diagnose. Although many women present with debilitating symptoms, others remain unaware of concerning changes to their vulvar tissue. HCPs should not hesitate to incorporate the vulvoscope into the evaluation of any woman presenting with vulvovaginal symptoms. And, most important, when doubt exists, a biopsy should be performed to discover the presence, cause, or extent of the condition.

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 serves as a speaker and advisory board member for Shionogi, Valeant, and Actavis and as an advisory board member for the Female Health Company.

References

1. Fischer GO. The commonest causes of symptomatic vulvar disease: a dermatologist’s perspective. Australas J Dermatol. 1996;37(1):12-18.

2. Farage MA, Miller KW, Ledger WJ. Determining the cause of vulvovaginal symptoms. Obstet Gynecol Surv. 2008;63(7):445-464.

3. Goldstein AT, Marinoff SC, Christopher K, Sroden M. Prevalence of vulvar lichen sclerosus in a general gynecology practice. J Reprod Med. 2005;50(7):477-480.

4. Powell JJ, Wojnarowska F. Lichen sclerosus. Lancet. 1999;353(9166):1777-1783.

5. Lewis FM, Bogliatto F. Erosive vulval lichen planus—a diagnosis not to be missed: a clinical review. Eur J Obstet Gynecol Reprod Biol. 2013;171(2):214-219.

6. Fritsch PO, Reider N. Other eczematous dermatoses. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. Vol. 1. New York, NY: Mosby; 2003:215-218.

7. Kurd SK, Gelfand JM. The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES 2003-2004. J Am Acad Dermatol. 2009;60(2):218-224.

8. Guglielmetti A, Conlledo R, Bedoya J, et al. Inverse psoriasis involving genital skin folds: successful therapy with dapsone. Dermatol Ther (Heidelb). 2012;2(1):15.

9. Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and The North American Menopause Society. Menopause. 2014;21(10):1063-1068.

When the warrior is a woman

The number of women serving in the United States Armed Forces has increased rapidly over the past decade and a half. The U.S. Department of Veterans Affairs (VA) has been implementing major changes to meet the growing demand for healthcare services after these women have been discharged from the military, as well as for older female Veterans who left the service long ago. This article describes the many and varied types of healthcare services that are available for female Veterans. These services are provided by healthcare professionals, including nurse practitioners, working in VA institutions or in the community.

Women comprise about 15% of active-duty military force members and 18% of National Guard and Reserve force members.Women serve in nearly every area of the military—including as fighter pilots, gunners, warship commanders, and military police— in locations stateside and abroad. They serve in every branch of the military. When they are discharged from the military, they become Veterans. At this time, 2.2 million women in the United States are Veterans.1

How many women use VA healthcare services? How is this population characterized?

Since 2000, the number of female Veterans using healthcare services provided by the U.S. Department of Veterans Affairs (VA) has more than doubled, from nearly 160,000 in fiscal year 2000 to more than 390,000 in fiscal year 2013.This growth has outpaced that of male Veterans. Among all female Veterans who served during Operation Enduring Freedom, Operation Iraqi Freedom, and/or Operation New Dawn (OEF/OIF/OND), 59.7% have received VA healthcare.Of this group who have received VA healthcare, 90.6% have used it more than once and 57.0% have used it 11 times or more. In fiscal year 2013, the average age of VA healthcare users was 48 years for women and 63 years for men.2

The VA serves women in every age bracket.Among female VA healthcare users, 43% are aged 18-44 years, 46% are aged 45-64 years, and the remainder are aged 65 years or older. Reproductive-aged women Veterans receive the gynecologic and obstetric care they need, and those in the menopausal years, many of whom served during the Vietnam or Gulf War eras, can rely on receiving more intensive healthcare because of their age.

In fiscal year 2012, 57% of women Veteran VA patients had some level of service-connected (SC) disability—that is, an injury or illness that occurred or worsened during service in the military.3 If a Veteran receives SC disability status, her SC disability is then assessed and rated for severity from 0% to 100%. In fiscal year 2012, 30% of women Veteran VA patients had an SC disability rating of 50% or higher.2

Women Veterans have higher physical and mental health burdens than their non-Veteran counterparts, as well as health burdens equal to or worse than those of male Veterans.They have substantial chronic disease and mental health problems; top diagnoses include post-traumatic stress disorder (PTSD), hypertension, depression, hyperlipidemia, chronic low back pain, gynecologic problems, and diabetes mellitus (DM). Among female OEF/OIF/OND Veterans, 20% have been diagnosed with PTSD and 20% have responded “yes” when screened for military sexual trauma (MST).1 In addition, women are the fastest growing segment of the homeless Veteran population, and are more likely to be homeless with children.

Recent research shows substantial co-morbidities among women Veterans, with 31% having physical and mental health conditions (vs. 24% of male Veterans). For example, among female Veterans with DM, 45% have a co-morbid serious mental illness or substance use disorder. Among female Veterans with cardiovascular disease, 21% have major depressive disorder.

Certain health risks may depend on the era of service.1,5,6 For example, women who served during the Vietnam War may present with diseases related to exposure to Agent Orange, such as Hodg kin’s disease, multiple myeloma, certain softtissue sarcomas, respiratory cancers, non-Hodgkin’s lymphoma, peripheral neuropathy, type 2 DM, Parkinson’s disease, and ischemic heart disease. Those who served during the Gulf War may present with chronic fatigue syndrome, fibromyalgia, gastrointestinal disorders, fatigue, skin disorders, headache, muscle pain, joint pain, neurologic or neuropsychological signs or symptoms (S/S), sleep disturbances, cardiovascular S/S, abnormal weight loss, or menstrual disorders. OEF/OIF/OND Veterans may be more likely to present with musculoskeletal and connective tissue disorders, mild depression, major depression, and readjustment difficulties.

Do women Veterans seek healthcare outside the VA system? What do providers need to know?

Approximately 83% of women Veterans seek healthcare outside the VA, either exclusively or along with the care that they receive from VA providers.7 Many healthcare providers (HCPs) may not realize that their patients are Veterans. Because such a large proportion of female Veterans receive healthcare outside the VA, either at academic centers or in private community practices, HCPs need to understand these women’s unique needs.

What can HCPs do? Because many female Veterans do not always identify themselves as such, HCPs should ask their patients “Have you served in the military?” If the answer is yes, HCPs should obtain a military history (branch of military, dates of service, occupation, deployment, reason for separation), including a description of their experiences in the military, and be familiar with local VA facilities so that they can refer Veterans appropriately. Women are eligible for VA healthcare if they have an honorable discharge and have completed 2 years of active duty service, were deployed in OEF/OIF/OND, or have experienced MST. A Veteran remains eligible for VA healthcare even if actively serving in the Guard or Reserve. Small copayments for some services are required. The sidebars list services available to women Veterans and additional resources.

How has the VA changed the face of women’s healthcare?

The VA created the Women’s Health Program in 1988 to streamline services for female Veterans in order to provide more cost-effective medical and psychosocial care. At that time, 4.4% of Veterans were women. The program was realigned within the Office of Public Health and Environmental Hazards in 2007, which increased the scope to include all women’s services. When the VA made additional alignment changes in 2011, the Women’s Health Program became part of the Office of Patient Care Services (PCS), The program’s name was changed to Women’s Health Services (WHS) in August 2012. Becoming part of PCS opened opportunities for WHS to collaborate with Primary Care, Mental Health, and Specialty Care.

The motto for WHS is “You served, you deserve the best care anywhere!” Women Veterans using VA healthcare services can expect:

• Women Veterans Program Managers to assist them at every facility;

• Comprehensive primary care, mental health services, and emergency and specialty care delivered by proficient and interested providers;

• Privacy, safety, dignity, and sensitivity to gender-specific needs;

• State-of-the-art healthcare equipment and technology;

and

• Pharmacy services by mail-order and online.1 

The goal of the VA is to ensure that every woman Veteran has access to a VA primary care provider (PCP) who can meet all her primary care needs, including gender- specific care. This approach ensures high-quality healthcare, with special emphasis on continuity of care and a strong relationship between PCP and patient.

Under ideal circumstances, female Veterans should receive complete primary care from one Designated Women’s Health Provider (DWHP) at one location.To provide enough DWHPs, along with nursing support, the national WHS office sponsors a 2.5-day national mini-residency program for PCPs and primary care nurses and offers it several times per year. The VA has also developed online training for core topics in women’s health. Every medical facility, including Medical Centers and Community-Based Outpatient Clinics (CBOCs), should have at least two DWHPs. Currently, all VA healthcare systems and 84% of CBOCs have at least one DWHP. These providers have an interest and special expertise in caring for women Veterans, many of whom have multiple physical and mental health co-morbidities.

The VA is working hard to ensure that every woman Veteran has access to the right kind of care at the right time and place. Facilities across the country are adding specialized equipment (e.g., digital mammography, DEXA scans) for women, updating facilities to ensure privacy and security, and expanding staff to provide convenient, equitable care.6

How is the VA addressing gender differences?

Beginning in 2008, the VA started a Women’s Health improvement initiative to focus on gender disparity data.8 Between 2008 and 2011, the VA saw tremendous reductions in gender disparity for many care measures, including Hypertension in Ischemic Heart Disease, A1C Testing for Diabetes, Retinal Exam in Diabetes, Nephropathy Screening in Diabetes, Pneumococcal Vaccine, Colorectal Cancer Screening, Depression Screening, PTSD Screening, and Alcohol Misuse Screening. Despite nationwide emphasis on gender differences in a variety of physical and mental health issues, gender gaps persisted for achieving these goals: LDL <100 in Ischemic Heart Disease, addressing A1C >9 in Diabetes, LDL <100 in Diabetes, and Influenza Vaccine. Analyses of best practices among VA networks revealed improvement based on education, support of leadership, collaborations among programs (Women’s Health, Primary Care, and Health Promotion Disease Prevention), and systems redesign. Success required multidimensional and multidisciplinary intervention aimed at patients, providers, and systems of care.

Progress is being made. Disparities in the rates of screenings and immunizations given to women and men VA patients are shrinking.8 For example, in 2008, 86% of eligible women Veterans received flu shots versus 94% of men. By 2011, there was only a 1% difference. One hundred percent of VA web pages have at least one topic of interest to women Veterans. Nearly half of these pages link to a facility-specific women’s health page and nearly one-third have images of women.

How does the VA fare with regard to provision of mental health services for women?

The VA provides a comprehensive system of mental health services for all Veterans, including psychological assessment and evaluation, outpatient individual and group psychotherapy, acute inpatient care, and residential-based psychosocial rehabilitation.2 Specialty services target problems such as PTSD, substance use problems, depression, and homelessness.

The VA has outpatient, inpatient, and residential services for women Veterans who have experienced MST and provides free care for all mental and physical health conditions related to MST.2 Veterans may be able to receive this free MST-related healthcare even if they are not eligible for any other VA care. An SC disability rating is not required, nor is the Veteran required to have reported the MST when it happened or have documentation that it happened. Every VA medical center has an MST Coordinator who specializes in this type of care and assists Veterans to access needed care. To accommodate female Veterans who do not feel comfortable in mixedgender treatment settings, many VA medical centers have women only programs or have specialized women’s treatment teams.

The VA offers a variety of programs designed to assist homeless Veterans, including special populations such as women with families.2 Programs include outreach and prevention, temporary and transitional housing, and permanent housing with supportive services. Among the homeless Veteran population, nearly 8% are female.2

The VA has dramatically increased mental health services because of the growing number of women Veterans, who use mental health services in larger numbers than their male counter-parts.Since 2012, more than 1,000 mental healthcare providers and more than 200 administrative support staff were hired, with a goal of hiring 1,600 providers and 300 support staff in 2013 alone.9 Mental health professionals include psychiatrists, psychologists, social workers, mental health nurses, licensed professional mental health counselors, licensed marriage and family therapists, and addiction disorder therapists. In addition, Veterans are being hired as Peer Specialists (up to 800 positions) who provide support to other Veterans. The number of phone lines for the Veteran Crisis Hotline has been increased by 50% to handle the additional volume of phone requests for mental healthcare services.

What type of maternity care does the VA offer?

Many female Veterans who served in OEF/OIF/OND are of reproductive age. Among these women, 81.1% were born in or after 1970 and 54.6% were born in or after 1980.2 With larger numbers of reproductive-aged women Veterans, the VA has recognized the need for expanded maternity care services. Maternity care is provided through outside community providers; costs are paid by the VA.10 The VA covers standard prenatal care, laboratory services, ultrasounds, and delivery costs. If a woman requires specialty care (such as Cardiology) during her pregnancy, her HCP can network within the VA if that service is available. Otherwise, necessary care is handled by other community providers. Each VA Medical Center has a Maternity Care Coordinator who contacts every pregnant Veteran at least every 2 months to review her physical and psychological needs, to ensure that she has the supplies and educational services that she requires, and to keep the Veteran in contact with her primary care and mental healthcare teams as needed. The newborn’s hospital healthcare is covered from birth through 7 days of life.10

What is the VA’s vision with regard to women’s healthcare?

The vision of the VA is to provide the highest quality care to every woman Veteran. Care of the highest quality….

• ensures that each woman Veteran coming to the VA will have her gender-specific primary care needs met by a proficient and interested PCP.

• includes privacy, dignity, and sensitivity to gender-specific needs.

• ensures that healthcare equipment and technology are state-of-the-art.

• ensures gender parity in performance measures.

• provides the right healthcare in the right place at the right time.

• builds necessary efficiencies into the delivery of women’s healthcare.

Each VA facility assesses its needs, strengths, and challenges to create a plan that works for its population of women Veterans, its areas of expertise, and its facilities, equipment, and staffing capacity. The VA is committed to exploring new approaches and pilot programs, all of which are designed to raise the standard to provide the best care anywhere.11 Beyond healthcare, the VA has a full range of benefits for women Veterans, including education and job training, vocational rehabilitation, benefits assistance, home loans, life insurance, and survivor and death/burial benefits.1 The VA is encouraging everyone to rethink the term Veteran (that former warrior might be a woman), to recognize the vital role women play in the military, and to appreciate what it means to be a woman Veteran.

Patrice C. Malena is Women Veterans Program Manager at Hampton VA Medical Center in Hampton, Virginia. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article. The content of this article does not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

References

1. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. A Profile of Women Veterans Today. Rethink Veterans: Who is the Woman Veteran? April 2012.

2. Department of Veterans Affairs. Office of Public Affairs Media Relations. Women Veterans Health Care Fact Sheet. Updated July 2014.

3. Department of Veterans Affairs. Sourcebook: Women Veterans in the Veterans Health Administration, Volume2: Sociodemographics and Use of VHA and Non-VA Care (Fee). October 2012.

4. Department of Veterans Affairs. Report of the Under Secretary for Health Workgroup. Provision of Primary Care to Women Veterans. November 2008.

5. Department of Veterans Affairs. Office of Public Affairs. Federal Benefits for Veterans, Dependents and Survivors. Last updated April 21, 2015.

6. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. On the Frontlines of VA Women’s Health: Enhancing Services for Women Veterans. August 2011.

7. Women Veterans Health Care. Resources for Non-VA Providers, Medical Students. Page last updated June 3, 2015.

8. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group, Office of Patient Care Services. Gender Differences in Performance Measures VHA 2008-2011; June 2012.

9. Department of Veterans Affairs. Office of Public and Intergovernmental Affairs. VA Hires More Mental Health Professionals to Expand Access for Veterans. February 11, 2013.

10. Department of Veterans Affairs. Women Veterans Health Care. FAQs. June 3, 2015.

11. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. Guide to Moving Forward in Providing Comprehensive Health Care to Women Veterans. August 2008.

Strategies for effective group prenatal care with pregnant adolescents

Managing the prenatal care of adolescents is both challenging and rewarding. Given adolescents’ developmental needs, group prenatal care (GPC) such as that modeled after Centering- Pregnancy is particularly well suited to members of this age group. The authors share their strategies for providing developmentally appropriate GPC for adolescents.

Most females receive prenatal care via a traditional model focused on screening for health-related complications. A healthcare provider (HCP) offers this care on an individual and regular basis throughout the pregnancy. At minimum, each visit involves assessment of maternal weight and blood pressure (BP), fundal height, and fetal heart rate. The initial visit is more comprehensive than subsequent visits, and includes taking a personal and family history, conducting a complete physical examination, and ordering laboratory tests. Education is provided about prenatal care and avoidance of risky behaviors. Subsequent visits include screening for problems and provision of information about nutrition, pregnancy complications, childbirth, and infant care. When indicated, special fetal assessment tests may be recommended and the need for genetic counseling discussed.1

In 1993, CenteringPregnancy (CP) was introduced as an alternative model for delivering prenatal care.2,3 The CP model provides comprehensive prenatal care to small groups of women at similar points in their pregnancies. For participants in this group prenatal care (GPC) program, learning and support are enhanced by group dynamics and by the HCP’s leadership.Compared with traditional care, CP has been associated with improved patient satisfaction, knowledge, and attendance; similar or superior maternal/newborn health outcomes; and greater affordability.4-10

The advent of the Affordable Care Act of 2010, with its provision of access to healthcare for additional millions of Americans, has created a distinct need for innovative, cost-effective, high-quality prenatal care models. GPC can be both safe and affordable, provided at convenient times for better access, and directed at meeting a group’s special needs. GPC is ideal for pregnant adolescents: Management of adolescent pregnancy in group settings has been shown to foster optimal maternal and neonatal outcomes.4-7,11,12 The authors, with many years’ experience in delivering prenatal care to adolescents using the group model, discuss their own program.

Background information on CenteringPregnancy

The authors’ adolescent GPC approach was based on principles of CP. According to Rising,developer of CP, attending prenatal sessions can result in better pregnancy outcomes, with less maternal stress, lower rates of substance abuse, improved labor progress, higher infant birth weights, and higher 5- minute Apgar scores. The CP model, which includes essential components of traditional prenatal care within a group framework, integrates three major components of prenatal care: health assessment, interactive learning, and community building.13 CP groups comprise 8-12 females at similar points in their pregnancies. After a one-onone prenatal visit with an HCP, participants attend regular group sessionslasting 1.5-2 hours, usually held in the late afternoon or early evening, for the remainder of their care. The sessions, typically led by an HCP and a nurse, meet every 4 weeks until the 28th week and then every 2 weeks until delivery.

At the start of every group session, each participant has a quick private visit with a nurse and an HCP for checks of weight, BP, fundal height, and fetal heart tones and for an opportunity to ask personal questions. During this time, the other participants chat or watch an educational video. Once individual checks are done, the group session begins. Topics discussed include nutrition, exercise and relaxation, discomforts of pregnancy, childbirth preparation, infant care and feeding, postpartum concerns, contraception, communication/self-esteem, and parenting skills. Participants are encouraged to ask questions, which can help others with similar concerns,12 and they are invited to bring a partner or a family member. Additional prenatal visits are necessary only if problems with the pregnancy arise or if a participant requires a confidential private exam.

The CP structure comprises 13 essential elements,14 which are also used in the authors’ prenatal program: (1) Health assessment occurs within the group space; (2) Women are involved in self-care activities; (3) A facilitative leadership style is used; (4) Each session has an overall plan; (5) Attention is given to the core content, but emphasis may vary; (6) There is stability of group leadership; (7) Group conduct honors the contribution of each member; (8) The group is conducted in a circle; (9) Group composition is stable but not rigid; (10) Group size is optimal to promote the process; (11) Involvement of family support is optional; (12) Opportunity for socializing within the group is provided; and (13) There is ongoing evaluation of outcomes. Primary differences between CP and traditional prenatal care are the time spent in care and the opportunity for group interaction. Traditional visits usually last 5-10 minutes, whereas CP visits are about 90 minutes long. This amount of time allows participants to grow comfortable with their HCPs and each other, which enhances discussions and learning. In addition, belonging to a group can help participants feel valued and important, and provide support during the pregnancy.12

Adolescents and group prenatal care: Literature review

Adolescence is a challenging stage of life, but when pregnancy complicates the picture, additional physical, social, and emotional stresses must be managed. Because pregnant adolescents are more likely than their non-pregnant counterparts to be in a lower socioeconomic bracket, they are less likely to receive adequate prenatal care unless it is accessible and affordable. GPC may be optimal for these individuals; not only can it be offered at convenient times and be covered by Medicaid, but it is also geared toward adolescents’ developmental level and learning needs.15,16 To ascertain  what the literature shows in terms of the usefulness of GPC for young females, especially adolescents, the authors searched the CINAHL and Medline databases for studies and systematic reviews reported from 2010 through 20115. Table 1. Selected studies on group prenatal care can be accessed here. 4 5,7,11,12,17-21

Authors’ experiences and strategies

The authors’ outpatient prenatal program was affiliated with a large urban medical center and enrolled adolescents aged 12-19 who were African American (65%), Caucasian (20%), Latino (10%), or Southeast Asian (5%). Most participants came from low-income families receiving public assistance. Initial training for the program’s staff was provided by two CP consultants during a 2-day workshop on content and process. Funding for the training came from the program’s budget; ongoing training for new staff was derived from continuing education funds and a community agency grant.

A nurse practitioner (NP), midwife, or nurse who saw prospective program participants at their intake and first obstetric visit invited  them to join the GPC program. The authors expected that all recruited adolescents would participate in the program, but they made exceptions when a patient needed individual care because of privacy concerns or a conflict with another participant. Each group was managed by an HCP (either an NP or a midwife) and a nurse. A social worker performed psychosocial evaluations and was available to address psychosocial concerns, and a nutrition specialist performed one-on-one  assessments early in the pregnancy and participated in a group discussion of prenatal nutrition and meal planning. The group meeting room accommodated 15 people and was set up to be comfortable and welcoming— similar to a setting for a baby shower. The CP model recommends that participants sit in a large circle with no table, but the authors used the existing large oval table in their space, which did not seem to affect group interactions. Educational aids available in the room included models of a bony pelvis, fetus, uterus, and dilating cervixes; posters; and a TV with a DVD player and videos to reinforce topics such as maternal nutrition, vaginal and cesarean delivery, and newborn and self-care.

The first GPC session took place when participants were at 12-16 weeks’ gestation. For scheduling purposes, the groups were referred to by their due dates (e.g., the September/October group). As with the CP program, at the start of each session, a nurse weighed each participant and checked her BP. Next, the participant lay on a small firm couch and an HCP assessed fundal height and fetal heart tones and obtained other relevant information. A curtain divider between the couch area and the group meeting area ensured privacy. During the initial group meeting, the HCP and the adolescents reviewed “Teen Rules for Group Prenatal Care” as follows:

• Be sensitive to others’ confidential information: “What is said in group stays in group.”

• Discuss who should be allowed to come to group (usually one guest who was a partner, friend, or mother figure, but no children).

• Behave politely and respectfully toward other group members (e.g., when one person is talking, others should listen).

• Do not use hand-held electronic devices during the sessions.

• Encourage everyone to be involved in discussions, and reinforce that no one should dominate or be excluded.

• Describe how group works: weight, urine sample, and fundal height measurement, followed by the education component, with the option of being seen individually after group as needed.

• Know the danger signs of pregnancy.

• Know how to contact the practice and use the after-hours oncall service for labor and emergencies.

In the authors’ program, 3-4 groups attended GPC sessions once weekly in the afternoon. Participants received phone reminders the day before the sessions; any transportation problems were resolved at this time. Although 8-10 participants were assigned to each group, only 5-6 attended regularly. Postpartum group reunions—including the infants— were scheduled to occur 4- 6 weeks after the last girl in each group had delivered. However, because of low participation, these sessions were discontinued.

At first, GPC participants kept copies of their health records. When the authors’ practice converted to an electronic health record (EHR) system, this information was stored on a laptop. Patient encounter forms were printed prior to group meetings for easy completion with billing codes and designations of return visits. GPC visits were reimbursed the same way as an individual visit. Some insurance was fee-forservice, but most patients were covered by Medicaid managed care programs that reimbursed globally. The prenatal portion was then applied to the adolescent   program budget and the delivery portion to the midwifery budget. Table 2 lists websites specific curriculum content for adolescent GPC and general information on teen pregnancy. Topics of greatest interest to participants in the authors’ program included preparation for labor and birth, pain management, bringing baby home, bottle feeding versus breastfeeding parenthood, relationships with their boyfriend, and contraception.

Table 3 lists GPC activities that the authors found particularly useful. GPC worked best when HCPs were facilitators of group activities rather than lecturers of content. The adolescents appreciate knowing what they could expect from their HCP as well as what was expected of them. HCPs reinforced the confidentiality of patient information and demonstrated respect to gain the trust and confidence that promote regular group attendance and participation. In the authors’ experience, HCPs who were seasoned clinicians, had senses of humor, were approachable, and had knowledge of community resources were best suited as GPC providers.  Group attendees completed a satisfaction survey at the last session. Over the years, the surveys demonstrated high satisfaction with the program, especially with regard to its structure, the knowledge it imparted, the relationships it fostered, and the preparation it provided for labor, delivery, and newborn care.

Discussion

Initiating a GPC model requires considerable planning and commitment. The authors learned the importance of gaining commitment to the program from everyone involved, from the clerical staff to the HCPs themselves, because they all needed to adapt to a new way of providing care. Periodic retreats were held to address the challenges that arose as the program was implemented.

The GPC program needed to be budget neutral; ensuring that reimbursement covered costs meant having at least 6-8 patients per session. Given the substantial no show rate among adolescents, the groups were intentionally overbooked. Obtaining funding for training and costs for snacks was an ongoing challenge. The program received contributions from various community organizations, and small grants were sought.

Regular planning time was essential for the administrative support staff to schedule groups, assign HCPs, write grants, and perform program evaluation. Nursing staff members took responsibility for setting up the room, providing handouts and snacks, and following up on no-shows. HCPs were busy managing traditional patients before and after groups, so a pre-group huddle was used to prepare co-leaders for the session.

The conversion to EHRs was an added challenge, particularly because laboratory test and ultrasound order entries and follow-ups became an HCP task rather than a nursing one. A laptop and Wi-Fi access were required to manage the EHR during the group sessions. The commitment of all staff to GPC and allocation of extra time were essential to successful transitioning to this system.

This GPC model encourages mutually beneficial relationships between pregnant adolescents and obstetric HCPs and provides opportunities for interdisciplinary collaboration.22,23  The authors’ program included a strong collaboration with the pediatric resident clinic, wherein GPC participants transitioned into well-child care groups that encouraged follow-up visits and immunizations. In addition, the authors had collaborative arrangements with the pediatric dental clinic and hospital social work department.

Conclusion

Given the developmental needs of adolescents, GPC provides a satisfying experience for both those who are pregnant and their HCPs.24   The authors modeled their program after CP principles for evidence-based care. 4-6,8,11 They created a supportive environment for prenatal care and helped adolescents learn the essentials about pregnancy, labor delivery, and postpartum and newborn care, with the goal of optimizing outcomes for both mother and child.

Joanne B. Stevens is Associate Professor at the University of Tampa, Department of Nursing, in Tampa, Florida. Elizabeth Cooper is Professor Emeritus in Obstetrics and Gynecology at the University of Rochester in Rochester, New York. Stasha Roberts is an alumna of the University of Tampa and an advanced registered nurse practitioner. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 7th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.

2. Thielen K. Exploring the group prenatal care model: a critical review of the literature. J Perinat Educ. 2012; 21(4):209-218.

3. Rising SS. Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery. 1998; 43(1):46-54.

4. Tanner-Smith EE, Steinka-Fry KT, Gesell SB. Comparative effective of group and individual prenatal care on gestational weight gain. Matern Child Health J. 2014; 18(7):1711-1720.

5. Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obset Gynecol.  2012;206(5):415.e1-7.

6. Kennedy HP, Farrell T, Paden R, et al. A randomized clinical trial o group prenatal care in two military settings. Mil Med. 2011;176(10):1169-1177.

7. Barr WB, Aslam S, Levin M. Evaluation of a group prenatal care-based curriculum in a family medicine residency. Fam Med. 2011;27(2):138-145.

8. Teate A, Leap N, Rising SS, Homer CS. Women’s experience of group antenatal care in Australia—the CenteringPregnancy Pilot Study. Midwifery. 2011;27(2):138-145.

9. Novick G, Sadler LS, Knafl KA, et al. The intersection of everyday life and group prenatal care for women in two urban clinics. J Health Care Poor Underserved. 2012;23(2):589-603

10. Gaudion A, Menka Y. ‘No decision about me without me’: centering pregnancy. Pract Midwife. 2010; 13(10):15-18.

11. Tandon SD, Colon L, Vega P, et al. Birth outcomes associated with receipt of group prenatal among low-income Hispanic Women. J Midwifery Womens Health. 2012;57(5):476-481.

12. Ickovics JR, Reed E, Magriples U, et al. Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled study. Psychol Health.2011;26(2):235-250.

13. Rising SS. Group prenatal care. UpToDate. Last updated April 29, 2015.

14.  Rising SS. Kennedy HpP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health. 2004;49(5):398-404.

15. Grady MA, Bloom, KC. Pregnancy  outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health. 2004;49(5):412-420.

16. Feldman JB. Best practice for adolescent prenatal care: application of an attachment theory perspective to enhance prenatal care and diminish birth risks. Child Adolesc Soc Work J. 2012;29(2):151-166.

17. Cypher RL. Collaborative approaches to prenatal care: strategies of successful adolescent programs. J Perinat Neonatal Nurse. 2013;27(2): 134-144.

18. Hale N, Picklesimer AH, Billings DL, Covington-Kolb S. The impact of Centering Pregnancy Prenatal Care on postpartum family planning. Am J Obstet Gynecol. 2014;210(1):50.e1-7.

19. Homer CS, Ryan C, Leap N, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2012;14(11): CD007622.

20. Novick G, Reid AE, Lewis J, et al. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol. 2013;209(2):112.e1-6.

21. Tanner-Smith EE, Steinka-Fry KT, Lipsey MW. Effects of CenteringPregnancy group prenatal care on breastfeeding outcomes. J Midwifery Womens Health. 2013;58(4):389-395.

22. Picklesimer A, Heberlein E, Covington-Kolb S. Group prenatal care: has its time come? Clin Obstet Gynceol. 2015;58 (2): 380-391.

23. Stevens J, Iida, H. Implementing an oral health program in a group prenatal practice. J Obstet Gynceol Neonat Nurs. 2007;26(6):244-249.

24. Ellison T. Group prenatal care: a pilot study evaluating patient satisfaction. Unpublished Honor’s Senior Thesis. Department of Nursing, The State University of NY at Brockport; 2010.

Web resource

A. npwomenshealthcare.com/?p=4641

Diagnosis and management of pelvic organ prolapse: The basics

Pelvic organ prolapse (POP) is a prevalent condition that can cause uncomfortable sensations of vaginal bulging, painful intercourse, and even stress urinary incontinence. This article presents a simple, evidence-based approach to diagnosing and managing POP that women’s healthcare providers can implement.

Pelvic organ prolapse (POP) is a common condition that occurs when one or more pelvic structures—the bladder, the urethra, the uterus, or the rectum—deviate from their normal anatomic position and bulge against the vaginal vault.Sometimes the prolapse is so severe that the affected area protrudes through the vaginal opening. The underlying cause of POP is a weakening of the pelvic floor muscles (PFMs) and fascia that support the pelvic organs.2

Risk factors

Loss of PFM tone may be caused by a variety of factors. One common risk factor for POP is multiple vaginal deliveries, particularly in those women who have experienced prolonged labor, instrumented delivery, and/or delivery of infants weighing more than 9 lb. In fact, women who have delivered vaginally, compared with those who have undergone cesarean section, have twice the risk of developing symptomatic POP.Women who have had pelvic floor trauma during childbirth or pelvic surgery such as hysterectomy are also at increased risk for POP.

Other risk factors for POP include conditions that increase intra-abdominal pressure such as chronic constipation, chronic cough, and work involving prolonged heavy lifting.3,4 Still other contributing factors are excess body weight, aging, menopause (related to loss of collagen), genetic predisposition, prolonged standing, and activities that involve jumping (e.g., trampoline use).5 Overweight and obesity are particularly strong risk factors: Studies have shown that the risk for symptomatic POP rises 3% with each unit increase of body mass index (BMI), and that women whose BMIs exceed 25 kg/m2, as compared with women whose BMIs are below 25, are twice as likely to develop POP.3,4 Health conditions that may disrupt pelvic neuromuscular function—and therefore increase the risk for developing POP—include multiple sclerosis, neuromuscular injuries related to childbearing, and spinal cord injury.5-7

Clinical picture

Many women with mild POP are asymptomatic. A woman with symptomatic POP may report feeling pressure or fullness in the pelvis, a pulling sensation in the groin or lower back, or vaginal bulging—all of which may ease up when she lies flat. She may describe a feeling that something is falling out of the vagina or even have a visible bulge from the vagina. Either way, she may experience vaginal pain or discomfort, particularly when having sex.4,6

Urinary symptoms of POP may include stress urinary incontinence (SUI), difficulty voiding, a sensation that one cannot empty the bladder completely, urinary frequency, urinary urgency, or nocturia. With some forms of POP, urinary symptoms are actually masked. Bowel symptoms of POP may include pain with defecation, fecal incontinence, or other types of defecatory dysfunction. A patient with a rectocele may report that she needs to press between the vagina and rectum to help her defecate.

The healthcare provider (HCP) must take a thorough history regarding these symptoms, as well as a detailed gynecologic, obstetric, sexual, and surgical history, to determine contributing factors. In addition, the HCP needs to identify chronic health conditions or situations that could be contributing to longer-than-average periods of elevated intra-abdominal pressure. These include chronic constipation and smoking or respiratory conditions that cause chronic cough.1,4 As part of the behavioral history, the HCP needs to ask about the patient’s exercise regimen (e.g., Does she lift weights? Does she do jumping jacks or use a trampoline?), whether the patient has gained weight recently, and whether the patient’s occupation may require her to perform heavy lifting or stand for long periods of time.

Physical examination

Because many patients have more than one type of prolapse, the HCP needs to examine each area of potential involvement within the vaginal vault separately. Performing each component of the pelvic exam with an individual focus results in greater accuracy of diagnosis.

Grading system

Various grading systems are available to determine the severity of POP based on physical examination. In this article, the authors use the Baden-Walker Halfway Scoring System, which assigns these gradations of severity:

• Grade 0: no prolapse;

• Grade 1: the lowest part of protrusion extends halfway to the hymen;

• Grade 2: the lowest part of protrusion extends to the hymen;

• Grade 3: the lowest part of protrusion extends halfway past the hymen; or

• Grade 4: the greatest degree of protrusion is observed.8, 9

The other commonly used grading system, albeit more complex than the Baden-Walker system, is the Pelvic Organ Prolapse Quantification (POP-Q) system.10

Inspection of external genitalia

Once the required equipment is assembled and available and the patient is placed in the lithotomy position, the exam begins with an inspection of the external genitalia.1,9,11 In a woman with normal findings, the vaginal introitus may be small or wide, depending on her sexual status, and hymenal remnants may be observed. Abnormal findings may include dry tissue, bruising, lesions, discharge,or prolapsed vaginal tissue. The introitus may gape open if vaginal vault/uterine prolapse is present. If prolapse is observed on inspection, the HCP should check for ulcerations. In severe POP, the prolapse may be observed on inspection even if the patient has not been asked to strain.

Speculum examination

During the speculum examination, the HCP inspects the vaginal mucosa for symmetry, atrophy, and any other abnormalities such as ulcerations or discharge that might explain the presence of symptoms.9 First, the speculum is placed into the vaginal vault and the cervix is inspected. Next, as the speculum is slowly removed, the vaginal mucosa is observed for any abnormalities such as abrasions or descent of the vaginal apex while the patient is asked to perform the Valsalva maneuver.The extent to which the cervix or the vaginal vault follows the speculum through and out of the vagina is noted.1

Next the HCP inserts the posterior blade of the speculum into the vagina, applying gentle pressure first to the posterior wall while asking the woman to perform the Valsalva maneuver to look for the extent of anterior compartment protrusion at the lowest point of the descent. The HCP then rotates the blade, applying gentle pressure to the anterior vaginal wall to determine if any prolapse is present in the posterior compartment and to what degree—based on the Baden-Walker system (Table).9,11

The patient may be concerned about leaking urine or stool when asked to bear down during these exams. The HCP should provide reassurance to her and equip the room with waterproof pads and hygiene products such as tissue or unscented, hypoallergenic moist cloths for cleaning as needed.

Bimanual examination

A bimanual exam is performed to evaluate the size and shape of the uterus and ovaries and to check for the presence of abdominal masses. The uterus should feel smooth and round and move slightly with manipulation. The ovaries, if palpable, should be no larger than the size of an almond. All organs should be non-tender on examination. The bimanual exam can help identify other pathologies that might be contributing to the chief complain of pelvic pressure and other reported symptoms.

During this exam component, the HCP can assess the adequacy of the patient’s vaginal muscle tone in supporting the pelvic organs by having her contract the PFMs. While performing this assessment, the HCP needs to determine whether voluntary or involuntary contractions are occurring, whether muscles remain in a contracted state, and whether the PFMs do not contract at all, even when the patient is asked to contract them.9

Examination while patient is standing

The inspection exam with Valsalva straining is repeated while the patient is standing. This exam provides the best estimation of the extent of prolapse as it relates to normal daily activities.9 Depending on the patient’s symptoms, the HCP may also perform a rectal exam with the patient standing to check for an enterocele as the cause of the symptoms.9 If the small bowel is involved, it will be palpable in the cul-de-sac.

Differential diagnoses

Differential diagnoses to consider when assessing a woman for POP include adnexal, uterine, and other genital tract masses that may cause symptoms similar to those of POP; and urinary tract infection (UTI).9 If the patient has urinary symptoms, a urinalysis is done to evaluate for UTI.9

Treatment

Treatment for POP is based on severity of the prolapse and the patient’s preferences, health, and symptoms. Conservative options, though associated with few adverse effects and cost-effective, tend to work only for milder forms of POP and require a high level of commitment from the patient. Examples of conservative options are behavior modification (e.g., weight-loss diet, smoking cessation), PFM strengthening, and pessaries.9,12 Goals of conservative therapy are to improve symptoms, reduce POP progression, and delay or avoid surgery.

Pelvic floor muscle strengthening

If POP is grade 2 or lower, PFM strengthening, including Kegel exercises, can improve symptoms of pelvic pain, vaginal pressure or bulging, and SUI.12,13 Evidence regarding the efficacy of PFM strengthening in improving POP symptoms and degree is limited, but recent studies have shown significant improvement with this approach.13,14 For a patient who wants to learn to perform Kegel exercises, she should start slowly and increase gradually, with the goal of performing 10 contractions held for 10 seconds each, 2-3 times daily.12,15

Pessary

The pessary, a flexible plastic or medical-grade silicone device that comes in a variety of sizes and shapes, can be used to treat any grade of POP.1 It is inserted into the vaginal vault to support weakened PFMs and prevent bulging. The pessary is a good choice for a woman with bothersome POP symptoms who is not a candidate for or does not desire surgery. The pessary may be used for temporary symptomatic relief while awaiting surgery. Potential adverse effects of the pessary include changes in voiding patterns, vaginal irritation, and vaginal ulcers or excoriations.12 Pessary use is avoided if a woman has a large vaginal outlet or a short vagina, and it may be challenging if a woman cannot insert or withdraw the device on her own.15 A woman may receive assistance from a home health nurse or return to the office at regular intervals to have the device removed, cleaned, and replaced, although the frequency with which she needs to return for pessary followup or periodic cleaning has not been established.12

Surgery

Surgery is an option for a woman whose symptoms are adversely affecting her quality of life. Several different surgical procedures are available. Colporrhaphy is done to repair the anterior or posterior vaginal wall in a woman with cystocele or rectocele. The affected organ (i.e., the bladder or rectum) is moved back into normal position and the affected vaginal wall is tightened to better support the organ. Surgical implantation of transvaginal mesh for correcting POP has become more common because of the higher rates of success compared with traditional colporrhaphy.16 However, postoperative complications (e.g., mesh erosion, operative site pain, painful urination) may arise, and longterm efficacy of the treatment has not been established.16-19

Patient counseling

If conservative management is desired and the grade of POP is 2 or lower, HCPs should counsel patients with regard to performing Kegel exercises and on behavior modification strategies, which include weight loss; smoking cessation; and avoidance of straining with bowel movements, prolonged standing, lifting, and exercise involving jumping. Patients need to know that conservative measures can be quite helpful in reducing POP progression. Patients also need to understand the risks of surgery, which include incontinence and erosion or contraction of the mesh.17

Referral

Need for referral depends on the plan for POP management and the HCP’s skills in diagnosing and managing the condition. If POP is only mildly bothersome, the HCP may choose to begin PFM strengthening and fit the patient with a pessary.13 Referral to a specialist is made if the diagnosis is uncertain or if surgical evaluation is desired. In addition, patients may be referred to a pelvic floor physical therapist for intense and focused assistance with PFM strengthening to relieve symptoms.

Conclusion

Pelvic organ prolapse can be an embarrassing, bothersome problem for women. HCPs need to know the risk factors and symptoms associated with POP, how to evaluate for the condition on physical exam,and the various treatment options that are available. Treatment choice is based on symptom severity and patient preference. Referral to a specialist is recommended when factors related to evaluation and treatment begin to exceed an HCP’s scope of practice.

Brittany S. Nutt is a DNP graduate of Texas Woman’s University in Dallas and a Women’s Health Nurse Practitioner in the United States Air Force. Susan Chaney is Master of Science Program Coordinator and Professor and Catherine Hill is Clinical Faculty, both at Texas Woman’s University in Dallas. Catherine Hill is also Managing Partner of Texas Nurse Practitioner Associates, LLP, in Dallas. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Physician. 2010;81(9):1111-1117.

2. American College of Obstetricians and Gynecologists. Frequently Asked Questions: Gynecologic Problems. FAQ012. Pelvic Support Problems. May 2011.

3. Gyhagen M, Bullarbo M, Neilsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in a singleton primiparae after vaginal or caesarean delivery. BJOG. 2013;120(2):152-160.

4. Rogers RG, Fashokun TB. An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapseUpToDate. Last updated February 19, 2015.

5. Lukanovic A, Drazic K. Risk factors for vaginal prolapse after hysterectomy. Int J Gynaecol Obstet2010;110(1):27-30.

6. Handa VL. Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirthUpToDate. Last updated May 27, 2015.

7. Mahajan ST, James R, Frasure H. Pelvic floor disorders and multiple sclerosis: are patients satisfied with their care? Int J MS Care. 2014;16(1):20-25.

8. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. 2007;110(3):717-729.

9. Fashokun TB, Rogers RG. Pelvic organ prolapse in women: diagnostic evaluationUpToDate. Last updated June 15, 2015.

10. Persu C, Chapple CR, Cauni V, et al. Pelvic Organ Prolapse Quantification System (POP-Q) – a new era in pelvic prolapse staging. J Med Life. 2011;4(1):75-81.

11. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination. Fifth Edition. St. Louis, MO: Mosby; 2003.

12. Hagen S, Thakar R. Conservative management of pelvic organ prolapse. Obstet Gynaecol Reprod Med2012;22(5):118-122.

13. Braekken IH, Majida M, Engh ME, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010;203(2):170.e1-7.

14. Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomized controlled trial. Lancet, 2013;383(9919):796-806.

15. Choi KH, Hong JY. Management of pelvic organ prolapse. Korean J Urol. 2014;55(11):693-702.

16. Turgal M, Sivaslioglu A, Yildiz A, Dolen I. Anatomical and functional assessment of anterior colporrhaphy versus polypropylene mesh surgery in cystocele treatment. Eur J Obstet Gynaecol Reprod Biol. 2013;170(2):555-558.

17. Dietz HP, Hankins KJ, Wong V. The natural history of cystocele recurrence. Int Urogynecol J. 2014;25(8): 1053-1057.

18. Walter JE; Urogynaecology Committee, Lovatsis D, et al; Society of Obstetricians and Gynaecologists of Canada. Transvaginal mesh procedures for pelvic organ prolapse. J Obstet Gynaecol Can. 2011;33(2):168-174.

19. Altman D, Vayrynen T, Axelsen S, Falconer C; Nordic Transvaginal Mesh Group. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med. 2013;364(19): 1826-1836.

Collaboration in practice: A framework for team-based care

Since passage of the Affordable Care Act in 2010, alternate care delivery models such as patient- centered health homes and accountable care organizations have emerged as tools for payment and healthcare delivery system reform. The intent of such clinical integration models is to drive improvement in individual and population health outcomes and in the quality and efficiency of healthcare service delivery.Although these models hold promise in moving our healthcare system from a disjointed paradigm to a seamless, value-driven standard, fragmentation persists at all levels of the healthcare continuum. Establishment of a well-functioning team is one mechanism by which healthcare providers (HCPs) can achieve the goal of patient-centric, well-coordinated, safe, and responsive healthcare.2

Healthcare providers have been challenged to respond to an evolving health policy landscape that demands movement to coordinated, value-driven care models in the face of HCP shortages and shrinking resources. In response to this changing landscape, and, reflective of his own commitment to a team approach to care, John Jennings, ACOG’s 2014 President, chose—as the priority issue of his presidential year—revision of ACOG’s Guidelines for Implementing Collaborative Practice (1995) to better reflect the demands of today’s healthcare system. To meet this charge, ACOG convened an interdisciplinary task force comprising delegates from nine different organizations representing physicians, nurse practitioners, midwives, physician assistants, clinical pharmacists, and consumers. The resulting Collaboration in Practice: Implementing Team-Based Care represents a paradigm shift for healthcare service delivery in which patients are integral participants; all team members are valued equally; and all HCPs are supported in practicing to the full extent of their education, certification, and experience and accept accountability for their practice. To date, this document has been endorsed or supported by 21 national organizations, including NPWH and our sister NP organizations AANP, GAPNA, NAPNAP, and NONPF.3 The Executive Summary of this document is available here.

Team-based care and collaboration

In crafting this document, the writing team worked with the following definitions. Team-based care is defined as the “provision of health services to individuals, families, and/or their communities by at least two healthcare providers who work collaboratively with patients and their families…to accomplish shared goals…”Effective implementation of team-based care requires interprofessional collaborationdefined as “a process involving mutually beneficial participation between autonomous individuals whose relationships are governed by shared norms and visions.”3

The terms team-based care and collaboration have sometimes been used in regulatory policies in a way that places barriers to qualified HCPs’ ability to practice to the full extent of their education, certification, and experience. However, implementing team-based care delivery models does not require team-based licensure or integrated regulatory frameworks. In some cases, linked licensure and restrictive regulations may inhibit the flexibility and innovation required for team-based, patient-centered care. Of note, the ACOG document uses the terms team-based care and collaboration in their truest forms, denoting an equitable practice environment wherein each team member’s knowledge and skills are valued contributions to the team’s work. As such, the terms team-based care and collaboration should not be construed as recommended policy constructs within the context of this document.

Core concepts: Application to women’s health practice

Collaboration in Practice identifies six principles as core components guiding team-based care, all of which are relevant to women’s healthcare and WHNP practice. First and foremost, successful team-based care recognizes the patient and family as central, actively engaged members of the healthcare team.4 In 2008, the National Priorities Partnership identified patient and family engagement as one of six priorities with the most potential to reduce harm, eliminate disparities, decrease disease burden, and remove inefficiencies in healthcare delivery.4 Given the disparities in maternal/child and women’s health outcomes across the lifespan,5 a team-based approach that supports active patient engagement and shared decision making holds merit as one strategy to improve women’s health outcomes.

The second, third, and fourth guiding principles recognize the importance of shared vision, role clarity, and accountability, respectively, as important components of team-based care. These principles underscore the value of mutual respect that recognizes the expertise of each team member. Likewise, there exists an expectation of professional accountability to one’s own practice and to the team. Maintaining competencies through continuous learning is an expectation within an accountable practice. Although regulation of scope of practice resides within the purview of each state, the document urges professional organizations to continue to provide guidance for clinical practice and promote uniform educational requirements and standards of care and conduct. The Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th edition (2014), available hereprovides a population-focused framework for WHNPs.

Communication, the fifth guiding principle, underscores the need for clear transfer of information regarding patient status and team tasks. The document recognizes the fluid nature of teams and appreciates evolving trends in healthcare. Teams range from a typical model wherein care is provided at a discrete location by a selected team of HCPs to virtual teams wherein care is provided by multiple HCPs across a variety of settings in disparate locations—in some instances using telehealth as a tool to expand access.The sixth guiding principle recognizes the fluid and dynamic nature of patient-centered care. Team leadership is described as being situational and dynamic. Within this principle, team leadership is determined in response to patient need at any given moment in time, rather than ownership by a specific role or discipline.

Women’s healthcare providers practicing in the maternal/child healthcare field may recognize parallels between team-based care and perinatal regionalization, a concept supported by the maternal/child healthcare community for more than two decades. Perinatal regionalization, which seeks to assure that high-risk pregnant women and/or infants receive the appropriate level of care at the appropriate time in order to optimize patient outcomes in high-risk situations, can be viewed as a key example of a virtual model for team-based care. In this model, communication to facilitate seamless transitions in care among community-based HCPs and perinatal care providers must be established to achieve optimal pregnancy outcomes. In-person or virtual consultation, education, and skill building help support open communication, professional accountability, and fluid team leadership. Just as the team-based care model recognizes the important role of each member, perinatal regionalization recognizes the important role of the community-based team, the perinatal center team, and wraparound service providers, all of whom contribute to an optimal outcome.7,8 Although perinatal regionalization serves as one example of the breadth of a team-based care model, the concept is transferable across a variety of healthcare settings and specialties, within a traditional or a virtual setting.

Conclusion

Women’s healthcare has always been a team-based endeavor recognizing the important role of access to gender-focused care throughout the lifespan, with attention to the realities of women’s lives outside the hospital and clinic walls. In this regard, it is especially fitting that women’s healthcare providers led the way in bringing together a diverse group of HCPs to chart a path applicable across specialties and disciplines. Furthermore, the collaborative process used in developing this document mirrored the equitable, collaborative approach recommended as a pathway to successful implementation of team-based care. NPWH was proud to be part of the working group that helped shape the concepts put forth in this document.

The aforementioned Executive Summary of the Collaboration in Practice document provides an overview of the process and key points. All of the essential elements of the work, including recommendations for implementing an equitable, accessible, reimbursable, patient-centric model of care, are elaborated in the full report. The Collaboration in Practice team invites you to consider how the full report can be used to enhance your practice and improve patient 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 served as the NPWH delegate to ACOG’s Collaborative Practice Task Force. She can be reached at 314-629-2372 or at skendig@npwh.org.

References

1. Guterman S, Drake H. Developing innovative payment approaches: finding the path to high performanceThe Commonwealth Fund. May 2010.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

3. Executive Summary: Collaboration in Practice: Implementing Team-Based Care. Report of the American College of Obstetricians and Gynecologists’ Task Force on Collaborative Practice. Obstet Gynecol. 2016;127(3):612-617.

4. National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s HealthcareWashington, DC: National Quality Forum; 2008.

5. Kendig S. Women’s health: more than an annual event. Womens Healthcare. 2014;2(3):36-39.

6. ACOG Task Force on Collaborative Practice. Collaboration in Practice: Implementing Team-Based CareWashington, DC: ACOG; 2016.

7. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 7th edition. Elk Grove Village, IL: AAP; Washington, DC: ACOG; 2012.

8. Obstetric Care Consensus No. 2: Levels of Maternal Care. Obstet Gynecol. 2015;125(2):502-515.

Sexuality in the aging population: Statement of the problem

This column is the first part of a 2-part series.

The aging process can compromise sexual functioning in both women and men. Many older persons deal with this situation by terminating sexual activity—perhaps because they are unaware of various therapeutic approaches that are available. If patients address this problem, they can find themselves enjoying sex as much now as they did in the past. Some patients even report experiencing an improvement in sexual functioning. When caring for older patients, then, healthcare providers should recognize sexuality as an important component of their overall health, diagnose sexual dysfunction if it exists, and either treat the condition or refer patients to specialists as needed.

According to a survey conducted by AARP in 2009, among 1,670 individuals aged 45 years or older, 77.4% of women and 67% of men reported having sexual intercourse infrequently: once or twice a month, less than once a month, or not at all. Table 1 shows this and other similar findings from the AARP survey.1 Although fairly large proportions of female and male respondents in the survey did not engage in sexual activities very often, 58% reported believing that sex is critical to a good relationship. Therefore, many midlife and older adults may not be experiencing the sex lives they want to have, but they have little recourse. Either they do not broach the topic with their healthcare providers (HCPs) or their HCPs are not as well informed as they might be about identifying sexual dissatisfaction or dysfunction in their patients or managing these situations.2

For example, Maes and Louis3 conducted a study to identify the sexual history-taking practices of 500 U.S. nurse practitioners (NPs) with regard to patients aged 50 years or older. Only 2% of the NPs reported always conducting a sexual history and 23.4% reported never or seldom doing so. The biggest barrier to sexual history taking was lack of time. Other barriers included interruptions, limited communication skills, embarrassment, and feeling that taking such a history in older patients was inappropriate. A study of general practitioners in Great Britain revealed that many of them did not discuss sexual health matters with older patients because they thought that these matters were of “legitimate” interest only to younger patients.From the perspective of midlife or older patients, many of them do not discuss sexual problems with their HCP because they do not feel their problems are serious or sufficiently bothersome.5 Many older patients, already assumed to be invisible and post-sexual by society, may be even less likely than their younger counterparts to approach their HCPs with sexual problems and concerns—even though research suggests that these patients often hope that their HCPs will approach them in this regard.6

Sexual dysfunction in older patients

In 1998, sildenafil (Viagra®) hit the market, initiating a sexual revolution. Advertisements for this product— and for two similar prescription products approved in subsequent years—targeted over-50 males, leaving similarly aged women “in the dust.” Desire, arousal, and orgasmic dysfunctions in the older female population remained without an FDA-approved treatment option. Although history was made in August 2015 when the FDA approved the firstever medication for hypoactive sexual desire disorder, this medication is indicated only for premenopausal women. With the exception of two medications used to treat dyspareunia related to menopausal changes, conjugated estrogens cream (Premarin® Vaginal Cream) and ospemifene oral tablets (Osphena®), sexual complaints in older women must be addressed with off-label options.7

Sexual interest/arousal disorders

A telephone survey of 1,491 U.S. adults aged 40-80 years showed that a lack of sexual interest (33.2%) and lubrication difficulties (21.5%) were the most common female sexual problems and early ejaculation (26.2%) and erectile difficulties (22.5%) were the most common male sexual problems.5 Fewer than 25% of these adults with a sexual problem had sought help for their problem from an HCP. A study of 3,005 female and male interviewees aged 57-85 years showed that as women got older, a larger proportion became unable to achieve orgasm.8 Table 2 shows the prevalence of sexual problems in the preceding year among sexually active female participants in this study.8

Genito-pelvic pain/penetration disorder

According to the aforementioned telephone survey, 12.7% of women aged 40-80 years reported pain with sex.5 Causes of dyspareunia in older women can include vulvovaginal atrophy (VVA), disuse atrophy, pelvic floor dysfunction, vaginal anatomic changes related to surgery such as vaginal hysterectomy, and vulvovaginal skin conditions and infections.7 

Menopause is accompanied by a significant drop in circulating estrogen levels, which adversely affects the maturation of vaginal epithelial cells, resulting in VVA.9 Subsequently, a shift in the vaginal ecosystem occurs, allowing overgrowth of pathogenic organisms.10 Nearly half of all postmenopausal women experience VVA symptoms, including burning with urination, dyspareunia, bleeding with intercourse, vaginal discharge, and vulvovaginal soreness, itching, and burning—all of which warrant regular screening in this population.9-13 Genital pain often results in avoidance of sexual encounters and/or involuntary tensing of pelvic floor muscles in response to anticipated pain. As a result, disuse atrophy and high-tone pelvic floor dysfunction are commonly seen in postmenopausal women.7

Sexually transmitted infections

Most sexually active individuals contract a sexually transmitted infection (STI) at some point in their lives.14 Midlife and older individuals who are engaging in sex are not immune. However, HCPs may be less likely to inquire about or test for STIs in older individuals, who may also be hesitant to discuss STI symptoms with their HCP. The most common risky behaviors in persons aged 50 or older include sexual contact with MSM (men who have sex with men), intravenous drug use, and receipt of blood products,although all sexually active individuals are at risk for STIs. Undiagnosed and untreated STIs can have longterm sequelae such as chronic pain, cancer, heart damage, blindness, and, in severe cases, death.

A British study showed that, over a 7-year period, the number of STI cases more than doubled in persons aged 45 years or older.15 Rates of chlamydia, genital herpes, genital warts, gonorrhea, and syphilis all increased. Genital warts and genital herpes were identified as the most common STIs, and persons aged 55-59 years were the most likely to be affected. In the U.S., trichomoniasis is most prevalent in women older than 40 years, whereas chlamydia and gonorrhea have the lowest prevalence in this age category.16

Conclusion

Statistics show that most people of any age are, or want to be, sexually active. HCPs should never assume that a given person, based on her or his age, appearance, or presence of a disability, does not engage in sexual activity or does not wish to do so. Regardless of a person’s age, HCPs should take a sexual history during healthcare encounters, and they should offer counseling, treatment, or referrals in appropriate cases of sexual dysfunction or disease.

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 serves as a speaker and advisory board member for Shionogi and Actavis and as an advisory board member for Valeant.

References

1. Fisher LL. Sex, Romance, and Relationships: AARP Survey of Midlife and Older Adults. April 2010.

2. Shindel AW, Parish SJ. Sexuality education in North American medical schools: current status and future directions. J Sex Med. 2013;10(1):3-17.

3. Maes CA, Louis M. Nurse practitioners’ sexual history-taking practices with adults 50 and older. J Nurse Pract. 2011;7(3):216-222.

4. Gott M, Hinchliff S, Galena E. General practitioner attitudes to discussing sexual health issues with older people. Soc Sci Med. 2004;58(11):2093-2103.

5. Laumann EO, Glasser DB, Neves RC, Moreira ED Jr; GSSAB Investigators’ Group. A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res. 2009;21(3):171-178.

6. Kleinplatz PJ. Sexuality and older people. BMJ. 2008;337:a239.

7. Moore A, Arthur R, Hull A, Faught B, Glass C. Sexual health issues in the aging population. In: Cash JC, Glass CA, eds. Adult-Gerontology Practice Guidelines. New York, NY: Springer Publishing Co.; 2016:516-535.

8. Laumann EO, Waite LJ. Sexual dysfunction among older adults: prevalence and risk factors from a nationally representative U.S. probability sample of men and women 57-85 years of age. J Sex Med. 2008;5(10):2300-2311.

9. Sturdee DW, Panay N; International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13(6):509-522.

10. Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15(1):36-44.

11. Tan O, Bradshaw K, Carr BR. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012;19(1):109-117.

12. The North American Menopause Society. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause. 2012;19(3):257-271.

13. Kingsberg SA, Krychman ML. Resistance and barriers to local estrogen therapy in women with atrophic vaginitis. J Sex Med. 2013;10(6):1567-1574.

14. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence estimates, 2008. Sex Transm Dis. 2013;40(3):187-193.

15. Bodley-Tickell, AT, Olowokure B, Bhaduri S, et al. Trends in sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Sex Transm Infect. 2008;84(4):312-317.

16. Ginocchio CC, Chapin K, Smith JS, et al. Prevalence of Trichomonas vaginalis and coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in the United States as determined by the Aptima Trichomonas vaginalis Nucleic Acid Amplification Assay. J Clin Microbiol. 2012;50(8):2601-2608.

Early pregnancy loss management for nurse practitioners and midwives

Early pregnancy loss (EPL), or miscarriage, is a common phenomenon in pregnancy; up to 30% of pregnancies result in miscarriage in women who have identified themselves as being pregnant.Various treatment modalities can be used to assist women who have experienced EPL, including expectant management, pharmacologic treatment, and vacuum aspiration. Patients should be assessed for their preferences for management of EPL based on their priorities for care. The role of the nurse practitioner or midwife in counseling women who have experienced EPL is to help them manage symptoms, resolve the passage of tissue, and cope with the emotional experience of losing a pregnancy.

Early pregnancy loss (EPL), or miscarriage—the spontaneous loss of a pregnancy before 13 weeks’ gestation1—is a devastating problem for women who lose a highly desired pregnancy. In addition to the emotional turmoil caused by the interruption of a wanted pregnancy, these women are faced with managing the physical reality of resolving a nonviable gestation. Nurse practitioners (NPs) and midwives are frequently the first providers to encounter women who have bleeding early in an already-diagnosed pregnancy. In addition to providing much needed emotional support and compassion, providers can help women and their families move through the steps of completing the process of EPL.

Most bleeding in pregnancy is the result of a disruption in the complex processes associated with implantation, including the formation of the decidua and the actual burrowing of the blastocyst into the uterine lining.2 Bleeding in the first trimester occurs in up to 40% of pregnancies; more than half of these pregnancies progress normally, with preterm delivery and low birth weight as possible outcomes.Although cervical polyps or friability, vaginal laceration, irritation, or neoplasm may also lead to bleeding in early pregnancy, the possibility of pregnancy loss or ectopic pregnancy must always be considered.3

Causes of early pregnancy loss

The three main causes of problematic bleeding leading to EPL are spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease (GTD).Ultrasound guidance and serum hCG assessment can assist in the diagnosis of ectopic pregnancy and GTD and in the assessment of pregnancy viability.3 Once ectopic pregnancy and GTD have been ruled out, the problematic bleeding can be classified as a threatened abortion, an incomplete abortion, or a complete abortion. A threatened abortion occurs when vaginal bleeding occurs in the absence of cervical dilatation; 30%-50% of women with these symptoms go on to have a complete abortion.3 An incomplete abortion is diagnosed when some fetal or embryonic tissue remains in the uterus. A complete abortion reflects the passage of all pregnancy tissue.

Management of early pregnancy loss

The focus of EPL management is on meeting the needs of each individual woman. After establishing that the patient is clinically stable, the provider should offer appropriate emotional support; regardless of whether or not the pregnancy was planned, the woman is experiencing the loss of the pregnancy and maybe a change in her sense of self. The provider should establish the meaning of the pregnancy for the woman, and recognize that her management options for resolving the EPL should be guided by her medical needs and by her self-identified needs and preferences.

One way to assess the needs and preferences of a woman experiencing an EPL is to ask her these questions: What are your priorities related to the timing and cost of the process? What is your previous experience with miscarriage and/or abortion? How do you feel about taking medications or undergoing a procedure, either in the office or the hospital? How do you assess your own ability to manage the pain and bleeding that you will experience?4 Her responses to these questions can guide the provider in helping her choose how to resolve the EPL.

Early pregnancy loss can be resolved in one of three ways: expectant management (watchful waiting); medication management to complete the process of uterine evacuation; or an aspiration procedure to empty the uterus, either in an inpatient or outpatient setting.Each approach has benefits and minimal risks. These approaches vary slightly in terms of efficacy, depending on how much tissue remains inside the uterus. All of these approaches are considered acceptable and should be offered to women experiencing EPL. However, if a woman presents with heavy bleeding or is medically unstable, the situation requires immediate resolution; her preference for expectant management or medication management cannot be honored because neither is a safe option.

Expectant management

In 85% of cases, EPL resolves with expectant management within 2 weeks of the first signs and symptoms (S/S) of miscarriage. Within an additional 2 weeks, 10% of the remaining cases resolve. Aspiration intervention is recommended for the resolution of pregnancies that continue after 4 weeks of bleeding.A woman who chooses expectant management must be counseled about the possibility of a prolonged period of waiting for resolution, as well as what to expect when she finally passes the pregnancy tissue. She may experience a short period of intense cramping and bleeding, followed by mild bleeding and/or spotting for up to 2 weeks. During this period of time, she needs to monitor her temperature and report any S/S that would indicate infection, such as a malodorous discharge or flu-like S/S. The provider should ascertain the woman’s ease of access to emergency resources if needed and encourage follow-up within 2 weeks of the passage of tissue to ensure that the pregnancy has been completely resolved.

Many women choose expectant management because it does not require any intervention, and can generally be experienced privately and without any increased cost or provider visits. However, they need to understand that they may see the pregnancy tissue and they may have considerable pain and bleeding with this option. In addition, they must have ready access to care if bleeding becomes excessive.

Medication management

Use of medications can enhance the speed with which the pregnancy tissue is passed. The most widely used medication for this purpose is misoprostol, a prostaglandin antagonist that has a variety of off-label obstetric and gynecologic uses in addition to its FDA-approved indication for the prevention of gastric ulcers and as part of the medication abortion regimen.Misoprostol causes cervical softening and uterine contractions that accelerate passage of the pregnancy tissue, producing the same symptoms as expectant management but within 24-48 hours of administration of the medication. Use of misoprostol to accelerate resolution of EPL is successful in about 90% of cases after two doses.7 Women should be counseled to expect the same S/S as with expectant management, but within a shorter time period. If no tissue passes, and increased bleeding does not occur, women should return for an assessment of retained products of conception. Misoprostol users should also have access to analgesics, and they should be aware of potential side effects: fever, nausea, diarrhea, and/or shaking. Over-the-counter medications can be used to treat fever and gastrointestinal side effects, and application of warm blankets can reduce shaking.

Aspiration management

An aspiration procedure may be the choice of women who prefer an expedient and closely managed process for resolution of the EPL. If ultrasound dating  shows a gestational age of less than 12 weeks 6 days, uterine evacuation can be performed in an outpatient clinic or ambulatory surgical center. In some places, aspiration procedures can be performed only in a hospital, but this approach consumes more resources and has not been shown to improve outcomes.In these circumstances, providers should counsel women about other settings in the community that offer outpatient management services and facilitate their obtaining care if they choose an outpatient procedure.

Aspiration management provides clear advantages for a woman who prefers to have a procedure that can be scheduled, has a limited impact on the amount of time before normal activities can be resumed, and during which she can receive additional pain management. Uterine evacuation with either a manual or electric vacuum procedure is highly successful but does carry minimal risks of infection, uterine perforation, cervical trauma, or damage to the endometrium.9

Resources

Various resources are available to NPs and midwives to help counsel women facing a decision about how to manage an EPL. TEAMM (Training, Education & Advocacy in Miscarriage Management), a project of the Department of Obstetrics and Gynecology at the University of Washington, provides educational materials and training for practitioners and educational materials for women about outpatient manual vacuum aspiration.10 The University of California San Francisco’s website, Innovating Education in Reproductive Health, has information about managing EPL, including a video and patient education materials for decision making following EPL.11

Conclusion

Early pregnancy loss can be a devastating experience for a woman, but the compassion and understanding of her provider can assist her in identifying the safest and most satisfying way for her to resolve her physical S/S while she is processing her emotional experience. Whether a woman chooses an inpatient or outpatient procedure, takes medication, or elects to wait for the natural course of miscarriage to occur, reviewing all the possibilities for resolution is an important part of the NP’s or midwife’s responsibility in caring for women who are undergoing an EPL.

Amy J. Levi is the Leah L. Albers Professor of Midwifery at the University of New Mexico in Albuquerque. Tara Cardinal is a Consultant at Training, Education and Advocacy in Miscarriage Management in Seattle, Washington. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Wang X, Chen C, Wang L, et al. Conception, early pregnancy loss, and time to clinical pregnancy: a populationbased prospective study. Fertil Steril. 2003;79(3):577-584.

2. Lykke JA, Dideriksen KL, Lidegaard O, Langhoff-Roos J. First-trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol. 2010;115(5):935-944.

3. Isoardi K. Review article: the use of pelvic examination with the emergency department in the assessment of early pregnancy bleeding. Emerg Med Australas. 2009;21(6):440-448.

4. Wallace RR, Goodman S, Freedman LR, et al. Counseling women with early pregnancy failure: utilizing evidence, preserving preference. Patient Educ Couns. 2010;81(3):454-461.

5. Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;3:CD003518.

6. Webber K, Grivell RM. Cervical ripening before first trimester surgical evacuation for non-viable pregnancy. Cochrane Database Syst Rev. 2015;11:CD009954.

7. Hasan R, Bhal K, Joseph B. The need for repeat evacuation of retained products of conception: how common is it? Obstet Gynaecol. 2013;33(1):75-76.

8. Dalton VK, Harris L, Weisman C, et al. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006;108(1):103-109.

9. Jurkovic D, Overton C, Bender-Atik R. Diagnosis and management of first trimester miscarriage. BMJ. 2013;346:f3696.

10. TEAMM Training, Education & Advocacy in Miscarriage Management. 2016.

11. Innovating Education in Reproductive Health. Early Pregnancy Loss.

Get your child vaccinated against HPV!

Why does my child need the HPV vaccine?

The HPV vaccine protects against cancers caused by human papillomavirus (HPV). HPV is a very common virus; nearly 80 million people in the United States—about 1 in 4—are infected by it. About 14 million people, including teens, are newly infected with HPV each year. HPV can cause cancer of the cervix, vagina, or vulva in women; cancer of the penis in men; and cancer of the anus or the back of the throat in both women and men.

When should my child be vaccinated?

Your daughter or son should get the HPV vaccine at age 11 or 12. The vaccine is given in three shots. The second shot is given 1 or 2 months after the first shot. The third shot is given 6 months after the first shot.

Why is the HPV vaccine recommended at such a young age?

For the vaccine to be effective, it should be given before a person is exposed to HPV. Exposure to this virus occurs with sexual activity with another person. Most people first engage in sex in their teenage or young adult years. Therefore, it is best to start the vaccination series early—before a person has sex and could potentially be exposed to HPV. Also, the HPV vaccine produces a stronger immune response in preteens than it does in older teens and young adults.

Who else should get the HPV vaccine?

Teen girls and boys who did not start or finish the HPV vaccine series when they were younger should get it now. Young women can get the HPV vaccine through age 26, and young men can get it through age 21. Men between the ages of 21 and 26 who have sex with men and/or who have poor immune systems (including those with HIV infection) can get the HPV vaccine if they did not get it when they were younger.

Is the vaccine still effective if a young person has had sex?

Yes. Even though HPV infection usually happens soon after someone has sex for the first time, a person might not be exposed to any or all of the HPV types that are in the vaccine. Females and males in the age groups recommended for vaccination are likely to get at least some protection from the vaccine.

How well does the HPV vaccine work?

Very well! Clinical trials have shown that the vaccines provide close to 100% protection against pre-cancers and genital warts caused by HPV.

How long will the HPV vaccine provide protection?

Studies show that the vaccine offers protection against HPV infection and HPV-related disease that lasts for at least 8-10 years. The vaccine has been available for only 10 years, so more will be known as time goes on. There is no evidence to suggest that the HPV vaccine loses the ability to provide protection over time.

Will the vaccine require a booster?

In the U.S., the HPV vaccine series requires three shots given over 6 months; booster doses are not recommended. Like all vaccines, HPV vaccine is monitored continually to make sure it remains safe and effective. If protection from HPV vaccine doesn’t last as long as it should, then the CDC will review the data and determine if a booster shot should be recommended.

Does someone need to restart the HPV vaccine series if too much time passes between the shots?

No. If someone waits longer than that the recommended interval between shots, she or he need not restart the series. Even if months or years have passed since the last shot, the series should still be completed.

What are some possible side effects of HPV vaccination?

Vaccines, like any medicine, can have side effects. Many people who get the HPV vaccine have no side effects at all. Some people report having very mild side effects such as pain, redness, or swelling in the arm where the shot was given; fever; headache or fatigue; nausea; muscle or joint pain; and brief fainting spells. Sitting or lying down for 15 minutes after a vaccination can help prevent fainting and injuries caused by falls. On very rare occasions, severe allergic reactions may occur after vaccination.

Will the vaccine cause cancer?

The HPV vaccine cannot cause HPV infection or cancer. By contrast, not receiving the HPV vaccine at the recommended ages can leave a person vulnerable to cancers caused by HPV. Will the vaccine cause my daughter to have trouble getting pregnant later on? No data suggest that the HPV vaccine has an effect on a woman’s ability to get pregnant in the future. In fact, getting vaccinated and protecting against cervical cancer can help women have healthy pregnancies and healthy babies. Not getting the HPV vaccine leaves people vulnerable to HPV infection; for women, this could lead to cervical cancer. Treatment of cervical cancer could leave a woman unable to have children. Even the treatment of cervical pre-cancers caused by HPV can cause preterm labor or problems at the time of delivery.

Readers are invited to photocopy Patient Education pages in the journal and distribute them to their patients.

Resources

Centers for Disease Control and Prevention. HPV Vaccines: Vaccinating your Preteen or Teen. Page last updated January 26, 2015.

Centers for Disease Control and Prevention.Fact Sheet for Parents Questions and Answers. Page last updated December 28, 2015.

Using simulation to practice and perfect gynecologic procedure skills

Minimally invasive office gynecology procedures such as endocervical polypectomy and endometrial biopsy are routinely performed by women’s health nurse practitioners (WHNPs). To ensure patient safety and comfort and to avoid complications, the WHNP must have knowledge of indications and contraindications, as well as skills needed to perform each of these procedurecompetently and efficiently. WHNP programs provide didactic and clinical instruction for these skills, often in a supervised clinical simulation format. However, the fast-paced clinical setting does not necessarily provide novice WHNPs or WHNP students with an environment conducive to feeling confident when they first perform these office gynecology procedures on their own.1

Simulation learning is a valuable strategy for acquiring skill and confidence in performing clinical procedures. The Institute of Medicine report, To Err is Human: Building a Safer Health System, recommends simulation learning as a means to help prevent errors in the clinical setting.2 Simulation learning provides a controlled, risk-free environment for learners that allows time for adequate practice to acquire skills and confidence.

The purpose of this article is to provide examples of simulation modules that can be used to review and practice the required steps previously learned to promote confidence prior to performing endocervical polypectomy or endometrial biopsy on a patient. The materials used in these simulation modules are readily available outside the clinical learning lab. Novice WHNPs who have not yet performed endocervical polypectomy or endometrial biopsy in clinical practice, WHNPstudents, and even instructors and preceptors for WHNP students, may find these simulation modules helpful. The photographs in this article are screen shots from the simulation modules.

Endocervical polypectomy

Case study presentation

A G4 P2204, 29-year-old female presents to the clinic with this complaint: “I’ve been spotting after sex for the past 2 months.” She denies vaginal discharge or odor. Her last menstrual period occurred 1 week ago and was described as heavy without visible clots. She is married and sexually active with one partner. The vaginal ring is used for contraception. The WHNP performs a speculum examination, which shows a thin, 2-cm-long, red, pedunculated growth protruding from the cervical os. Given the patient’s presenting complaint and physical exam findings, the WHNP thinks that a pathology report will confirm a diagnosis of endocervical polyp.

Indications for procedure

The purpose of an endocervical polypectomy is to remove the pedunculated growth from the cervix and rule out malignancy of the tissue. Although fewer than 5% of all endocervical polyps are malignant, all of them should undergo biopsy.3 Removal is indicated to stop intermittent spotting and bleeding symptoms related to the polyp.4

Diagnosis

The diagnosis in this case is endocervical polyp. The ICD-10 code for endocervical polyp is N84.1. The current procedural terminology (CPT) code for an endocervical polypectomy is 58999.

Procedure directions

Prior to the procedure, the WHNP reviews risks and benefits with the patient and obtains her signature on the consent form. The WHNP confirms any allergies with the patient, especially those related to solutions that may be used to cleanse the cervix. A urine pregnancy test is obtained if the patient is sexually active and premenopausal. Endocervical polypectomy is contraindicated during pregnancy because increased blood flow to the cervix may result in substantial bleeding. The WHNP assists the patient in reclining in the dorsal lithotomy position on the exam table, with both feet placed in the stirrups, provides appropriate draping, and confirms her comfort.

After washing the hands and applying clean gloves, the WHNP inserts an appropriate-size speculum into the vagina and visualizes the cervix with the polyp protruding from the endocervical canal (Photograph 1). A benign endocervical polyp is thin, red, and smooth in appearance.5 Caution to proceed is exercised if the endocervical mass appears thick. Cervical cancer, an endometrial polyp, and uterine fibroids may resemble an endocervical polyp.5

The WHNP cleans the cervix with povidone iodine or other appropriate antiseptic solution. The WHNP then inserts a small sterile cotton swab just inside the endocervical canal and moves it in a clockwise direction completely around the inside of the canal to confirm the location of the polyp base. If the WHNP cannot locate the polyp base or freely move the swab in the cervical canal, the procedure is halted and the patient is referred to a gynecologist for further evaluation of the endocervix and endometrial cavity with a hysteroscope.

Otherwise, the next step is to securely close a ring forceps around the endocervical polyp as close to the base as possible and twist the polyp in a clockwise direction, applying gentle tension. The WHNP continues twisting the polyp until the base is no longer attached to the cervix. The specimen is then placed in a container of liquid formalin (Photograph 2). If bleeding is observed at the site, the WHNP applies pressure using a large cotton swab. If necessary, a silver nitrate stick or Monsel’s solution can be applied to manage bleeding. The speculum is then gently removed, and the patient is slowly assisted into an upright sitting position, with her stability assessed.

The WHNP confirms that the patient’s identification information is on the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form always includes the patient’s name, second patient identifier, date and time of collection, specimen source, diagnosis, and practitioner’s name.

Post-procedure patient education

The WHNP informs the patient that vaginal spotting/bleeding is not uncommon a few hours after the procedure. A peri-pad is offered to the patient, who is advised to avoid placing anything into the vagina for a few days post-procedure. The patient is asked to notify the WHNP if any of these situations occur: pelvic pain not relieved with a non-steroidal anti-inflammatory drug (NSAID), malodorous vaginal discharge, continuous bright red vaginal bleeding, or fever.6

Description of the simulation 

Supplies (Table 1) may be purchased from a medical supplier, a craft store, a grocery store, or an online store. Most supplies are disposable, but some are reusable. Simulation learning is a cost-effective way to practice procedures. This endocervical polypectomy

simulation can be performed at a cost of about $6.

Step-by-step simulation assembly and video link

Cut off a 5-cm piece of red chenille pipe cleaner. Insert the pipe cleaner into the center of a hot dog, leaving approximately 2-3 cm of it on the outside of the hot dog. Readers can access a video link for the endocervical polypectomy simulation.  This video is the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Endometrial biopsy

Case study presentation

A 55-year-old menopausal patient presents to the clinic with this complaint: “My period has come back on. I’ve been spotting and bleeding from my vagina intermittently for the past 3 months.” The woman’s last menstrual period took place when she was 52 years old. The patient, a widow, has not had sexual intercourse in the past 2 years.

Indications for procedure

The purpose of an endometrial biopsy is to rule out endometrial cancer. Based on the American Congress of Obstetricians and Gynecologists’ Committee Opinion Number 557, an endometrial biopsy should be performed for  women older than 45 years as a first-line screen for abnormal uterine bleeding (AUB).7 Another indication for an endometrial biopsy is exposure to unopposed estrogen in a woman younger than 45 who experiences persistent AUB after failed medical management.7

Diagnosis

The diagnosis in this case is postmenopausal bleeding. The ICD-10 code for postmenopausal bleeding is N95.0. The CPT code for an endometrial biopsy without cervical dilation is 58100.

Procedure directions

Prior to the procedure, the WHNP reviews risks and benefits with the patient and obtains her signature on the consent form. The WHNP confirms any allergies with the patient, especially those related to solutions that may be used to cleanse the cervix. A urine pregnancy test is obtained if the patient is sexually active and premenopausal. Endometrial biopsy is contraindicated during pregnancy. The WHNP assists the patient in reclining in the dorsal lithotomy position on the exam table, with both feet placed in the stirrups, provides appropriate draping, and confirms her comfort.

After washing the hands and applying clean gloves, the WHNP performs a bimanual exam to determine the position of the uterus and cervix and the presence of any tenderness or masses in the pelvis. The WHNP inserts an appropriate-size speculum into the vagina to visualize the cervix, which is then cleaned with povidone iodine or other appropriate antiseptic solution (Photograph 3). After confirming patency of the cervical os and measuring the depth of the uterus with a uterine sound (i.e., sounding the uterus), the WHNP obtains a sterile endometrial pipelle and inserts it into the cervix and uterus.

Difficulty inserting the pipelle may be due to a natural curvature in the cervix or uterus. Depending on this curvature, the WHNP may need to use a sterile method to slightly bend the tip of the pipelle in order for it to slide completely into the uterine cavity. The WHNP may need to apply an instrument, such as a tenaculum, a ring forceps, or a long hemostat to the cervix to help straighten the natural curvature of the cervix and uterus, ensuring that the patient is prepared for the use of an additional instrument (Photograph 4).

Once the pipelle is inserted to the top of the uterine fundus, the WHNP pulls back rapidly on the piston as far as it will go to create suction. The WHNP passes the pipelle in and out between the fundus and internal cervical os 3 or 4 times while continuously turning it a full 360°, rolling it between the thumb and index finger. Endometrial tissue will begin to collect inside the pipelle. Once an acceptable amount of tissue is visualized, the pipelle is removed from the uterus. The WHNP carefully expels the tissue from the pipelle by pushing the piston forward into a plastic container of formalin, and confirms that a sufficient amount of tissue has been collected (Photograph 5). The vaginal speculum is then gently removed. The patient is slowly assisted to an upright sitting position and her stability is assessed.

The WHNP confirms that the patient’s identification information is on the container and that a pathology requisition form is included in the biohazard bag that accompanies the biopsy specimen to the laboratory. The requisition form always includes the patient’s name, second patient identifier, date and time of collection, specimen source, diagnosis, and practitioner’s name.

Post-procedure patient education

The WHNP informs the patient about the most common symptoms experienced with an endometrial biopsy, which include pelvic pain, vaginal bleeding, and fainting.8 The patient is advised to notify the WHNP if she experiences

uterine cramping lasting longer than 48 hours or not resolved with an NSAID, malodorous vaginal discharge, heavy vaginal bleeding, or fever.6

Description of the simulation 

Supplies (Table 2) may be purchased from a medical supplier, a craft store, a grocery store, or an online store. Most supplies are disposable, but some are reusable. Simulation learning is a cost effective way to practice procedures. This simulation endometrial biopsy can be performed at a cost of about $5. Readers can access a video link of the endometrial biopsy simulation. This video is the intellectual property of the University of Alabama at Birmingham and cannot be shared without request of a license (to do so, please contact the author at aimeeholland@uab.edu). However, NPWH members are encouraged to share the article itself, which contains links to the videos, with their colleagues.

Conclusion

Women’s health nurse practitioners are important performers of minimally invasive gynecology procedures such as endocervical poly pectomy and endometrial biopsy. However, the fast-paced clinical setting may not provide the novice WHNP or WHNP student with an environment conducive to mastering newly learned skills. Simulation learning has educational and clinical benefits to enhance practice.9 In a controlled, simulated environment, individuals can focus on achieving competency, efficiency, and confidence when performing these procedures.9, 10

Aimee Chism Holland is Assistant Professor at the University of Alabama at Birmingham School of Nursing. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.  The author heartily thanks Mr. James Clark, Instructional Design Specialist at the UAB School of Nursing, for recording these procedures for her.

References

1. Nakajima AK, Posner GD. Human Simulation for Women’s Health. New York, NY: Springer Publishing Company; 2012.

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in American, Institute of Medicine; 2000.

3. Beckmann C, Ling F, Herbert W, et al. Obstetrics and Gynecology. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.

4. Stewart EA. Endometrial polypsUpToDate. October 21, 2013.

5. Hoffman BH, Schorge J, Schaffer J, et al. Williams Gynecology. 2nd ed. New York, NY: McGraw Hill; 2012.

6. Sulik S, Heath C. Primary Care Procedures In Women’s Health. New York, NY: Springer Publishing Company; 2010.

7. American Congress of Obstetricians and Gynecologists. ACOG committee opinion no. 557. Management of acute abnormal uterine bleeding in non-pregnant reproductive aged women. Obstet Gynecol. 2013;121(4): 891-896.

8. Blumenthal PD, Berek JS. A Practical Guide to Office Gynecologic Procedures. Philadelphia, PA: Lippincott, Williams & Wilkins; 2013.

9. Cooper S, Cant R, Porter J, et al. Simulation based learning in midwifery education: a systematic review. Women Birth. 2012;25(2):64-78.

10. Nitschmann C, Bartz D, Johnson NR. Gynecologic simulation training increases medical student confidence and interest in women’s health. Teach Learn Med. 2014;26(2):160-163.

Reaching postpartum women in the U.S.: Demographics and generational characteristics

The postpartum period, defined traditionally as the first 6-8 weeks after birth, is a time of rapid change for new mothers and their families. Mothers are not only recovering physically but also making psychosocial adjustments related to their family role and relationships. In addition, mothers are adding or refining skills and responsibilities such as breastfeeding and infant care. This process of becoming a mother starts with the initial transformation and continues with the growth and change of maternal identity.1

Although the postpartum period can be fraught with changes foreseen and unforeseen, most women in the United States who have given birth receive only minimal care during the critical early months after delivery.2 Unfortunately, postpartum care has not evolved along with the changing demographic and generational characteristics in this country over the past few decades, so many women’s needs are not being met. Healthcare providers (HCPs) have an opportunity to optimize the care they deliver to postpartum mothers of today.

Routine postpartum care

In the U.S., routine postpartum care consists of 2-4 days in the hospital, depending on the type of delivery, vaginal or cesarean.3 Follow-up consists of one visit to the maternity care provider, typically at 6 weeks. The focus of this office visit is on uterine involution, contraception, and management of complications. By contrast, in most northern and western European countries, HCPs make home visits to their patients after childbirth.4 According to Cawthorne and Arons,5 postpartum home visits by trained professionals/paraprofessionals can provide valuable information and practical support that family and friends may not be able to provide.

Scope of the problem

Although home visit support services are available in the U.S., many new mothers are unfamiliar with these services or they cannot afford these services. In addition, families of today are more fragmented and geographically dispersed than in previous generations, making the advice and support of grandparents or other elders less available. High-risk U.S. populations such as teenagers and certain low-income women may qualify to receive home visiting services without charge. Although these services have been shown to be helpful,6 most qualified families do not receive them. For the most part, then, after parents take their babies home from the hospital, they are left to handle their new responsibilities alone.4

The nature and extent of postpartum healthcare in the U.S. may be too limited to meet the needs of most women.7, 8 The first postpartum year is a period of vulnerability during which HCPs should be focusing on weight management,prevention of postpartum depression, breastfeeding support, promotion of healthy relationships, and postpartum morbidities such as fatigue.9 In addition, women would benefit from acquiring life skills known to support postpartum health, including mobilization of social support, development of positive coping skills, enhancement of self-efficacy, and having realistic expectations.10 A recent systematic review of postpartum interventions suggested that further research is needed to design interventions focused on health promotion, not just on treatment of adverse health conditions.11

Postpartum maternal healthcare is a neglected aspect of women’s healthcare.12 Much of the knowledge about new mothers’ role transition was developed in the 1960s to 1980s.13-16 But times have changed. The old rules no longer apply. HCPs need to remain up to date in terms of the trends and concerns that affect today’s women and provide postpartum care that is culturally competent— that is, care that is based on the demographic and generational characteristics of the population being served. In particular, the U.S. Department of Health and Human Services calls for HCPs to provide care that takes into account patients’ cultural health beliefs and practices, preferred language, health literacy, and other communication needs.17

Demographic trends

The sociocultural climate in the U.S. has changed for women giving birth in the early 21st century. Mothers of today are decidedly different from those of past generations.

First-time mothers are older.

According to the National Center for Health Statistics, the number, percentage, and rate of first births to older women have increased over the past four decades.18 In 2012, as compared with four decades ago, there were more than 9 times as many first births to women aged 35 years or older. First-birth rates of women older than 35 years have increased from 2000 to 2012 even as total births in the U.S. have declined.18

By contrast, first-birth rates for women younger than 30 years, and especially those younger than 20, have declined in the past decade.18 In 2013, there were 26.5  births for every 1,000 females aged 15-19, or 273,105 babies born to females in this age group.19 The 2013 teen birth rate was 10% lower than that in 2012 (29.4 births/1.000 females) and less than half the rate in 1991 (61.8 births/1,000 females).

In the 1960s and 1970s, new mothers were typically younger and married when they started their families. Families had more children, and many mothers stayed home to raise their children. According to a recent Pew Research Report on Social and Demographic Trends,20 in 2012, only 20% of mothers were married to a working husband and stayed home to care for their children; in 1967, 67% of mothers met these criteria. The workforce participation rate for mothers with children younger than 1 year old was 57.3% in 2013.4

Mothers are better educated and have more money. Older mothers of today, relative to their younger counterparts, are better educated and more likely to have greater resources, including higher incomes.6 As a result of new mothers having been in the workforce for some time, many of them have the means to choose the circumstances under which they want to raise a family.21 At the same time, although many older mothers could benefit from postpartum home visiting services and could afford these services, it is still not common practice to pay for them out of pocket because they are quite expensive.

Family composition has diversified.

Nowadays, it is relatively more common to see households headed by two women, two men,  an unmarried woman and man, single adults, or multiple generations.22 A recent report based on the 2006-2010 National Survey of Family Growth showed that 23% of recent births among women aged 15-44 occurred among cohabiting couples, whereas 60% of the women were married.Other newer phenomena include increases in blended families (from previously divorced couples with children who remarry or cohabit) and interracial families.9 Between 2000 and 2010, the number of unmarried-partner households increased 41%. Over this time period, opposite-sex unmarried partner households grew from 4.9 million to 6.8 million and samesex unmarried partner households grew from 358,000 to 646,000 (or from 0.3% to 0.6% of house holds).9 These trends have profoundly changed the U.S. family and, following the trends of other Western countries, are unlikely to reverse in the near future.23

Generational characteristics

Although generalizations about various age cohorts can be hotly debated, one point is undeniable: Age cohorts are affected by external events, and each generation has a unique “persona” by virtue of the fact that members occupy the same time period as they age.24 Contemporary new mothers come from Generation X (Gen X; persons born in the mid-1960s to the early 1980s) or Generation Y (Gen Y; persons born in the early 1980s to 2000); members of Gen Y are often dubbed the Millennials.

Members of Gen X have been described as family oriented, secondarily career oriented, and relatively independent. This generation is the first to grow up as latch-key children; as a consequence, many Gen-Xers did not spend a lot of time with their parents. They entertained themselves during their youth and, as adults, place high regard on entertainment and fun. They also value knowledge and expect regular feedback.25

Members of Gen Y tend to be more team oriented; they work well in groups rather than on their own. They are technologically savvy, willing to work hard, and wonder “What’s in it for me?” Gen-Yers seek balance between work and family and believe that one can successfully have it all. They multitask and respect learning. Compared with earlier generations, Gen-Yers experience a high degree of job and life satisfaction. They are constantly questioning, need immediate feedback, and believe that money buys happiness. Of interest, according to a Pew Research Center analysis of attitudinal surveys, the Millennials value parenthood far more than marriage.26

These two generations of childbearing women have had access to the Internet for much of their lives. Through the Internet, they have been able to obtain a vast quantity of information about childbearing, although it is not known whether most of them fully understand and can put into perspective what they read.27 In addition, the Internet provides opportunities for social networking and connecting with like-minded individuals. Gen X and Gen Y mothers may seek support from online groups and individuals whom they have never met in person. These two generations of women have had instant communication for much of their lives and have come to expect this type of communication from their HCPs. Email, texting, online social networking, and the many forms of social media are all modes of communication for contemporary mothers.

Healthcare has been slower to adopt the use of social media. Despite the risks, social media can bring major benefits, particularly for patient and community outreach and communication.28 In an article examining Millennial healthcare values, Rupp29 stated that Millennials are more likely than members of previous generations to participate in mobile health applications, finding these tools convenient, motivating, and empowering.

Clinical implications

Most contemporary new mothers expect to be informed and supported through digital means. The recent Listening to Mothers III survey showed that 67% of the respondents used subscription email services and 27% received short text messages to obtain pregnancy and childbirth information.30 Short online videos are also useful; when this content is culturally appropriate, it can help women develop self-efficacy as new parents.10 The greater the resemblance of the video viewers to the women in the videos, the more they will be able to sense that they, too, can achieve the skills being demonstrated.10 The Box lists websites where HCPs and patients can find culturally appropriate videos regarding pregnancy, childbirth, and motherhood.

Text4Baby is an innovative use of interactive mobile technology that provides evidence-based information for new mothers.31 This free service connects new mothers with health information on topics such as breastfeeding and infant development. Interactive features such as mobile pages, videos, appointment reminders, quizzes, and modules on specific health problems and resources have been integrated into the service.

Maternity leave is an optimal time for HCPs to provide new mothers with opportunities to learn postpartum self-care and to connect them with other new mothers in their area (if possible and if of interest). During this time, practices could offer individual and group support programs on topics such as postpartum fatigue, emotions and depression, breastfeeding continuation, mobilization of social support, expansion of social networks to include other new mothers, relationship building, community resources, and newborn and infant continuing care.

The concept of CenteringPregnancy is gaining momentum as a model to deliver pregnancy and postpartum care.32 The principle of sharing used in CenteringPregnancy helps normalize the experience, and can be applied to postpartum and infant care. The axiom that “wisdom and experience are valuable only when shared by others” is particularly true for new mothers, who are eager to learn how to integrate all the new information, experiences, doubts, tensions, and challenges into their new self-concept as mother.

As the composition of families has diversified, so, too, have the challenges of adjusting to having a newborn. New mothers in blended families tend to experience an even greater challenge in integrating their newborn into a pre-existing family environment.33 These new mothers benefit from connecting with other mothers who have similar family compositions. Social networks and social support systems can also have a beneficial effect on postpartum women’s mental health and adjustment.34, 35

Older first-time new mothers, versus their younger counterparts, demonstrate greater intensity and preparedness.36 These mothers are usually well educated and highly organized, and have a planned approach to pregnancy and new parenting. In addition, they can be quite demanding of their HCPs, and have many questions and concerns. Older first-time mothers may experience more fatigue and be less physically active than their younger counterparts. They may be at higher risk for chronic diseases such as obesity, diabetes, and hypertension.37 In the long run, HCPs benefit by spending more time with these mothers during office visits. Offering reassurance about their mothering abilities can build maternal confidence.36 Educational group sessions for older new mothers can help them feel accepted, connected, and nurtured.

Improving postpartum healthcare in the U.S. will require more funding, more research, and more dissemination of effective approaches. From the administrative side, allocation of practitioner time to group postpartum services would be money well spent. In the professional literature and at conferences, more sharing and dissemination of postpartum exemplars is needed. To move postpartum care forward, there must be more demonstrated evidence of successful and unsuccessful approaches. Without systematic reviews and meta-analyses, the pinnacles of evidence-based practice, the chances of reaching these higher levels of evidence diminish. In a sense, postpartum care in the U.S. is still in its infancy as far as improving outcomes is concerned. With increased documentation of successful outcomes with various approaches, as well as increased funding, more plentiful and effective services can be offered to postpartum women.

Conclusion

To provide optimal care for postpartum women today, HCPs need to be well informed about demographic and generational trends and apply this knowledge to their practices. Healthcare services need to be continuously updated—for example, by providing postpartum care that is tailored to individual women’s needs and not based on a set schedule, and by using digital means to communicate with patients. These recommendations are particularly important in the U.S., where postpartum services are still minimal but greatly needed.

Suzanne F. Foley, formerly an Assistant Professor of Nursing at Widener University in Chester, Pennsylvania, works as a women’s health consultant in the Philadelphia area. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Mercer RT. Becoming a mother versus maternal role attainment. J Nurs Schol. 2004;36(3):226-232.

2. Centers for Disease Control and Prevention. PRAMS Publications: Postpartum Care Visits. December 21, 2007.

3. Matthews TJ, Hamilton BE. First Births to Older Women Continue to Rise. Hyattsville, MD: National Center for Health Statistics; May 2014.

4. Bureau of Labor Statistics. Washington, DC: United States Department of Labor; 2014.

5. Cawthorne A, Arons J. There’s No Place Like Home. Center for American Progress; 2010.

6. Martinez GM, Daniels K, Chandra A. Fertility of Men and Women Aged 15–44 Years in the United States: National Survey of Family Growth, 2006–2010. Hyattsville, MD: United States Department of Health and Human Services. National Center for Health Statistics; 2012.

7. Albers LL. Health problems after childbirth. J Midwifery Womens Health. 2000;45:55-57.

8. Declercq ER, Sakala C, Corry MP, et al. Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York, NY: Maternity Center Association; October 2002.

9. United States Census Bureau. 2010 Census Shows Interracial and Interethnic Married Couples Grew by 28 Percent over Decade. Washington, DC; 2012.

10. Fahey J, Shenassa E. Understanding and meeting the needs of women in the postpartum period: the perinatal maternal health promotion model. J Midwifery Women’s Health. 2013;58(6):613-621.

11. Cardemil EV, Moreno O, Sanchez M. One size does not fit all: cultural considerations in evidence-based practice for depression. In: Beevers C, Springer D, Rubin A, eds. Treatment of Depression in Adolescents and Adults: Clinician’s Guide to Evidence-Based Practice. Hoboken, NJ: John Wiley and Sons; 2011:221-243.

12. Cheng C-Y, Fowles E, Walker LO. Postpartum maternal health care in the United States: a critical review. J Perin Educ. 2006;15(3):34-42.

13. Rubin R. Attainment of maternal role. Part 1: Processes. Nurs Res. 1967;16:237-245.

14. Rubin R. Attainment of the maternal role. Part ll: Models and referents. Nurs Res. 1967;16:324-346.

15. Mercer RT. A theoretical framework for studying factors that impact on the maternal role. Nurs Res. 1981;30:73-77.

16. Mercer RT. The process of maternal role attainment over the first year. Nurs Res. 1985;34:198-203.

17. Culturally Competent Nursing Care: A Cornerstone of Caring. 2012.

18. Mathews TJ, Hamilton BE. First Births to Older Women Continue to Rise. Hyattsville, MD: National Center for Health Statistics; 2014.

19. Hamilton BE, Martin JA, Osterman MJK, et al. Births: Final Data for 2013. Hyattsville, MD: National Center for Health Statistics; 2015.

20. Cohn DV, Livingston G, Wang W. After Decades of Decline, a Rise in Stay-at-Home Mothers. Washington, DC: Pew Research Center’s Social & Demographic Trends; April 2014.

21. Newitz A. Three ways that women are about to change the world. io9.com. 2010.

22. Vespa J, Lewis JM, Kreider RM. America’s Families and Living Arrangements: 2012 Current Population Reports. Washington, DC: U.S. Census Bureau; 2013.

23. Klein HS. The changing American family. Hoover Digest. July 30, 2004.

24. Hoover E. The millennial muddle: how stereotyping students became a thriving industry and a bundle of contradictions. Chronicle Higher Educ. October 11, 2009.

25. Wallis L. Born to be different. Nurs Stand. 2009;23(33):62-63.

26. Wang W, Taylor P. For Millennials, Parenthood Trumps Marriage. Washington, DC: Pew Research Center; March 9, 2011.

27. Carolan M. Health literacy and the information needs and dilemmas of first-time mothers over 35 years. J Clin Nurs. 2007;16(6):1162-1172.

28. Institute E. Social Media in Healthcare: Executive Summary. November 2011.

29. Rupp SE. Millennials are reshaping healthcare. Multibriefs: Exclusive. January 26, 2015.

30. Declercq ER, Sakala C, Corry MP, et al. Listening to Mothers III: Pregnancy and Birth. New York, NY: Childbirth Connection; May 2013.

31. Jordan ET, Bushar J, Ingersoll S, Goodman A. Text4baby: an innovative example of utilizing interactive mobile health to provide evidence-based information.J Obstet Gynecol Neonat Nurs. 2014;43(suppl 1):S55-S56.

32. Reid J. Centering pregnancy: a model for group prenatal care. Nurs Womens Health. 2007;11(4):382-388.

33. Bernstein AC, ed. Remarriage: Redesigning Couplehood. New York, NY: Guilford Press; 2000.

34. Surkan PJ, Peterson KE, Hughes MD, Gottlieb BR. The role of social networks and support in postpartum women’s depression: a multiethnic urban sample. Matern Child Health J. 2006;10(4):375-383.

35. Haga SM, Lynne A, Slinning K, Kraft P. A qualitative study of depressive symptoms and wellbeing among first-time mothers. Scand J Caring Sci. 2012;26(3):458-466.

36. Nelson AM. A qualitative study of older first-time mothering in the first year. J Pediatr Healthcare. 2004;18(6): 284-291.

37. University of Eastern Finland. New evidence on risks of advanced maternal age. Science Daily. February 11, 2015.

Sexual enhancers: Lubricants, aids, and toys

Many sexually active women use products and devices to enhance their sexual experiences. Other women may not be aware of the wide variety of products that are available or how to acquire them, or they may not be comfortable venturing into this territory. Two experts in the field of female sexuality—Brooke M. Faught, the regular author of this column, and Susan Kellogg-Spadt, our esteemed guest co-author—describe the types of products that women can use to broaden and heighten their sexual experiences. In addition, the authors provide a list of Web resources to which healthcare providers can direct their inquisitive patients.

Women in the United States differ greatly with respect to their usual sexual practices. What some women may consider eccentric or wild, others find conventional or vanilla. In our healthcare practices, we support satisfying, consensual sexual activities that do not bring emotional or physical harm to oneself or others. When relevant, partners must be capable of providing legal consent. Keeping these basic principles in mind, we encourage our patients to explore a wide array of sexual activities. For many women, inclusion of vaginal products, supplements, and sexual aids and toys can greatly enhance their sexual experiences.

Moisturizers and lubricants

Let’s start with the difference between moisturizers and lubricants. Moisturizers are made of bioadhesive polymers and are designed to provide long-term relief of vaginal dryness. They are typically used several times per week irrespective of the timing of sexplay. Lubricants remain on top of the skin, provide temporary relief of vaginal dryness, and ease intromission during sexual activity. In other words, moisturizers are used on an ongoing, every-few-days basis, whereas lubricants are used as needed at the beginning of or during sexual acts. Because the FDA classifies moisturizers and lubricants as cosmetics, scientific data regarding their efficacy and safety are limited.

More about moisturizersVaginal moisturizers work by attaching to mucin and epithelial cells on the vaginal wall. They hold water in place on the vaginal epithelial surface until it is sloughed off after a few days. Under ideal circumstances, moisturizers do not require reapplication before sexual intercourse.1 Moisturizers such as Luvena, Replens, Rephresh, and KY Longlasting are found in the feminine care aisle at many stores and pharmacies. Another option is coconut oil, which we recommend as a natural moisturizer and which can be bought at most grocery and health food stores. Yet another option is Neogyn Vulvar Soothing Cream. This product, although technically different from a moisturizer, has been found effective in premenopausal women with vulvar pain and in postmenopausal women with genitourinary syndrome of menopause.2

More about lubricants Vaginal lubricants minimize friction and irritation around the clitoris, labia, and vaginal entrance. They are available in gel or liquid form and contain a water, oil, or silicone base. Lubricants on the market include the KY products, Astroglide, Pjur, Wet, Silk, Slippery Stuff, Pink, Replens, and Sliquid. Organic options include Good Clean Love, Aloeglide, and Yes.

Healthcare providers (HCPs) should take note if a patient presents with sudden-onset pruritus, vesiculation, and weeping lesions associated with the use of specific lubricants. These dermatologic reactions may be due to exposure to a lubricant constituent such as glycerin, benzoyl alcohol, benzocaine, chlorhexidine, parabens, propylene glycol, or lanolin. These chemicals, in addition to those found in spermicides, bactericides, and latex, can irritate the vulva and vagina. Women whose partners wear latex condoms should avoid the use of oil-based lubricants, which can weaken and damage the latex. One survey of U.S. women showed that 66% of respondents reported ever having used a lubricant.Another survey found that 75% of respondents had purchased a lubricant in the past 4 weeks.4 Among this group, 96% reported greater sexual comfort and 94% reported greater sexual pleasure associated with lubricant use.

Supplements

Although data supporting the use of supplements to enhance female sexual function are limited, certain products have been studied, with results published in peer-reviewed journals. One such product is ArginMax for Women, an oral supplement that contains L-arginine, ginseng, ginkgo, damiana, multivitamins, and minerals. This product demonstrated significant benefit over placebo in multiple areas of female sexual functioning, although pre- and perimenopausal women reported more benefit than did their postmenopausal counterparts.5 Vesele and Stronvivo, dietary supplements that both contain Larginine, have shown promise in early clinical studies. Zestra, a topical product, contains borage seed oil, evening primrose oil, angelica root extract, and Coleus forskohlii extract. Zestra is designed to enhance arousal and orgasm after application to the clitoris and labia.6

Sexual accessories

Anyone who has ever been inside an adult entertainment store has seen the plethora of devices and products available for improving sexual experiences. Although few women were thought to use these devices and products, recent data suggest that approximately 54% of women use vibrators.7 Vibrators intensify stimulation to erogenous areas such as the clitoris, labia, vagina, anus, and breasts. They are available in a variety of shapes, sizes, speeds, colors, and intensity levels. Many women prefer using vibrators on the external clitoris and labia, whereas others prefer devices designed for internal use.

Bullet vibrators are small and hand held, and are intended to be used for external sexplay. Because of their size, they can be used more discreetly than larger vibrators. Many of them are waterproof. Gspot vibrators typically have a curved tip to stimulate the anterior vaginal fornix or G-spot area. The new Fiera Arouser for Her is a small, hands-free device intended to be used as a sexual primer. It is placed over the clitoris and provides suction, warmth, and vibration simultaneously. The Jopen Intensity Kegel Exerciser is a hybrid vibrator and pelvic floor exerciser designed to strengthen pelvic floor muscles and improve orgasmic potential.

Although originally designed for men with erectile dysfunction, flexible rings that fit on the base of the penis and that offer a small vibrator attachment can benefit both male and female partners. Additional products that stimulate both male and female partners include the We-Vibe collection. For personal use, the Lelo collection offers high-quality products of various shapes and sizes. Some couples like to incorporate options such as the hands-free, wireless butterfly vibrator. For individuals with decreased dexterity, larger, electric massagers can be useful. The Liberator Collection of “bedroom adventure gear” includes specially designed sexual pillows and furniture that can facilitate more comfortable and enjoyable positions.

For women who prefer sexplay without vibration, many different types of dildos are available, including those made from silicone, jelly, rubber, glass, or latex. Strap-on versions can be used by same-sex couples who prefer hands-free, penetrative play. When anal stimulation is desired, butt plugs and anal beads can be used with foreplay or to stimulate to orgasm.

A list of discreet websites through which to order sexual accessories is listed at the end of the article.

General recommendations

When teaching patients about incorporating enhancers into their sexual experiences, HCPs need to appear comfortable with the topic and remain nonjudgmental. Some women may be reluctant to discuss sexuality in a healthcare setting, particularly with regard to their use of products and devices. One way to alleviate embarrassment is to compare the use of sexual aids to that of any other healthcare product. HCPs should also keep in mind that, as is the case with other healthcare products, what works for one woman may not work for another. Women should be encouraged to experiment. Another way of destigmatizing the situation is to explain that these sexual enhancers can be used in lieu of medications to rehabilitate desire, arousal, and orgasm.

All this being said, HCPs must remain sensitive to each woman’s personal values and her cultural and religious beliefs and norms. There truly is no one size-fits-all when it comes to individual sexual preferences (pun intended).

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. Susan Kellogg-Spadt is Director of Female Sexual Medicine, Academic Urology Center for Pelvic Medicine, in Bryn Mawr, Pennsylvania, and has multiple academic titles and affiliations. Ms. Faught reports that she is a speaker and/or advisory panel member for Shionogi, Actavis, and Female Health Company. Dr. Kellogg-Spadt reports that she is a consultant for NeoGyn, Lelo, and Nuelle.

Websites

pureromance.com

goodvibes.com

adamandeve.com

middlesexmd.com

lelo.com

fiera.com

References

1. Bachmann GA, Notelovitz M, Gonzalez SJ, et al. Vaginal dryness in menopausal women: clinical characteristics and nonhormonal treatment. Clin Pract Sexuality. 1991; 7:25-32.

2. Donders GG, Bellen G. Cream with cutaneous fibroblast lysate for the treatment of provoked vestibulodynia: a double-blind randomized placebo-controlled crossover study. J Low Genit Tract Dis. 2012;16(4):427-436.

3. Herbenick D, Reece M, Schick V, et al. Women’s use and perceptions of commercial lubricants: prevalence and characteristics in a nationally representative sample of American adults. J Sex Med. 2014;11(3):642-652.

4. Jozkowski KN, Herbenick D, Schick V, et al. Women’s perceptions about lubricant use and vaginal wetness during sexual activities. J Sex Med. 2013;10(2):484-492.

5. Ito TY, Polan ML, Whipple B, Trant AS. The enhancement of female sexual function with ArginMax, a nutritional supplement, among women differing in menopausal status. J Sex Marital Ther. 2006;32(5):369-378.

6. Ferguson DM, Hosmane B, Heiman JR. Randomized, placebo-controlled, double-blind, parallel design trial of the efficacy and safety of Zestra in women with mixed desire/interest/arousal/orgasm disorders. J Sex Marital Ther. 2010;36(1):66-86.

7. Herbenick D, Reece M, Sanders S, et al. Prevalence and characteristics of vibrator use by women in the United States: results from a nationally representative study. J Sex Med. 2009;6(7):1857-1866.

Dyspareunia for a dozen years in a young woman

A 30-year-old woman named CL presents to the office as a new patient. Her health history is notable for dysmenorrhea; irritable bowel syndrome (IBS), diarrhea dominant; and dyspareunia since the onset of sexual activity at age 18. CL has never been pregnant.

CL tells the nurse practitioner (NP) that her dysmenorrhea has been well managed since age 15 with combination oral contraceptives (COCs) and an occasional NSAID on day 1 of her period. She does not take any medication for her IBS, and she avoids foods that might cause bouts of diarrhea. CL tells the NP she is seeking relief of the pain she experiences during sex, which has worsened over the past 6 months and which she fears might ruin her current relationship. She tearfully tells the NP that three prior relationships ended badly because she was unable to have comfortable, enjoyable sex. Although she said she was able to tolerate sexual touching and intercourse in the past, her symptoms have been gradually getting worse.

She goes on to tell the NP that she has been dating her current partner for 6 months and that they have had sex 3 times, which caused great discomfort. She says she tried various over-the-counter (OTC) lubricants and different positions, to no avail. Although CL says she enjoys cuddling and kissing with her partner, she has been avoiding this type of contact for the past 2 months because of fear that it would lead to intercourse. At the same time, she wants to enjoy intercourse and please her partner.

What else would be helpful to know about CL’s symptoms and health history?

CL tells the NP she feels she is “a mess down there.” She reports experiencing itching and burning in the vulvar area. The symptoms are present on most days and worsen with her period. She ascribes the symptoms to yeast infections (3-4 in the past year), which she treats with OTC antifungal creams. She also reports that, in the past year, she has been treated by another healthcare provider (HCP) for bacterial vaginosis with a vaginal gel. In addition, she has gone to an urgent care center twice for treatment of urinary tract infections— even though she is unsure whether the urine culture findings were positive or negative.

A year ago, at the suggestion of a friend to whom she mentioned the painful sex, CL went to a clinic for sexually transmitted disease testing and a Pap smear with a human papillomavirus (HPV) co-test. She reports that all findings were negative but adds that she hesitates to “go through that again” because the speculum examination was very painful. She says, “I don’t even use tampons because they hurt too much.” She tells the NP that she wears a panty liner every day because she does not take her COC consistently; when she forgets to take a pill or takes it late, she has some spotting. She remarks that she never feels really clean because of the frequent diarrhea, and uses feminine wipes daily.

As she tears up again, CL tells the NP that, over the past few months, she has felt more stressed than usual because of worries about her relationship and because of work pressures with a new boss. She laughs a little as she says, “I don’t drink, use drugs, or smoke, but when I get home from work, all I want to do is take a long hot bath with some scented oils to help me relax and feel clean.”

The NP seeks more details about the dyspareunia, and asks CL to rate the pain she experiences during and after sexual intercourse using a Likert scale, with 0 = no pain and 10 = maximum pain. CL rates the pain she feels in the vestibule area when her partner’s penis enters the vagina as an 8, and describes it as burning or a “razor blade” sensation. During penile thrusting, she experiences vaginal pain rated as a 6. After sexual touching, she has heightened burning pain in the vestibule area rated as a 4; the pain lasts 12-24 hours.

Which differential diagnoses would you consider at this point?

CL describes chronic vulvar itching and burning, significant vestibular pain during and after sex, and vaginal pain with thrusting. These symptoms may have similar or overlapping causes such as:

• Vulvitis;

• Vulvar dermatoses (e.g., lichen sclerosus);

• Vulvar cancer (pruritus is the most common early symptom);

• Vulvovaginal atrophy (associated with the patient’s prolonged COC use);

• Vaginismus; and

• Vulvodynia.

What would you include in your problem-focused physical examination?

The NP begins with inspection of the vulva and vestibule to assess for anatomic changes or variations, pigmentation changes, lesions, and integrity of vulvar tissues. The inspection reveals normal vulvar structures and mildly erythematous, dry labia majora with no other pigmentation changes or lesions. The labia minora are moist and pink. Vulvar hair is absent; CL reports that she has been removing this hair with a razor and shaving cream for years.

In the absence of abnormal visible findings other than mild erythema of the labia majora, the NP performs a cotton-swab test to specifically localize any areas of altered sensation in the vulvar area. The test is done prior to digital palpation and an attempt at insertion of a speculum. A standard cotton tip applicator is used to apply light touch starting on the upper inner thigh and following in a clockwise fashion in a manner that includes the labia majora, the vestibular duct openings for Skene’s and Bartolin glands, the clitoris/hood, and the perineum. The patient is asked to rate her pain on a scale of 0-10 at each location (Figure). CL’s cotton-swab test produces scores of 0 on the inner thighs and labia majora, 2 at the clitoris, and 2 at the perineal body. Pain at the vestibular gland duct openings is rated at 6-7 for the Skene’s glands and 7-8 for the Bartholin glands.

Because CL has high vestibular pain scores, the NP does not perform a speculum exam. The NP uses a cotton swab to obtain a vaginal specimen for pH and microscopic wet mount evaluation.

The pH is 4.0. A whiff test is negative. Mature squamous epithelial cells are present, with no pseudohyphae, clue cells, or motile trichomonads seen on the wet mount. A vaginal specimen is sent for fungal culture to assess for infection caused by atypical Candida species. The culture results are negative.

Pelvic floor muscle (PFM) assessment is done using one finger inserted into the vagina without touching the vestibule. The Oxford Grading System uses a 6-point scale to measure PFM strength: 0 = no contraction; 1 = flicker; 2 = weak; 3 = moderate; 4 = good (with lift); and 5 = strong. CL’s PFM strength is rated a 4. Palpation of the levator ani group and obturator internus muscles reveals hypertonicity and tenderness.

Based on the history and exam findings, what is the diagnosis?

CL has three interconnected diagnoses contributing to the dyspareunia: contact vulvitis, vulvodynia, and vaginismus.

Vulvitis may be caused by chronic or recurrent infection by pathogens such as Candida, herpes simplex virus, or HPV; contact with allergens or irritants; or injury/trauma. CL has reported regular use of vulvar contact irritantsuch as panty liners, feminine wipes, shaving cream, and scented bath oils. Pubic hair shaving may heighten one’s sensitivity to contact irritants. CL’s physical exam and wet mount findings tend to rule out infection as the cause of the vulvitis. The labia majora dryness may be related to prolonged use of COCs.

Vulvodynia is defined as vulvar discomfort (usually described as burning pain) occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder.1 It is a diagnosis of exclusion when all other potential causes have been ruled out and when symptoms persist longer than 3 months.1 The etiology of vulvodynia is unknown but may be related to genetic susceptibility,chronic inflammation,3 a combination of factors (e.g., PFM abnormalities, neuropathic pain, anxiety, primary/secondary sexual dysfunction),4 regionally elevated cytokines produced by vulvar vestibule-specific fibroblasts,hormonal changes,6 or dietary oxalates.7, 8 Chronic inflammation related to the contact irritants, recurrent infections, hormonal changes, or chronic skin conditions acts as a trigger. Normal sensations are perceived as abnormal, resulting in heightened sensitivity.

Estimates of vulvodynia prevalence range from 3% to 18%.9 Onset is most likely to occur between the ages of 18 and 25. Among symptomatic women, 60% see an average of three HCPs before receiving the correct diagnosis and 40% remain undiagnosed.9

Vulvodynia is classified as localized or generalized. Localized vulvodynia is subdivided into primary, in which vestibular pain begins during the first attempt at vaginal penetration, or secondary, in which pain occurs after a period of pain-free sex. Generalized vulvodynia may include all of the vulva or be limited to one side, with pain occurring in the absence of a triggering event. Of note, about 10% of women with generalized vulvodynia have a co-existing pain syndrome such as interstitial cystitis/painful bladder syndrome, IBS, fibromyalgia, or chronic fatigue syndrome.10

Prolonged use of COCs as a risk factor for vulvodynia is controversial. Several studies have supported the theory that use of COCs or progesterone-only contraceptives in females younger than age 18 causes down-regulation of estrogen receptors, leading the vestibular epithelium to become thin and fragile.11, 12 Although some women with vulvodynia have increased perception of pain when taking COCs, stopping COCs does not necessarily lead to resolution of the symptoms.12

Vaginismus is defined as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration and that causes personal distress or interpersonal difficulties.13

What can the NP offer CL as first-line treatment?

Because studies on the cause and treatment of vulvodynia are limited, the American College [now Congress] of Obstetricians and Gynecologists recommends that therapy be based on evidence from descriptive studies, expert reports, and clinical experience— with the understanding that the condition is difficult to treat and that no single approach is successful for all women.14

Individualized treatment usually involves multiple therapies over time.Treatment is considered in a step-wise progression, starting with self-management and moving upward on the scale of complexity. Total symptom resolution can be unrealistic. Primary goals are symptom reduction, return of satisfactory sexual function, and improved quality of life. Patient education concerning the manageability yet chronicity of this neuropathic condition is essential in setting realistic goals and in instituting a treatment plan that leads to improvement and satisfaction.

Mental health counseling is an important component. Approximately 50% of women with vulvodynia have a concordant diagnosis of anxiety.15 An increased occurrence of childhood physical/sexual abuse in women with vulvodynia has been reported.16 Referral to a mental health specialist with expertise in women’s sexual health and chronic pain conditions can be helpful.

Self-management is essential in CL’s case. She is educated to avoid use of feminine hygiene wipes/washes, panty liners (at times other than menses), and repetitive use of OTC antifungals.She is encouraged to stop removing her vulvar hair, which provides a protective barrier for sensitized vestibular tissues. She is advised to avoid exposure to very hot water in bathtubs and hot tubs, which can exacerbate vestibular discomfort. Application of unscented, hypoallergenic emollients to the vulvar skin and sitz baths in lukewarm water can be soothing, however.

CL and her partner should explore alternatives to penetrative sex (e.g., light physical contact with her genitalia). As pain diminishes with treatment over time, CL can consider restarting penetrative sex. The NP advises her to implement strategies for PFM relaxation, to adopt positions during intercourse that minimize pressure on sensitive areas, and to use liberal amounts of water-soluble lubrication.

A low-oxalate diet has been suggested to reduce high levels of oxalate in urine. However, little evidence supports the efficacy of this dietary modification in reducing vulvar pain.7, 8

What types of pharmacologic agents are appropriate?

Topical medications can be used on a short-term basis.17 Options include lidocaine 5% ointment, doxepin 5% cream in water-soluble base, gabapentin 2%-6% in watersoluble base, and amitriptyline 2% with baclofen 2% in water-soluble base. When topicals are used, those with an ointment base, rather than a cream base, are preferred.17 Cream bases contain more preservatives and stabilizers, which can act as contact irritants and cause burning upon application.

The next line of treatment is the use of oral neuropathic pain modulators, either antidepressants (e.g., amitriptyline, desipramine, venlafaxine) or anticonvulsants (e.g., gabapentin, pregabalin, lamotrigine, topiramate).17 Side-effect profiles and patient tolerance drive dosing regimens. Pruritus can be managed with an antihistamine such as hydroxyzine or cetirizine. In addition, nerve blocks, topical nitroglycerin, topical capsaicin, interferon injection, and trigger point injections have shown some efficacy in treating vulvodynia.17 Vaginal valium, injectable botulinum toxin, and topical baclofen have been used in the treatment of vaginismus.

What role does physical therapy play in CL’s treatment?

Pelvic floor physical therapy (PT) is an essential component of treatment for CL once she can withstand cotton-swab touch with lowered vestibular pain scores. A person with expertise in pelvic floor PT may use a combination of interventions to decrease CL’s dyspareunia and to improve her sexual function.17, 18 Interventions include (1) bio-feedback, which can help CL learn to relax her PFMs; (2) external soft tissue mobilization and myofascial release techniques; (3) trigger point pressure; and (4) transcutaneous electrical stimulation applied to the sacral nerve. The physical therapist or NP may teach CL how to use vaginal dilators to gradually overcome the tension in the PFMs. When CL is ready to resume sexual activity, she can use the dilator to prepare herself for and facilitate penetration.

When is surgery an option?

For women who continue to experience intractable symptoms after all other treatments have been tried, vestibulectomy—excision of the vestibule with vaginal advancement— is an option. Patient selection is critical for success; women can consider this option only if symptoms are confined to the vestibule. Success rates range from 60% to 85%.19, 20 Referral to a pelvic and reconstructive surgeon is advised in these cases.

Reflection for practice

Vulvodynia is a complex chronic pain condition. The interrelated physical, psychological, and psychosexual components make management challenging for both clinician and patient. CL has sought an NP’s help in seeking relief of her dyspareunia. The treatment plan focuses on symptom reduction to allow for sexual functioning that provides intimacy and satisfaction. Total relief of pain may not be achievable. A multidisciplinary approach to treatment may produce the best results. In fact, when available, referral to vulvovaginal disease specialists can facilitate an individualized, coordinated, comprehensive approach to treatment.

Susan Hoffstetter is a Fellow in the International Society of the Study of Vulvovaginal Diseases and an Associate Professor at Saint Louis University School of Medicine in St. Louis, Missouri. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Haefner HK. Report of the International Society for the Study of Vulvovaginal Disease terminology and classification of vulvodynia. J Low Genit Tract Dis. 2007;11(1):48-49.

2. Goldstein AT, Kim N, Burrows LJ, Goldstein I. Genetic differences may reflect differences in susceptibility to vulvodynia in general or in spontaneous remission propensity: a response. J Sex Med. 2015;12(2):578-579.

3. Akopians AL, Rapkin AJ. Vulvodynia: the role of inflammation in the etiology of localized provoked pain of the vulvar vestibule (vestibulodynia). Semin Reprod Med. 2015;33(4):239-245.

4. Edwards L. Vulvodynia. Clin Obstet Gynecol. 2015;58(1):143-152.

5. Foster DC, Piekarz KH, Murant TI, et al. Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: implications for vulvar vestibulitis. Am J Obstet Gynecol. 2007;196(4):346e1-8.

6. Eva LJ, MacLean AB, Reid WM, et al. Estrogen receptor expression. Am J Obstet Gynecol. 2003;189(2):458-461.

7. Greenstein A, Militscher I, Chen J, et al. Hyperoxaluria in women with vulvar vestibulitis syndrome. J Reprod Med. 2006;51(6):500-502.

8. Harlow BL, Abenhaim HA, Vitonis AF, Harnack L. Influence of dietary oxalates on the risk of adult onset vulvodynia. J Reprod Med. 2008; 53(3):171-178.

9. Harlow BL, Stewart EG. A population based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58(2):82-88.

10. Reed BD, Harlow SD, Sen A, et al. Relationship between vulvodynia and chronic comorbid pain conditions. Obstet Gynecol. 2012;120(1):145-151.

11. Bohm-Starke N, Johannesson U, Hilliges M, et al. Decreased mechanical pain threshold in the vestibular mucosa of women using oral contraceptives: a contributing factor in vulvar vestibulitis? J Reprod Med. 2004;49(11):888-892.

12. Goldstein AT, Krapf J, Belken Z. Do oral contraceptive pills cause vulvodynia? Time to finally end the controversy. International Pelvic Pain Society Blog. October 2015.

13. Curtis M, Linares S, Antoniewicz L. Glass’ Office Gynecology. 7th ed. Philadelphia, PA: Wolters Kluwer Health; 2014.

14. American College of Obstetricians and Gynecologists. 2006. Committee Opinion Number 345. Vulvodynia. Washington, DC: American College of Obstetricians and Gynecologists; 2006.

15. Tribo MJ, Andio O, Ros S et al. Clinical characteristics and psycho-pathological profile of patients with vulvodynia: an observational and descriptive study. Dermatology. 2008; 216(1):24-30.

16. Harlow BJ, Stewart EG. Adult onset vulvodynia in relation to childhood violence victimization. Am J Epidemiol. 2005;161(9):871-880.

17. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis. 2005;9(1):40-51.

18. DeBevoise TM, Dobinsky AF, McCurdy Robinson CB, et al. Pelvic floor physical therapy: more than Kegels. Womens Healthcare. 2015;3(2):34-41.

19. McCormack WM, Spence MR. Evaluation of surgical treatment of vulvar vestibulitis. Eur J Obstet Gynecol Reprod Biol. 1999;86(2):135-138.

20. Haefner HK. Critique of new gynecologic surgical procedures: surgery for vulvar vestibulitis. Clin Obstet Gynecol. 2000;43(3):689-700.

Overactive bladder: Assessing patient goals and implementing individualized treatment

 

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Overactive bladder (OAB) is a common condition affecting women in every age bracket. OAB symptoms need no longer undermine a woman’s quality of life. After ascertaining a patient’s goals, a healthcare provider can devise an individualized treatment plan that may include simple lifestyle changes, an FDA-approved medication regimen, and nonpharmacologic interventions such as pelvic floor muscle exercises, bladder training, and use of a pessary.

Key words: overactive bladder, OAB, urinary incontinence, nocturia, anticholinergics, beta-3 adrenergic agonist

Anita Padd, age 69, is a retired registered nurse who presents with a list of urinary complaints that she attributes to the fact that, when she was working, she was too busy to take time to go to the bathroom. A week before her appointment, Anita had attended a luncheon sponsored by a nurse practitioner (NP) who recently opened a pelvic health center around the corner. Anita says that she is glad both that she attended the luncheon—“For the first time in years, I realized that I am not alone and that help is available for my bladder problems”—and that she has made an appointment to see this NP.

Why are so many women experiencing bladder problems now?

Anita, born in 1946, was among the first Baby Boomers to turn 65. She, like many of her peers, is healthier than members of previous generations and has lived long enough to develop one or more chronic health conditions such as hypertension, diabetes, and overactive bladder (OAB). According to the U.S. Census Bureau, in 2014 there were 76.4 million Baby Boomers—that is, persons born between 1946 and 1964.1 The number and proportion of elderly persons in the country will keep rising for many years to come.
Anita believes that her bladder problem is a normal consequence of aging. She has been managing the problem by restricting her fluid intake and wearing pads. She tells the NP that she didn’t broach the topic to her primary care provider (PCP) because she was embarrassed and because she feared that surgery was the only treatment available.

Are Anita’s perceptions/concerns about her bladder problem common?

Results of a 2012 nationwide survey of women aged 40-65 years showed that those who had mild to moderate OAB symptoms (n = 652), as compared with those who had no OAB symptoms (n = 1,017), tended to feel much less “in charge” of their lives and their health and were much more fearful of public embarrassment related to not being able to reach a toilet in time to avoid having an accident.2 OAB sufferers were also more likely to think that bladder problems, like wrinkles and gray hair, were a normal part of aging.

Anita’s PCP has never screened her for urinary problems. Like many PCPs, she manages hundreds of patients with multiple conditions and feels that investigating a condition such as OAB would be “opening Pandora’s box.” Like her patient, this PCP is not aware of conservative treatments for bladder problems and is confused by all the medications on the market.

How common is OAB? Should healthcare providers (HCPs) be routinely screening their patients for it?

The prevalence of OAB among women is 15%-17%.3,4 In raw numbers, at least 11-16 million women in the United States have OAB symptoms.4 Most women with OAB symptoms do not talk with their HCPs about their urinary dysfunction, and providers may not routinely inquire about it. As a result, only a small minority of women with OAB receive treatment for it.4
Healthcare providers who see women on a regular basis in their practice can fill the gap by routinely screening for OAB and by gaining the knowledge to treat it appropriately. In an NPWH member survey of 300 NPs that was conducted in 2013, 48.3% of respondents reported being confident in their ability to diagnose OAB and 41.1% felt sure of themselves with regard to treating OAB, but only 28.5% thought that most OAB sufferers in their practice had been identified (H.A.C., unpublished NPWH member survey data, 2013). With proper screening for OAB, most, if not all, of the patients with this condition can be identified and treated.

What exactly is overactive bladder?

Overactive bladder is a symptom complex consisting of urgency, frequency, and nocturia and, in 37% of cases, urge incontinence. Sudden and compelling urinary urgency, the hallmark of OAB, occurs as a result of premature and independent contractions of the bladder that escape inhibition by the central nervous system. Urinary frequency is defined as voiding 8 or more times in a 24-hour period.5 Nocturia entails awakening more than 2 times a night to urinate.5 For OAB sufferers who have urge incontinence, urine loss varies from a few drops to a “gush.”

The three main categories of urinary incontinence are urge incontinence, stress incontinence, and mixed incontinence. Urge incontinence is an involuntary loss of urine immediately preceded by or synchronous with a strong urge to void. Urine loss can be substantial, because bladder contractions may continue until the bladder is empty. Urge incontinence, also described as detrusor instability or detrusor hyperactivity,6 differs from a normal strong urge to void that can be controlled. It is due to spontaneous bladder spasm, which can result from dietary factors (bladder stimulants such as caffeine or alcohol), increased fluid intake, side effects of medication (e.g., diuretics, bethanechol), urinary tract infection/cancer, or nerve dysfunction associated with nerve trauma, diabetes, multiple sclerosis, or spinal cord injury.5,6 Many episodes of urge incontinence have triggers such as unlocking the door to one’s house upon return (key-in-lock syndrome), approaching a toilet, or hearing the sound of running water.7Stress incontinence is marked by an involuntary loss of urine due to increased abdominal pressure on the bladder that exceeds maximal urethral closure pressure.8 An episode of stress incontinence is precipitated by an activity such as coughing, sneezing, laughing, lifting, stepping off a curb, or tripping. Stress incontinence is due to an increase in abdominal forces in the presence of an anatomic weakness of the bladder neck, which typically maintains the seal of urine during activity. It can stem from a variety of situations (e.g., coughing) or conditions such as vaginal delivery, aging, estrogen deficiency associated with meno­pause, or obesity.6 Stress incontinence differs from urge incontinence in that it (1) is rarely associated with nocturia or an urge to urinate; (2) is precipitated by an activity such as coughing; and (3) often occurs at unexpected or inappropriate times.

Mixed incontinence is a combination of stress incontinence and urge incontinence. It is described as stress dominant or urge dominant. Its occurrence increases with aging.

Anita sits on the examination table at the NP’s office. Her complaints include (1) severe urgency to urinate when she arrives at home; (2) urinary frequency in the late morning; (3) nocturia: she needs to urinate 3-4 times a night, although she is thankful that she can usually go back to sleep; (4) urine leaking with position change when her bladder is full; and (5) feeling exhausted all the time. Anita indicates that she took hormone therapy years ago, but not recently. She reports vaginal dryness and long-standing constipation. She also reports that she takes cranberry pills because they are “good for the bladder.”

What does the workup for a patient with suspected OAB entail?

In its most recent guideline. the American Urological Association (AUA) lists these clinical diagnostic principles:

  • Minimum requirements are a careful history, physical examination, and urinalysis.
  • If deemed necessary, a urine culture and/or post-void residual assessment may be performed and information from bladder diaries and/or symptom questionnaires may be obtained.
  • Urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound are not needed in the initial workup of a patient with an uncomplicated pre­sentation.9

History

The history includes a general health history and a focused history regarding lower urinary tract symptoms, including their onset, nature, duration, severity, and effect on quality of life.5 The HCP inquires about the presence or absence of diabetes, neurologic disorders, recurrent urinary tract infection, hematuria, kidney stones, previous lower abdominal or pelvic surgery, pelvic organ prolapse (POP), and vaginitis.10 In addition, the HCP asks the patient about her use of prescription and over-the-counter medications, particularly with regard to anticholinergics or antimuscarinics, antidepressants, antipsychotics, sedatives or hypnotics, diuretics, caffeine, alcohol, opioids, alpha-adrenergic blockers, alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers.5 The HCP then poses screening questions specific to OAB:

  • Do you ever leak urine when you have a strong urge on the way to the bathroom? How often?
  • How frequently do you urinate during the day?
  • How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?
  • How many pads a day do you wear for protection?
  • Does this problem inhibit any activity or prevent you from doing things you like to do?

Physical examination

A comprehensive physical examination for OAB includes a pulmonary and cardiovascular evaluation and neurologic, abdominal, pelvic, and rectal exams.9,10 The pelvic exam can reveal findings such as genitourinary syndrome of menopause (GSM; also known as urogenital atrophy, vulvovaginal atrophy, and atrophic vaginitis) or POP, which can cause or exacerbate urinary symptoms. Assessment of pelvic muscle tone is done by inserting 1 or 2 fingers 2 cm into the patient’s vagina, palpating at 5 and 7 o’clock, asking the patient to tighten her rectal muscles, comparing the contralateral sides, noting her muscle strength and endurance (i.e., her ability to hold for 10 seconds), monitoring for inappropriate use of accessory muscles (e.g., abdominal or gluteal muscles), and encouraging the patient to relax her abdominal muscles.

Bladder diary

If a patient answers affirmatively to any of the screening questions posed during the history, she is asked to complete a bladder diary that will be reviewed during a subsequent visit. This diagnostic tool shows a woman’s day-to-day bladder habits and voiding patterns. She is asked to document the time, type, and amount of fluid intake (the type of fluid can indicate whether she is ingesting bladder irritants), the time of each void, each accidental leaking, and a notation of the volume of urine loss in subjective terms: large (>¼ cup), medium (<¼ cup), or small (dribbles).
Readers can access a daily bladder diary from the National Institute of Diabetes and Digestive and Kidney Diseases.11 A 3-day bladder diary is ideal.5 To evaluate the data in the bladder diary, HCPs need to be familiar with normal voiding values, which are as follows:

  • Mean 24-hour urinary output (both men and women): 1,700 mL
  • Mean number of daily voids:
    6 to 7
  • Mean bladder capacity: 330 mL (individual patients vary considerably; 300-500 mL is considered the normal range).<supP12

Vaginal pH

Without estrogen, the pH of vaginal secretions changes and the normal discharge becomes more alkaline (usually above 4.5), which is due to a decrease in vaginal lactobacilli. These changes cause vaginal tissues to thin, which can have adverse implications for the urogenital tract. Vaginal pH (normal range, 3.5-4.5) can be easily and inexpensively measured in the office by collecting a sample from the upper lateral vaginal wall and using litmus paper for pH testing.

Anita’s bladder diary indicates that, despite her best intentions, she is ingesting a host of bladder irritants, including the aforementioned cranberry pills, orange juice, green tea, and lemon seltzer. She voids 11-12 times a day and 3-4 times a night, and feels the urge to void even after she has just emptied her bladder. The exam shows that Anita has weak pelvic muscle contractions, a grade 2 cystocele, and GSM related to long-term estrogen deficiency. Her urinalysis results are negative or normal and her vaginal pH is in the alkaline range.

How is OAB identified?

The condition is identified by the presence of urinary urgency and frequency, nocturia and, in more than one-third of cases, incontinence.

Based on findings from the workup, Anita’s NP concludes that she has OAB. In addition, Anita meets diagnostic criteria for mixed urinary incontinence, urge dominant; urinary frequency; pelvic floor muscle weakness; urogenital atrophy; and chronic constipation.

What are the goals of OAB treatment?

Treatment goals are individualized and may vary from symptomatic improvement to complete symptomatic relief of urgency, frequen­cy, nocturia, and urge incontinence. Asking patients with bladder control problems about their goals before treatment begins is useful in determining how aggressive the treatment should be.

At her initial appointment, although Anita is experiencing symptoms of both urge incontinence and stress incontinence, she reports that her most bothersome complaint is the nocturia. She states that she is tired all day as a result of awakening 3-4 times per night to urinate. She has even ceased participating in certain social activities because of her fatigue. When asked about her goals for treatment, Anita asserts that she does not want surgery or “anything invasive,” and that she would be delighted if she could get more sleep and was not always rushing to get to the bathroom. She and her HCP agree that the initial phase of treatment will focus on the urge aspect of her mixed incontinence symptoms.

What constitutes first-line treatment for OAB?

Many nonpharmacologic and pharmacologic approaches are available as first-line treatment for OAB.

Lifestyle changes

One of the simplest lifestyle changes is to avoid ingesting bladder irritants, many of which appear on the Carcio “C” List (Figure). Another easy approach is to manage fluid intake. The amount of fluid intake recommended depends on each patient’s body size, temperature, and physical activity level. In general, though, most women should aim to consume 4-8 cups of fluid (water plus all other liquids) a day. They should limit the amount of fluid ingested past 6 PM (or within 5 hours of the time when they plan to go to sleep). If they are excreting pale yellow urine, they are neither under-hydrating nor over-hydrating.

Figure

Pharmacotherapy

Two different classes of drugs, anticholinergics (antimuscarinics) and a beta-3 adrenergic agonist, are approved by the FDA for the treatment of OAB with symptoms of urge incontinence, urgency, and frequency (Table). The Sidebar lists pearls to prescribing these agents.
Anticholinergics work by blocking the effects of acetylcholine at muscarinic receptors in the bladder, thereby inhibiting involuntary detrusor contractions and reducing urgency.10 Side effects such as dry mouth, constipation, and blurred vision may be bothersome enough to prompt treatment discontinuation. Side effects are generally milder with extended-release formulations. Initiating the use of artificial saliva mouthwash and instituting measures to control constipation may enhance compliance with the regimen. All of the anticholinergics have similar efficacy in clinical trials; the key is finding a particular product that an individual patient can tolerate.
The beta-3 adrenergic agonist relaxes the detrusor smooth muscle during the storage phase of the urinary bladder fill-void cycle by activation of beta-3 adrenergic receptors, which increases bladder capacity.13 This agent can increase blood pressure.

Table

Other approaches to management

The AUA supports the use of behavioral therapies such as bladder training, bladder control strategies (e.g., urge suppression), pelvic floor muscle training (PFMT; also known as Kegel exercises), and fluid management as first-line therapy for all patients with OAB.9 Studies have suggested that PFMT, alone or combined with biofeedback training or electrical stimulation, may be effective for treating OAB.14-16 Avoidance of constipation, which can further weaken the pelvic floor as a result of chronic straining, is another strategy.17 Increasing the amount of dietary fiber to 30 g/day can help prevent constipation.
A vaginal pessary, a flexible device made of silicone indicated for the treatment of POP or stress urinary incontinence,17,18 can be used to treat symptoms of OAB. A retrospective parallel cohort study was conducted on women whose OAB was treated with a ring pessary or multi-component behavioral therapy (MCBT) over a 42-month period.19 The ring pessary and MCBT had similar cure rates (29 of 150 [19%] vs. 46 of 231 [20%], respectively; P = .889), regardless of whether women were premenopausal (4 of 31 [13%] vs. 14 of 68 [21%], P?=?.358) or postmenopausal (25 of 119 [21%] vs. 32 of 163 [20%]; P?=?.776). Pessaries are usually fitted by an HCP and require a prescription, but a new over-the-counter pessary is also available.
Vaginal estrogen, indicated for treatment of the symptoms of GSM, may help relieve symptoms of OAB. The epithelial linings of the vagina and urethra have the highest concentration of estrogen receptors in the body and are therefore highly sensitive to alterations in estrogen levels.20 The estradiol vaginal ring (Estring®), which works particularly well in older women, is changed every 3 months. It can be used in conjunction with a pessary, which is also changed every 3 months. Vaginal estrogen cream products include estradiol cream (Estrace® Cream) and conjugated equine estrogens cream (Premarin® Vaginal Cream), which are inserted with an applicator. These creams are considered messy by some women, but they do add lubrication. Estradiol vaginal tablets (Vagifem®), less messy than the creams, are a good choice for women with a stenotic introitus because of the smaller applicator.

Anita returns to the NP’s office after 3 weeks. She reports that she has modified her diet to decrease her intake of bladder irritants. She drinks an adequate amount of fluids each day but limits her fluid intake, with sips only, after 6 pm. She takes a daily medication to treat her OAB, and denies any dry mouth, constipation, or drowsiness. She uses a pessary, which she finds comfortable, and inserts an estradiol vaginal ring every 3 months. She takes a stool softener to reduce constipation. She has attended two pelvic floor rehabilitation sessions and does Kegel exercises at least twice daily, and she can now wait up to 2.5 hours in between voids. She needs to urinate only twice during the night and rarely experiences a leak with position changes. Although Anita wears a pad only when she goes out, for “insurance,” she really doesn’t need it any longer. As a result of this multifaceted therapeutic approach, her urinary urgency and frequency, nocturia, leaks, fatigue, and worries have all diminished.

Conclusion

Women’s healthcare providers can routinely screen their patients for symptoms of OAB. In those patients who screen positive and in whom other causes of the symptoms have been excluded, a tool such as a bladder diary can be used to identify OAB. HCPs can then educate patients about avoidance of bladder irritants and about techniques to strengthen their pelvic floor muscles. If these measures are unsuccessful, HCPs can prescribe an FDA-approved medication to further alleviate symptoms. In all cases, a treatment approach based on a woman’s own needs and goals is most likely to be successful.

References
1. Population Reference Bureau. Just How Many Baby Boomers Are There? April 2014. prb.org/Publications/
Articles/2002/JustHowManyBabyBoomersAreThere.aspx

2. Muller N. Anxiety and fears in women with overactive bladder. Ostomy Wound Manag. January 2013. .o-wm.com/files/owm/pdfs/OWM_January2013_Muller.pdf

3. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20(6):327-336.

4. Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of overactive bladder in women. Evidence Report/Technology Assessment No. 187. 2009. ahrq.gov/clinic/tp/bladdertp.htm

5. Ellsworth PI. Overactive bladder. Medscape Drugs and Diseases. Updated April 25, 2014. emedicine.
medscape.com/article/459340-overview#aw2aab6b2b2

6. Brigham and Women’s Hospital website. Types of Incontinence and Risk Factors. Last modified on August 22, 2014. brighamandwomens.org/departments_and_services/obgyn/services/urogynecology/incontoverview.aspx

7. Carcio HA. Calming the overactive bladder: a nurse practitioner perspective. Womens Healthcare. 2014;
2(3):25-26, 49.

8. Tanagho EA, Bella AJ, Lue TF. Urinary incontinence. In: Tanagho EA, McAninch JW, eds. Smith’s General Urology. 17th ed. New York, NY: McGraw-Hill Medical. 2008:473-489.

9. Gormley EA, Lightner DJ, Burgio KL, et al; American Urological Association; Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188(6 suppl):2455-2463.

10. Association of Reproductive Health Professionals. Diagnosis and Management of Overactive Bladder. April 2011. arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/OAB/Diagnosis

11. National Institute of Diabetes and Digestive and Kidney Diseases. Your Daily Bladder Diary. niddk.nih.gov/
health-information/health-topics/urologic-disease/daily-bladder-diary/Documents/diary_508.pdf

12. Parsons M, Amundsen CL, Cardozo L, et al. Bladder diary patterns in detrusor overactivity and urodynamic stress incontinence. Neurourol Urodyn. 2007;26(6):800-806.

13. Andersson KE, Martin N, Nitti V. Selective ?3-adrenoceptor agonists for the treatment of overactive bladder. J Urol. 2013;190(4):1173-1180.

14. Burgio KL. Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training. Curr Urol Rep. 2013;14(5):457-464.

15. Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148(6):459-473.

16. Liaw Y-M, Kuo H-C. Biofeedback pelvic floor muscle training for voiding dysfunction and overactive bladder. Incont Pelvic Floor Dysfunct. 2007;1:13-15.

17. Lukacz ES. Patient information: Urinary incontinence treatments for women (Beyond the Basics). UptoDate. Last updated May 11, 2015. uptodate.com/contents/urinary-incontinence-treatments-for-women-beyond-the-basics

18. Clemons JL. Vaginal pessary treatment of prolapse and incontinence. UptoDate. Last updated March 20, 2014. uptodate.com/contents/vaginal-pessary-treatment-of-prolapse-and-incontinence

19. Sze EH, Hobbs G. A retrospective comparison of ring pessary and multicomponent behavioral therapy in managing overactive bladder. Int Urogynecol J. 2014;25(11):1583-1588.

20. Brincat M, Muscat Baron Y, Galea R, Buhagiar A. Estrogen deficiency and connective tissues. In: Crosignani PG, Paoletti R, Sarrel PM, et al, eds. Women’s Health in Menopause: Behaviour, Cancer, Cardiovascular Disease, Hormone Replacement Therapy. Springer Science+Business Media Dordrecht; 1994.

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

PDF 50

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

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

FSH_Table

#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.

Conclusion

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.

References
1. Laumann, EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;
281(6):537-544.

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. fda.gov/News
Events/Newsroom/PressAnnouncements/ucm458734.htm

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.

Focus on sexual health

PDF 50

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

Menopause affects many areas of a woman’s body, including vulvar and vaginal tissue. Most women present with some degree of atrophic vulvovaginal tissue changes in the years following menopause, and up to nearly half of all menopausal women are symptomatic. In 2014, a name change was proposed to include the entire genitourinary tract, not just the vulva and vagina, with regard to all the changes that occur in this area of the body as a result of menopause: genitourinary syndrome of menopause (GSM). Women’s healthcare providers have a variety of FDA-approved options to treat women presenting with symptomatic GSM, including local hormonal therapies, a nonhormonal oral tablet, and an intra­vaginal CO2 laser device.

For years, the terms vulvovaginal atrophy (VVA) and atrophic vaginitis have been used to describe menopause-related changes to the vulvovaginal tissue. These terms have been used despite the negative connotation of the word atrophy and the specificity to vulvar and vaginal tissue. In May 2013, two organizations, the International Society for the Study of Wom­en’s Sexual Health (ISSWSH) and The North American Menopause Society (NAMS), came together to develop more appropriate nomenclature through a terminology consensus conference. Late last year, the more appropriate and all-encompassing term genitourinary syndrome of menopause was adopted to replace the terms vulvovaginal atrophy and atro­phic vaginitis.1 The term genitourinary syndrome of menopause, or GSM, acknowledges the full spectrum of menopause-related atrophic changes that occur within the entire genitourinary tract.1

The terms VVA, atrophic vaginitis, and GSM are used interchangeably throughout this column. Readers will continue to see the terms vulvovaginal atrophy and atrophic vaginitis in the literature for some time because these terms were used in research completed before adoption of the term GSM.

During perimenopause and the years following, the drastic decline in circulating sex hormones, including estrogen, progesterone, and testosterone, results in changes to multiple areas of the body. Some of the more widely recognized symptoms of menopause, including hot flashes, weight gain, and mood changes, diminish over time as the body acclimates to functioning without cyclical changes in hormone levels. By contrast, the effects of the ongoing hypoestrogenic state of menopause on genitourinary tissue intensify, at least in women who do not receive any type of treatment for them.2 Objective findings related to this hypoestrogenic state include vaginal tissue thinning, diminished elasticity, and increased friability, which can result in petechiae, fissuring, erosions, and, in severe cases, stenosis.3 Symptoms related to these physical changes—that is, the symptoms of GSM—include vulvovaginal dryness, itching and burning, painful intercourse, dysuria, urinary urgency and frequency, and recurrent urinary tract infections.1

The average age of menopause in the United States is 51 years. Because life expectancy in this country continues to climb,4 the population of menopausal women is steadily rising, and women may expect to live up to 40% of their lives in a postmenopausal state.5 Of the millions of women who spend years or decades in a perimenopausal and then a postmenopausal state, nearly half will experience bothersome symptoms of GSM/VVA.6 Given these numbers, GSM is an area that warrants major interest in the healthcare community.

Despite the widespread prevalence of GSM, healthcare providers (HCPs) must keep in mind that many women are not comfortable discussing symptoms of GSM with their HCP, and vice versa. According to the Women’s Voices in the Menopause international survey, nearly 80% of online respondents felt that women were not comfortable discussing vaginal atrophy.7 The Real Women’s Views of Treatment Options for Menopausal Vaginal Changes (REVIVE) survey reported that only 56% of women had ever discussed their VVA symptoms with an HCP.8 In the VIVA (Vaginal Health: Insights, Views & Attitudes) survey, 80% of respondents stated that vaginal discomfort adversely affected their lives, and 75% of respondents reported adverse consequences on their sex lives.9

In the recent past, nonhormonal lubricants and local hormonal therapies were the only treatment options for women with GSM. To date, six FDA-approved therapies for VVA/GSM are available (Box). Intravaginal CO2 laser therapy, approved in late 2014, offers a unique, nonpharmacologic option for women, including breast cancer survivors, who are not candidates for hormonal treatment.

FoSH_FDA

Regardless of the treatment chosen, HCPs caring for women must encourage open communication regarding symptoms of GSM with patients who may be otherwise unlikely to initiate conversation on such sensitive matters. With healthcare advances, many treatment options are available for all degrees of GSM severity and all circumstances.

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 serves on the speakers’ bureau for Actavis Pharma, Inc., and Shionogi Inc.

References
1. Portman D, Gass M. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and The North American Menopause Society. Menopause. 2014;21(10):1063-1068.

2. North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902.

3. Tan O, Bradshaw K, Bruce RC. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012;19(1):109-117.

4. U.S. Census Bureau. Statistical Abstract of the United States. 2012. https://www.census.gov/prod/2011pubs/
12statab/pop.pdf

5. Parish SJ, Nappi RE, Krychman ML, et al. Impact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy. Int J Womens Health. 2013;5:437-446.

6. Santoro N, Komi J. Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med. 2009;6(8):2133-2142.

7. Nappi RE, Kokot?Kierepa M. Women’s voices in the menopause: results from an international survey on vaginal atrophy. Maturitas. 2010;67(3):233-238.

8. Kingsberg SA, Wysocki S, Magnus L, et al. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013;10(7):1790-1799.

9. Simon JA, Kokot-Kierepa M, Goldstein J, Nappi RE. Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey. Menopause. 2013;20(10):1043-1048.

BDSM: The 50 Shades Revolution

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

Until recently, BDSM has remained largely “underground” in the United States because of the explicit nature of the activities and social stigma surrounding such participation. Although many books and movies have included BDSM in their content, it was not until 50 Shades of Grey was published in 2011 that open discussion and inquiry about this topic became commonplace. For healthcare pro­viders (HCPs), many considerations are relevant in terms of caring for patients who partake in BDSM play. This article presents answers to some frequently asked questions from HCPs regarding alternative sexual practices.

What is BDSM?

BDSM stands for bondage & discipline, dominance & submission, and sadism & masochism. The first two terms refer to erotic behavior shared between consenting adults involving physical restraints (bondage) and psychological obedience (discipline). A dominant, also known as the top, is the partner with the active or controlling role. A submissive, also known as the bottom, relinquishes control to the dominant. Sadism and masochism refer to the act of gaining pleasure (often sexual gratification) from inflicting (sadism) or receiving (masochism) physical or psychological pain on or from another person. Many persons who partake in BDSM refer to themselves as kinky or kinksters. Many kinksters consider BDSM a lifestyle rather than an alternative sexual practice. In fact, in a dominant/submissive relationship, the roles of each partner are frequently a constant, and may be relevant in a healthcare setting.

How do I distinguish between BDSM play and abuse?

Kinky play can result in markings similar to those of physical abuse, including bruises, cuts, burns, piercings, and blisters. The factor separating kinky and abusive acts is consent. As in any other form of sexual behavior, roles and activities in BDSM should be mutually agreed upon. Many kinksters sign contracts that include an escape word that results in termination of activity at any given time by either partner. BDSM markings derived from consensual behavior are typically symmetric and occur on fleshy parts of the body such as the hips and buttocks. Abuse markings tend to be found on bony and/or sensitive parts of the body such as the spine, the face, or the flank. Kinky patients may hesitate to discuss their activities in a healthcare setting, but, unlike patients who have been abused, they are unlikely to demonstrate fear, shame, or avoidance behavior.

How do I diagnose these behaviors?

Kinky behavior without self-reported clinical impairment does not classify an individual as having a paraphilic disorder. The DSM-5, released in May 2013, has de-pathologized BDSM. Kinky activities without clinical impairment are now defined as “unusual sexual interests” that do not necessarily warrant intervention by an HCP. By contrast, persons who have sex with non-consenting partners or with children, animals, or individuals with intellectual/developmental disabilities, and persons who deliberately cause harm to themselves or others can be diagnosed with a paraphilic disorder.

Where do kinky individuals play?

Kinky play can occur anywhere. However, many kinksters seek out designated BDSM dungeons. These facilities, located in most major cities across the U.S., typically require membership and allow for safer kinky play with others who share similar interests and desires. Most dungeons have monitors who protect members against unwanted acts committed against them.

How do I discuss BDSM with kinky patients without offending them?

Like all patients, kinky patients should be addressed in a nonjudgmental manner. To facilitate honest communication, HCPs should establish rapport with these patients, assure them of confidentiality, and allow for open and safe conversation. HCPs who are uncomfortable caring for patients in this community can go to the National Coalition for Sexual Freedom’s website to locate a Kink Aware Professional.

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.

Resources

National Coalition for Sexual Freedom (www.ncsfreedom.org)

FetLife (www.fetlife.com)

The Alternative Sexualities Health Research Alliance (http://www.tashra.org)

Rape, Abuse & Incest National Network (http://www.rainn.org/public-policy/laws-in-your-state)

 

Managing female sexual dysfunction

 

By Casey B. Giebink, MSN, NP-C, WHNP-BC and Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN

Although about one-third of women report concerns with sexual functioning, many healthcare providers (HCPs) do not feel comfortable screening for, diagnosing, or managing female sexual dysfunction (FSD). The authors offer guidance to HCPs for screening and diagnosing a variety of FSD disorders. In addition, the authors discuss pharmacotherapeutic options for managing these conditions, as well as these agents’ benefits, risks, and monitoring parameters.

Key words: female sexual dysfunction, estrogen, testosterone, bupropion, ospemifene, flibanserin

Female sexual dysfunction (FSD) is highly prevalent among women in the United States, yet patients rarely discuss sexual concerns with their healthcare provider (HCP). Investigators of the Women’s International Study of Health and Sexuality sent questionnaires to 2,050 U.S. women regarding health status, sexual desire, and distress caused by low desire.1 The study showed that 24%-36% of women aged 20-70 years could be classified as having low sexual desire. This prevalence highlights the need for HCPs to know how to communicate with, identify, and manage patients’ sexual concerns. To this end, the authors provide evidence-based recommendations drawn from the current literature regarding assessment and diagnosis of FSD, with an emphasis on pharmacologic options available to treat FSD. Most of the pharmacologic options for desire, arousal, and orgasm problems are prescribed off label.

Common barriers to identifying and managing FSD

Despite the high prevalence of FSD, many women do not broach the topic with their HCP, and many HCPs do not screen their patients for sexual disorders.2 In fact, fewer than 20% of HCPs ask about their patients’ sexual activity, including difficulties, enjoyment, and frequency.3

Urologists, gynecologists, and psychiatrists are the HCPs most likely to inquire about sexual functioning.4 However, one study showed that among 187 urologists, only 10% asked every patient about sexual function on a regular basis, as opposed to 87% who asked about sexual activity when the chief complaint was related to abdominal pain, urgency/frequency, incontinence, or a urinary tract infection.5 A survey of the attitudes of nurse practitioners (NPs) and physician assistants (PAs) toward management of sexual dysfunction revealed that only one-half felt comfortable discussing the topic and only 21% of NPs and 11% of PAs felt confident in managing FSD.6 Nevertheless, most NPs and PAs had a positive attitude toward the possibility of evaluating and managing their female patients’ sexual concerns.6

Various factors may hinder HCP–patient communication regarding sexual concerns. Potential barriers for HCPs include lack of time, lack of knowledge about FSD management options, and lack of training in how to communicate about FSD; barriers for patients include embarrassment and a belief that their HCP cannot help them.7 Some HCPs fear embarrassing or offending patients if they raise the topic,3 although most patients will discuss their sex practices if the HCP initiates the conversation.8

Even if a patient does discuss her sexual problems with her HCP, her concerns may not be properly addressed. One survey showed that among 3,807 women who considered seeking help for sexual dysfunction, fewer than half reported feeling hope, relief, validation, or satisfaction after discuss­ing their concerns with a provider.9 In addition, patients were disappointed by their HCPs’ inability or unwillingness to evaluate, treat, and follow up on their complaints.9

Overcoming the barriers

Healthcare providers can increase the likelihood that FSD will be identified and addressed by initiating the conversation with patients, which will strengthen the HCP–patient relationship and help normalize patients’ concerns.9 Once both parties are comfortable, the HCP can take a sexual history, perform a thorough physical examination, and order appropriate laboratory tests.

History
To transition smoothly into taking a sexual history, HCPs can incorporate questions into the genitourinary/gynecologic/obstetric review of systems.10 Some patients may feel uneasy answering these questions, so HCPs can explain why such questions are being posed. For example, one can say, “I will be asking you some questions about your sexual activity to get a better idea of you as a whole and to ensure we are providing the most comprehensive care possible.” Informing women that FSD is common can facilitate a frank conversation.10

Screening for FSD with just a few questions can be informative. A literature review by Giraldi et al11 indicated that although multiple FSD screening tools are available, few standardized and culturally acceptable questionnaires are validated in general populations and can be used to assess for FSD in women with or without a partner and independent of the partner’s gender. As a result, HCPs can develop their own unbiased FSD screening questions based on their unique patient population. A patient’s sexual orientation should not be assumed; instead, HCPs need to ask about any and all sexual partners. Brief questions regarding sexual satisfaction and pain and the ability to reach an orgasm can determine if further screening is warranted.12 Three targeted questions include the following13:

• Do you have any questions or concerns about your sexual activity?
• Have you experienced any changes in sexual response, lubrication, or pain with sexual activity?
• Are you aware of any changes in your level of interest or desire for sexual activities?

If a woman—premenopausal or postmenopausal—answers “yes” to any of these questions, then further investigation is needed.

For a specific problem, HCPs need to explore the nature of the problem, its severity and duration, the degree of distress it causes, and any history of similar problems.13 The patient is asked to use her own words to describe any sexual difficulties she may be having.14 Because sexual functioning is multifaceted, HCPs need to consider a woman’s physical, surgical, medication, and social histories to uncover all possible factors causing or contributing to the sexual dysfunction (Table 1).14-16Physical examination
A physical exam is conducted to identify or exclude conditions that might cause or exacerbate FSD. This exam includes a general systemic survey with a focused cardiovascular exam, which can uncover systemic perfusion abnormalities that might contribute to FSD.15 A neurologic assessment of the effects of light touch and pressure on the external genitalia may reveal locations with hypersensitivity. A genitourinary exam is done to evaluate for structural abnormalities such as an imperforate hymen or vaginal septum and to look for signs of estrogen depletion (e.g., loss of vaginal rugae, pale mucosa, thin lining).15 An evaluation of pelvic muscle tone is important; both high tone and low tone can be associated with FSD. This evaluation is best done using a perineometer, a device placed within the vagina that provides feedback on the tone of the levator ani complex and obturator internus muscles.17 In the absence of this device, HCPs can evaluate tone during an internal exam by asking the woman to squeeze and relax the vaginal muscles.17 Of note, many women with FSD have normal physical exam findings.

Laboratory testing
Evaluating certain lab values can aid in identifying health conditions that may be contributing to sexual dysfunction. These lab tests include a complete blood count, fasting prolactin, a lipid profile, blood glucose, and thyroid hormone levels.18 Abnormal test results may reveal an underlying condition (e.g., anemia, thyroid disease, dyslipidemia, metabolic disorders, hormonal imbalances) causing or exacerbating the FSD.19 Evaluating the calculated free androgen index can also help in classifying sexual complaints; age-based normative values have been established.20 When a patient’s primary complaint is dyspareunia, vaginal, cervical, and/or vulvar cultures can be obtained to rule out infectious causes.14

DSM-5 changes to FSD diagnoses

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which was published by the American Psychiatric Association in 2013, includes revisions to previous editions based on new research.21 Specific to the category of sexual dysfunction, the DSM-5 now requires that symptoms be present for at least 6 months. In addition, the DSM-5 includes gender-specific diagnoses, combines disorders that were previously separate, and removes the subtype of FSD due to psychological factors versus combined factors. Research suggests that sexual response cannot be categorized into specific stages and is not always linear. As a result, the DSM-5 combines sexual arousal disorder and sexual desire disorder into female sexual interest/arousal disorder. Another combined disorder in the DSM-5 is genito-pelvic pain/penetration disorder, which was developed because of the difficulty distinguishing between vaginismus and dyspareunia.

Treatment approaches

Initial management of FSD requires treating any contributing underlying physical conditions. If treatment of these conditions does not result in restoration of sexual function, other interventions for FSD are considered. Although this article focuses on pharmacotherapeutic options, patients can try nonpharmacologic interventions such as cognitive behavioral therapy (CBT), sex therapy, self-stimulation, and lubricating gels (Table 2).22,23 If nonpharmacologic therapies do not offer relief, pharmacologic options are considered.

Estrogen
Declining estrogen levels after menopause can lead to vulvovaginal atrophy (VVA), which can result in vaginal dryness, itching, and pressure and can lead to pain during sexual activity.24 Painful intercourse (dyspareunia) can diminish sexual pleasure and desire for sex. Exogenous estrogen therapies, both systemic and topical, are used to increase vaginal lubrication and promote a more pleasurable sexual experience.25

Compared with systemic estrogen products, vaginal estrogen products have been found to heighten genital vasculature (despite resulting in lower systemic levels of estrogen); systemic estrogen is more useful for relieving vasomotor symptoms (VMS) accompanying menopause.25 Conjugated estrogens vaginal cream (Prem­arin® Vaginal Cream) has an FDA indication for treatment of moderate to severe dyspareunia, a symptom of VVA due to meno­pause.26 Although estrogen therapies alone have not been found to directly increase sexual desire, they diminish dyspareunia, which may indirectly increase a woman’s interest in sexual activity.25

Many formulations of systemic and vaginal estrogen are available. If a woman’s FSD complaint is related to VVA, a vaginal formulation is preferred.27 Three vaginal estrogen formulations are available: creams, a ring, and a tablet (Table 3).27 For the tablet and creams, a higher dose and/or dosing frequency is typically used for 1-2 weeks until relief is achieved; a tapered dose can then be used for maintenance.27 Whereas most women find relief after 3 weeks of treatment, some may require up to 4-6 weeks.28 Low-dose vaginal estrogen therapy can be used indefinitely because of the low adverse effect profile; however, given limited data on use beyond 1 year, women should be evaluated annually to determine the need for continued treatment.29

The most common side effects of topical estrogen cream are headache, breast pain, pelvic pain, vasodilation, leukorrhea, metrorrhagia, vaginitis, and vulvovaginal disorder.26 Most side effects subside with ongoing use. Although systemic estrogen use has been linked to an increased risk for endometrial hyperplasia, venous thromboembolism, and breast cancer, little evidence suggests an increased risk with topical estrogen use.27 The North American Menopause Society (NAMS) released new guidelines for prescribing hormone therapy.30 According to these 2012 guidelines, topical estrogen is less likely than standard-dose oral estrogen to cause blood clots or stroke; however, more research is needed to reach definitive conclusions. A Cochrane review showed no increase in endometrial proliferation with vaginal estrogen versus placebo.27 Nevertheless, local estrogens can be absorbed into the bloodstream and increase the amount of systemic estrogen. Given the limited research, HCPs need to use clinical judgment when prescribing estrogen and monitor women closely for vaginal spotting/bleeding and other worrisome complaints.

Testosterone
If estrogen alone does not ease FSD symptoms, off-label addition of testosterone to estrogen therapy (ET) may increase libido and enhance sexual response.31 Use of testosterone in women is off label; this agent is prescribed with caution after patients are educated about the risks. A 2005 Cochrane review of 23 trials concluded that addition of testosterone therapy (TT) to ET improved sexual desire in postmenopausal women.32 The likely mechanism of action of combined therapy was related to the fact that use of exogenous testosterone increases circulating free testosterone and decreases sex hormone-binding globulin (SHBG). The subsequent increase in bioavailable testosterone may correlate with increased sexual desire.

Limited data on the long-term effects of TT led the FDA to reject a proposed testosterone patch for women with FSD. However, a 1% testosterone gel, FDA-approved for use in men only, is often prescribed off label to postmeno­pausal women with sexual dysfunction.33 One study showed that a dosage of 10 mg/day, applied in a thin layer to 15 cm2 of the inner thigh, led to mean testosterone levels of 3.0 nmol/L, which is in the high-normal range for premenopausal women (?2.5-3.0 nmol/L).33 The advantage of the transcutaneous route of administration over other routes (e.g., subcutaneous implant, intramuscular injection) is that it avoids the high hormone levels in the hepatic portal vein, which helps minimize assault to the liver.33

The most common short-term side effects of TT in women are hirsutism, acne, and a deepened voice, all of which are mild and reversible.34 Long-term side effects of concern are cardiovascular disease (CVD) and breast cancer. Preliminary studies have shown that TT reduces high-density lipoprotein cholesterol levels and increases low-density lipoprotein cholesterol levels; however, no study has looked at the correlation between TT in women and CVD.32 Studies examining the effects of TT on breast cancer risk are incon­clu­sive.32 Absolute contraindications to TT include a history of breast cancer, endometrial cancer, veno­thrombotic events, or CVD.14

When prescribing TT, HCPs should ask women to undergo baseline and annual breast exams and mammography, along with a pelvic exam—with special consideration paid to abnormal bleeding.14 In addition, women must be regularly evaluated for acne, hirsutism, and androgenic alopecia.14 Laboratory parameters monitored at baseline, after 3-6 months of use, and then periodically thereafter include SHBG, total testosterone, fasting lipid panel, and liver function tests.14

In 2005, NAMS published a position statement regarding the role of TT in postmenopausal women. The society concluded that TT is a valuable pharmacologic option for postmenopausal women who pre­sent with symptoms of decreased sexual desire.35 Nevertheless, NAMS cautions that insufficient data are available regarding the safety and efficacy of TT in women for longer than 6 months.35 Given these data, testosterone is prescribed with caution, with extensive patient education.

Bupropion
Bupropion is a norepinephrine and dopamine reuptake inhibitor antidepressant without serotonergic effects.36 Although bupropion is most commonly used as an antidepressant, this agent is used off label to treat sexual dysfunction in non-depressed women.37 The exact mechanism of bupropion’s efficacy for this indication is unknown but may be related to increased uptake of dopamine and norepinephrine, both of which are correlated with increased sexual responsiveness.36

The prescribed dosage of bu­pro­pion should not exceed 400 mg/day for the sustained-release formulation or 450 mg/day for the immediate- or extended release formulations; higher dos­ages can increase the incidence of side effects such as headache, agitation, insomnia, nausea, and possibly seizures.38 Bupropion is not prescribed to patients with a history of anorexia, bulimia, or seiz­ure disorders. Bupropion users must be monitored for neuro­psychiatric changes such as hostility, agitation, depression, and suicidality.39 Patients are counseled that treatment efficacy may not occur for 4-6 weeks.

Bupropion is a promising non-hormonal treatment option for FSD. Preliminary studies have shown encouraging results; however, more extensive research is needed before FSD can be listed as an indication for bupropion use.40Ospemifene
In 2013, the FDA approved ospemifene (OsphenaTM) for treatment of moderate to severe dyspareunia caused by VVA in menopausal women.41 Ospemi­fene, an oral selective estrogen receptor modulator, is the only non-estrogen compound approved in the U.S. to treat moderate to severe dyspareunia.42 This medication can be offered to women who are not candidates for ET but who have FSD related to dyspareunia. In two 12-week phase III clinical trials, ospemifene significantly improved vaginal dryness and dyspareunia, vaginal maturation index, and vaginal pH.43 The most effective dosage is 60 mg/day.43

The most common adverse effect of ospemifene is VMS.43 This agent is contraindicated in women with genital bleeding of unknown cause, estrogen-dependent neoplasia, personal history of deep vein thrombosis, pulmonary embolism, stroke, or myocardial infarction. Ospemifene should not be prescribed to women with a history of breast cancer or who are at high risk for breast cancer. Pre-clinical and clinical trials show a promising effect of ospemifene on bone density and breast tissue, but long-term data on the safety of this medication are limited.42Flibanserin
Flibanserin, an oral agent proposed for treatment of premeno­pausal hypoactive sexual desire disorder, has been shown to significantly increase sexual desire and the number of sexually satisfying events among women taking 100 mg at bedtime.44 The FDA initially rejected this medication in 2010.44 When Sprout Pharmaceuticals reapplied for approval in 2013, flibanserin was once again rejected; this time, the FDA indicated that additional studies in healthy subjects were needed to evaluate drug interactions and the drug’s possible adverse effect on driving.45 Sprout is expecting to resubmit the proposal by the end of the first quarter of 2015.45 No more information on the proposal was available as this article went to press.

Conclusion

Given the prevalence of FSD, HCPs must know how to screen for and diagnose FSD, and then manage it or know when to refer. HCPs need to take a short sexual history in all women, and ask them whether they have concerns about their sexual activity or about changes in their sexual desire or response. If the history uncovers a possibility of FSD, a thorough physical exam and lab testing are done. For women in whom FSD is diagnosed, nonpharmacologic interventions include CBT, sex therapy, self-stimulation, and lubricants. Two medications—conjugated estrogens vaginal cream and ospemifene —have a specific indication for dyspareunia. Although no pharmacologic agent has been approved by the FDA to treat desire, arousal, or orgasmic dysfunction in women, interest in such agents is growing. In each case, HCPs weigh the risks and benefits of specific treatments, offer extensive patient counseling, and provide close follow-up.

Casey B. Giebink is an adult and women’s health nurse practitioner at Medstar Georgetown University Hospital, Department of Ob&Gyn in Washington, DC. Ivy M. Alexander is an adult nurse practitioner specializing in midlife women’s health at the University of Connecticut Health Center in Storrs and Clinical Professor at the University of Connecticut School of Nursing. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Leiblum SR, Koochaki PE, Rodenberg CA, et al. Hypoactive sexual desire disorder in postmenopausal women: US results from the Women’s International Study of Health and Sexuality (WISHeS). Menopause. 2006;13(1):46-56.

2. Harsh V, McGarvey EL, Clayton AH. Physician attitudes regarding hypoactive sexual desire disorder in a primary care clinic: a pilot study. J Sex Med. 2008;5(3):640-645.

3. Loeb DF, Aagaard EM, Cali SR, Lee RS. Modest impact of a brief curricular intervention on poor documentation of sexual history in university-based resident internal medicine clinics. J Sex Med. 2010; 7(10):3315-3321.

4. Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, et al. Predictors of physicians’ involvement in addressing sexual health issues. J Sex Med. 2006;3(4):583-588.

5. Bekker M, Beck J, Putter H, et al. The place of female sexual dysfunction in the urological practice: results of a Dutch survey. J Sex Med. 2009;6(11):2979-2987.

6. Mansell D, Salinas G, Sanchez A, Abdolrasulnia M. Attitudes toward management of decreased sexual desire in premenopausal women: a national survey of nurse practitioners and physician assistants. J Allied Health. 2011;40(2):64-71.

7. Roos A-M, Thakar R, Sultan A, Scheer I. Female sexual dysfunction: are urogynecologists ready for it? Int Urogynecol J. 2009;20(1):89-101.

8. Julien JO, Thom B, Kline NE. Identification of barriers to sexual health assessment in oncology nursing practice. Oncol Nurs Forum. 2010;37(3):E186-E190.

9. Berman L, Berman J, Felder S, et al. Seeking help for sexual function complaints: what gynecologists need to know about the female patient’s experience. Fertil Steril. 2003;
79(3):572-576.

10. Peck SA. The importance of the sexual health history in the primary care setting. J Obstet Gynecol Neonatal Nurs. 2001;30(3):269-274.

11. Giraldi A, Rellini A, Pfaus J, et al. Questionnaires for assessment of female sexual dysfunction: A review and proposal for a standardized screener. J Sex Med. 2011;8(10):2681-2706.

12. Andrews WC. Approaches to taking a sexual history. J Womens Health Gend Based Med. 2000;9 (suppl 1):S21-S24.

13. Sarrel PM. Sexual dysfunction: treat or refer. Obstet Gynecol. 2005;
106(4):834-839.

14. Basson R, Wierman ME, Van Lankveld J, Brotto L. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2010;7(1 pt 2):314-326.

15. Zakhari R. Female sexual dysfunction: a primary care perspective. J Am Acad Nurse Pract. 2009;21(9): 498-505.

16. Kaplan C. Assessing & managing female sexual dysfunction. Nurs Pract. 2009;34(1):42-48.

17. Rogalski M, Kellogg-Spadt S, Hoffmann A, et al. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J. 2010;21(7):895-899.

18. Wylie K, Daines B, Jannini EA, et al. Loss of sexual desire in the postmenopausal woman. J Sex Med. 2007;4(2):395-405.

19. Krychman ML, Dizon D, Amsterdam A, Spadt SK. Evaluation of the female with sexual dysfunction. In: Mulhall JP, Incrocci L, Goldstein I, Rosen R, eds. Cancer and Sexual Health. Humana Press; 2011:351-356.

20. Guay A, Jacobson J, Munarriz R, et al. Serum androgen levels in healthy premenopausal women with and without sexual dysfunction: Part B: Reduced serum androgen levels in healthy premenopausal women with complaints of sexual dysfunction. Int J Impot Res. 2004;16(2):121-129.

21. American Psychiatric Association. Highlights of Changes from DSM-IV-TR to DSM-5. 2013. http://www.psychiatry.org/dsm5

22. Leiblum SR, Wiegel M. Psychotherapeutic interventions for treating female sexual dysfunction. World J Urol. 2002;20(2):127-136.

23. Palacios S, Graziottin A. Patient scenario: A 53-year-old woman with hypoactive sexual desire disorder. Maturitas. 2009;63(2):164-168.

24. Katz A. When sex hurts: Meno­pause-related dyspareunia. Am J Nurs. 2007;107(7):34-36.

25. Long CY, Liu CM, HSU SC, et al. A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal wom­en. Menopause. 2006;13(5):737-743.

26. Premarin Vaginal prescribing information. Wyeth Pharmaceuticals Inc., a subsidiary of Pfizer Inc. May 2012. http://labeling.pfizer.com/showlabeling.aspx?id=132

27. Simon JA. Identifying and treating sexual dysfunction in postmenopausal women: the role of estrogen deficiency and estrogen therapy. J Womens Health (Larchmt). 2011;20(10):1453-1465.

28. Sturdee DW, Panay N, International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010; 13(6):509-522.

29. North American Menopause Society. Estrogen and progestogen use in postmenopausal women: position statement of the North American Menopause Society. Menopause. 2010;17(2):242-255.

30. North American Menopause Society. The 2012 hormone therapy position statement of The North American Menopause Society. Menopause. 2012;19(3):257-271.

31. Raghunandan C, Agrawal S, Dubey P, et al. A comparative study of the effects of local estrogen with or without local testosterone on vulvovaginal and sexual dysfunction in postmenopausal women. J Sex Med. 2010;7(3):1284-1290.

32. Somboonporn W, Davis S, Seif MW, Bell R. Testosterone for peri-and postmenopausal women. Cochrane Database Syst Rev. 2005;
(4)CD004509.

33. Nathorst böös J, Jarkander-Rolff M, Carlström K, et al. Percutaneous administration of testosterone gel in postmenopausal women-a pharmacological study. Gynecol Endocrinol. 2005;20(5):243-248.

34. Kingsberg SA, Simon JA, Goldstein I. The current outlook for testosterone in the management of hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2008;5(suppl 4):182-193.

35. North American Menopause Society. The role of testosterone therapy in postmenopausal women: position statement of the North American Menopause Society. Menopause. 2005;12(5):496-511.

36. Segraves RT, Clayton A, Croft H, et al. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. J Clin Psychopharmacol. 2004;24(3):339-342.

37. Segraves RT, Croft H, Kavoussi R, et al. Bupropion sustained release (SR) for the treatment of hypoactive sexual desire disorder (HSDD) in nondepressed women. J Sex Marital Ther. 2001;27(3):303-316.

38. Ginzburg R, Wong Y, Fader JS. Effect of bupropion on sexual dysfunction. Ann Pharmacother. 2005; 39(12):2096-2099.

39. GlaxoSmithKline. Wellbutrin: Medication Guide. 2009.

40. Safarinejad MR, Hosseini SY, Asgari MA, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of bupropion for treating hypoactive sexual desire disorder in ovulating women. BJU Int. 2010;106(6):832-839.

41. US Food and Drug Administration. FDA Approves Osphena for Postmenopausal Women Experiencing Pain During Sex. 2013. www.fda.gov/NewsEvents/Newsroom/Press
Announcements/ucm341128.htm

42. Soe L, Wurz G, Kao CJ, DeGregorio M. Ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy: potential benefits in bone and breast. Int J Womens Health. 2013;5:605-611.

43. North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. 2013;20(9):888-902.

44. Thorp J, Simon J, Dattani D, et al. Treatment of hypoactive sexual desire disorder in premenopausal women: efficacy of flibanserin in the DAISY Study. J Sex Med. 2012;9(3):
793-804.

45. Reuters. PR Newswire. Sprout Pharmaceuticals receives clear guidance from FDA on path forward to resubmit new drug application for flibanserin, the first potential medical treatment for hypoactive sexual desire disorder in premenopausal women. February 11, 2014. www.reuters.com/article/2014/02/11/sprout-pharmaceutical-idUSnPn
CGr7Dhn+164+PRN20140211

Billable coding for female sexual dysfunction disorders

PDF 50
 
By Brooke M. Faught, MSN, WHNP-BC, IF

Billable coding for general medical diagnoses and procedures is a complicated process. Within a subspecialty such as female sexual health, which lacks a clear consensus regarding diagnostic coding for sexual dysfunctions, the process can be even more challenging and frustrating. As such, some women’s healthcare providers do not even treat patients with sexual dysfunction in their practices. The purpose of this very first article in the “Focus on sexual health” department is to shed light on the billable coding process for female sexual dysfunction disorders in order to clarify, if not simplify, this process.

DSM-5 categories

The World Health Organization’s International Classification of Diseases (ICD) is utilized in the United States for diagnostic coding for most diseases and other health problems. However, female sexual dysfunction (FSD) diagnoses were developed through the American Psychiatric Association and are listed in the Diagnostic and Statistical Manual (DSM). A text revision of the fourth edition, the DSM-IV-TR,1 published in 2000, included five categories of FSD: hypoactive sexual desire disorder (HSDD), female sexual arousal disorder, female orgasmic disorder, dyspareunia, and vaginismus. With release of the fifth edition, the DSM-5,2 desire and arousal disorders were merged into one unified diagnostic category—female sexual interest/arousal disorder—and vaginismus and dyspareunia were merged into genito-pelvic pain/penetration disorder (Table 1).1,2 A subcategory of HSDD, sexual aversion disorder, was removed.2

According to the DSM-5, in order to meet diagnostic criteria, a person must experience the FSD condition 75%-100% of the time for at least 6 months.2 In addition, the condition must result in significant distress. The disorder must not better be explained by a nonsexual mental disorder, a consequence of severe relationship distress such as domestic violence, or other significant stressors. Also, a new severity scale, which designates a condition as mild, moderate, or severe, was added to allow for more diagnostic specificity.

Current and future ICD diagnostic codes

With regard to the complicated matter of translating these definitions into billable coding, women’s healthcare providers must consider the landscape of the ninth edition, clinical modification, of the ICD (ICD-9-CM).3 Diagnostic codes are categorized into chapters of different body systems, symptoms, and conditions. One of the chapters is mental and behavioral disorders, which coincides with DSM definitions. This chap­ter includes the FSD diagnostic codes. When billing for patient care specific to FSD diagnoses, providers will find that these disorders are typically covered through a separate division of a patient’s healthcare plan or that they are not covered at all. To overcome this challenge, providers can find codes in other areas of the ICD-9-CM that cover symptoms of FSD such as low libido and dyspareunia (Table 2).3

To complicate matters further, the tenth edition of the ICD (ICD-10) is slated to be released in October 2015. Whereas previous revisions to the ICD were fairly easy to follow, ICD-10 coding will not resemble the familiar ICD-9 terrain at all. To begin, the first character of each code is a letter of the alphabet, not a number.4 F codes will cover mental, behavioral, and neuro­developmental disorders. Other chapters of relevance to women’s healthcare providers are E codes for endocrine, nutritional, and metabolic diseases; L codes for diseases of the skin and subcutaneous tissue; M codes for diseases of the musculo­skeletal system and connective tissue; N codes for diseases of the genitourinary system; and R codes for symptoms, signs, and abnormal clinical and laboratory findings.4Table 3 compares ICD-9-CM and ICD-10 codes related to FSD (with the latter codes still subject to change) and Table 4 lists additional codes that may apply to female sexual complaints.

CPT codes

Table 5 lists Current Procedural Terminology® (CPT) codes for procedures commonly performed in a sexual health practice. In many cases, though, time spent with female patients reporting sexual complaints can surpass that spent performing hands-on examinations and procedures. In these circumstances, providers should bill based on time spent, assuming that more than 50% of the time spent with the patient was face to face and for counseling. If a procedure is performed on the same day as an evaluation and management visit for a separately identifiable complaint, providers should use modifier 25 so that each element can be billed at 100%.

Conclusion

Although navigating the complicated billable coding process for FSD can be confusing and frustrating, treatment for these conditions is frequently reimbursable. General understanding of ICD and DSM terms and codes is critical to smart billable coding. If uncertain about a particular situation, women’s healthcare providers should consult with a billing and coding specialist.

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.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA; 2000.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC; APA; 2013.

3. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) Professional Edition. USA: Elsevier/American Medical Association; 2013.

4. ICD-10-CM: The Complete Official Draft Code Set. USA: American Medical Association; 2014.

It’s not just physical: The adverse psychosocial effects of polycystic ovary syndrome in adolescents

 

Management of polycystic ovary syndrome (PCOS) in adolescents entails dealing not only with the physical manifestations but also the troubling psychosocial effects related to these physical manifestations. The author conducted a literature review to ascertain the adverse psychosocial effects of PCOS in adolescents, as well as what nurse practitioners can do to mitigate these effects.

Key words: polycystic ovary syndrome, PCOS, adolescence, psychosocial effects

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects 5%-10% of women and typically begins during adolescence.1-5 Common physical manifestations of PCOS—acne, obesity, hirsutism, and anovulation—can have adverse effects on adolescents’ self-image and mood.6,7 As a result, many of these girls may withdraw from their peers because of emotional distress or embarrassment. In addition to lowering self-esteem, obesity and the features of metabolic syndrome can increase the risk for future health complications,8,9 which in turn can provoke anxiety in adolescents who are aware of these risks. With all of these negative forces at play, adolescents with PCOS are also at increased risk for depression.10 In this article, the author shares the results of a literature search on the psychosocial concerns related to PCOS in adolescents and what nurse practitioners can do to address these concerns.

Literature review

The author searched the PubMed, Google Scholar, CINAHL, and JSTOR databases to find articles published between 2002 and 2013 that pertained to the adverse psychosocial effects of PCOS in adolescents, including management of these effects. Key words in the search were polycystic ovarian syndrome, PCOS, adolescence, teens, quality of life,
psychosocial, psychosocial issues, depression, anxiety, eating disorders, hirsutism, obesity, and metabolic syndrome. Other articles were found by hand-searching relevant studies cited in the articles initially found.

Articles met inclusion criteria if they covered psychosocial concerns related to PCOS in adolescents. Articles describing the physical effects of PCOS were included if they served to provide relevant background information. Studies focusing only on adults were excluded unless, again, they provided useful background information or they compared PCOS-related psychosocial concerns in adolescents versus adults.

Psychosocial concerns related to PCOS

Table 1 lists selected studies related to psychosocial concerns in adolescents with PCOS. These concerns include anxiety and depression,1,4 social interaction,11,12 body image,11 body weight,1,11,13,14 eating disorders,15 hirsutism,13 fertility,2,11,13 and decreased quality of life (QOL) related to sexual behavior.2,11 Health-related QOL (HQOL) scores in adolescents have been correlated with the level of PCOS symptomatology.14 A qualitative study showed that a PCOS diagnosis had an adverse impact on HQOL, with emotional and social functioning being more affected than physical health.11

Psychological problems

According to a report by Dowdy,10 adolescents with PCOS commonly use words such as nerd or freak to describe themselves; PCOS changes their bodies, which makes them feel different from other adolescents. A small study showed that adolescents with PCOS, compared with healthy adolescents, had higher anxiety scale scores.4 Dowdy10 reported that anxiety among adolescents with PCOS was related to their appearance, body-image concerns, and fear of future infertility.

Insulin resistance and increased levels of insulin in the bloodstream, which are common in patients with PCOS, have been thought to cause problems with mood.16 Insulin levels in the blood can affect serotonin levels in the brain and vice versa, so it is unclear whether insulin abnormalities initiate depressive symptoms or are the result of them.10

Body weight and body-image disturbances

Overweight/obesity (OW/O) and an elevated body mass index (BMI) are more common in adolescents with PCOS than in those without PCOS.8,14 Excess weight, among all the physical manifestations of PCOS in adolescents, has the greatest adverse impact on HQOL.17,18 One study showed that HQOL scores were inversely proportional to BMI values in teens with PCOS and high BMIs.14 PCOS-related OW/O has been linked to decreased academic achievement and lower income, even after controlling for socio­economic status and intelligence. In addition, many females with OW/O are the recipients of hurtful comments and actions from peers, family members, colleagues, strangers, and even some healthcare providers,19 which can lower their self-esteem.

Other body-image concerns in adolescents with PCOS involve male-pattern hair on the face and body and acne.10 Adolescents with hirsutism, versus those without the condition, have lower HQOL scores and self-esteem and an increased prevalence of anxiety disorders.20 Some adolescents report feeling that hirsutism has robbed them of their female identity.10 PCOS-related insulin resistance increases the risk for developing acanthosis nigricans (a brown to black, poorly defined, velvety hyperpigmentation of the skin),21 another body-image concern because of its physical visibility.

Femininity, fertility, and sexuality concerns

According to the dictionary, feminine means “having the qualities traditionally ascribed to women.”22 Menstruation is an important symbol of femininity; menarche and a normal menstrual cycle serve as rites of passage that prove that a female has the ability to reproduce.4 Adolescents with PCOS, versus their healthy peers, are more likely to have concerns about their future fertility because of their menstrual irregularities.2 Fear of potential infertility has an adverse impact on HQOL.

Adolescents with PCOS, compared with adolescents who do not have PCOS, may feel more self-conscious, less desirable, and less inclined to be outgoing with persons to whom they are attracted.10 A teen with PCOS may feel unsexy or unwomanly because her body has “let her down,” and she may have less sexual interest because of the many PCOS-related stressors with which she must cope.10Eating disorders
Results of a retrospective study showed that adolescents with menstrual disturbances were at greater risk of having an eating disorder.23 Adolescents with OW/O may develop unhealthy eating habits such as binge eating, purging, dieting, and using diuretics or laxatives to lose weight.24 Some adolescents with PCOS feel that their efforts to lose weight are not as successful as those of their peers who do not have PCOS.10

Screening for adverse psychosocial effects of PCOS

Screening for psychosocial concerns related to PCOS should start early in adolescence. Table 2 lists screening tests available for identification of psychosocial problems.25 An evaluation of the Polycystic Ovary Syndrome Questionnaire (PCOSQ) by Jones et al26 found this tool reliable for determining HQOL in women with PCOS. Validity of the tool could be improved with the addition of acne to the questionnaire because of acne’s identification as an important factor involved in HQOL. Although the PCOSQ was first developed based on research conducted on women,27 it has been used in adolescents to assess psychosocial concerns related to PCOS.13

NP role in managing psychosocial effects of PCOS

Goals of therapy for adolescents with PCOS—amelioration of psychological problems, weight loss, reduction of the manifestations of hyperandrogenism, and improvement in body image and self-esteem—are best achieved by a multidisciplinary team that includes NPs.3,4,28 The physical and psychosocial aspects of treatment go hand in hand. Meeting physical management goals (e.g., weight loss, reduction in hyperandrogenism manifestations) can lessen some of the troubling psychosocial effects, and enhancing self-esteem can motivate weight-loss efforts and perhaps even improve adherence to the pharmacotherapeutic regimen. One of the best ways that NPs can help is to supply adolescent patients with information about PCOS and its treatment that they can understand.

Mental health approaches

An open trial of weekly cognitive behavioral therapy sessions and family sessions has shown that these modalities may help treat both depressive symptoms and obesity in adolescents with PCOS.1 Participating in individual and family sessions can help patients develop positive methods of coping with PCOS and find constructive ways to manage their feelings. Support groups that meet in person or online can help motivate adolescents to make and maintain healthy lifestyle choices.29,30 NPs can recommend any or all of these psychotherapeutic approaches.

Lifestyle changes

Weight loss of 5%-10% may not only decrease cardiovascular risks and insulin resistance but also help improve HQOL.8,14,31 NPs should ascertain which weight-loss strategies have worked or not worked in the past, and identify any unsafe weight-loss strategies and eating patterns in which patients may be engaged.24,29 In these cases, NPs should offer patients safe alternatives for losing weight.24

A case–control study showed that, compared with controls, girls with PCOS engaged in physical activities less often (if they did exercise, they did so with less frequency and intensity), and they were less likely to be aware of the beneficial effects of exercise on their health.32 NPs should encourage patients to exercise regularly, which may help increase their self-esteem and overall health.13,19 Yoga may be even more beneficial; results of a recent randomized, controlled trial indicated that yoga effectuated a significantly greater increase in HQOL than did traditional exercise.33

With regard to approaches to counter the effects of hyperandrogenism, unwanted hair can be removed temporarily via shaving, waxing, and/or plucking (which unfortunately may cause other unwanted effects such as irritation, scarring, or folliculitis). Laser treatments can provide more permanent results, but many treatments may be needed and the treatments may be costly.34

Medications

Oral contraceptives (OCs) regulate menstrual cycles and treat hirsutism and acne.28,34 Insulin sensitizers such as metformin can be used to treat underlying insulin resistance.34,35 However, a randomized, placebo-controlled trial showed that adding metformin to a regimen of lifestyle changes and OC use did not lead to a significant improvement in HQOL.13 Anti-androgens such as spironolactone can help manage the hyperandrogenism effects.34,36 Statins are first-line treatments for lowering low-density lipoprotein cholesterol levels.37 Antidepressants and anxiolytics can be used to treat psychiatric disorders related to PCOS; in these cases, NPs may want to consult with a mental health specialist.

Further research

An important topic for future study is the efficacy of implementing a HQOL survey at every primary care visit for adolescents with PCOS. The purpose of this survey would be to assess for psychosocial co-morbidities common in individuals with PCOS. The studies should ascertain whether implementing such a screening would make providers more aware of the adverse psychosocial effects of PCOS, help identify psychosocial symptoms, and facilitate more comprehensive treatment when needed. Additional research should determine the outcomes of losing weight, how other PCOS-specific interventions affect overall HQOL, how to address infertility concerns, and how primary care practitioners can best manage adolescents holistically to help improve HQOL. More research is needed regarding how providers should teach and communicate with adolescents with PCOS.

Conclusion

Polycystic ovary syndrome in adolescents involves a myriad of physical manifestations that can compromise psychosocial health. These adverse psychosocial effects may have a major impact on HQOL. Early diagnosis of PCOS, screening for adverse psychosocial effects, and treatment that reduces physical manifestations of PCOS are important. Lack of attention to these problems can force adolescents to endure adverse psychosocial effects that can lead to further unhealthy behaviors. NPs have an opportunity to educate adolescents about the disease process of PCOS and to implement strategies to treat these patients’ physical and psychosocial problems to improve their HQOL for a lifetime.

Joyce S. Lee is a certified pediatric nurse practitioner who graduated from Columbia University School of Nursing in New York, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author thanks Rita Marie John, DNP, EdD, CPNP-PC, DCC, for her help, editing, and counsel during the preparation and writing of this article.

References
1. Rofey DL, Szigethy EM, Noll RB, et al. Cognitive–behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. J Pediatr Psychol. 2009;34(2):156-163.

2. Trent ME, Rich M, Austin SB, Gordon CM. Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life. J Pediatr Adolesc Gynecol. 2003;16(1):33-37.

3. Bekx MT, Connor EC, Allen DB. Characteristics of adolescents presenting to a multidisciplinary clinic for polycystic ovarian syndrome. J Pediatr Adolesc Gynecol. 2010;23(1):7-10.

4. Laggari V, Diareme S, Christogiorgos S, et al. Anxiety and depression in adolescents with polycystic ovary syndrome and Mayer-Rokitansky-Küster-Hauser syndrome. J Psychosom Obstet Gynaecol. 2009;30(2):83-88.

5. Rachmiel M, Kives S, Atenafu E, Hamilton J. Primary amenorrhea as a manifestation of polycystic ovarian syndrome in adolescents: a unique subgroup? Arch Pediatr Adolesc Med. 2008;162(6):521-525.

6. Perrin JM, Gnanasekaran S, Delahaye J. Psychological aspects of chronic health conditions. Pediatr Rev. 2012;33(3):99-109.

7. Leventhal H, Leventhal EA, Contrada RJ. Self-regulation, health, and behavior: a perceptual-cognitive approach. Psychol Health. 1998; 13(4):717-733.

8. Coviello AD, Legro RS, Dunaif A. Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance. J Clin Endocrinol Metab. 2006;91(2):492-497.

9. Snyder BS. Polycystic ovary syndrome (PCOS) in the adolescent patient: recommendations for practice. Pediatr Nurs. 2004;31(5):416-422.

10. Dowdy D. Emotional needs of teens with polycystic ovary syndrome. J Pediatr Nurs. 2012;27(1):55-64.

11. Jones GL, Hall JM, Lashen HL, et al. Health-related quality of life among adolescents with polycystic ovary syndrome. J Obstet Gynecol Neonatal Nurs. 2011;40(5):577-588.

12. Trent ME, Rich M, Austin SB, Gordon CM. Quality of life in adolescent girls with polycystic ovary syndrome. Arch Pediatr Adolesc Med. 2002;156(6):556-560.

13. Harris-Glocker M, Davidson K, Kochman L, et al. Improvement in quality-of-life questionnaire measures in obese adolescent females with polycystic ovary syndrome treated with lifestyle changes and oral contraceptives, with or without metformin. Fertil Steril. 2010;93(3):1016-1019.

14. Trent M, Austin SB, Rich M, Gordon CM. Overweight status of adolescent girls with polycystic ovary syndrome: body mass index as mediator of quality of life. Ambul Pediatr. 2005;5(2):107-111.

15. Wiksten-Almstromer M, Linden-Hirschberg A, Hagenfeldt K. Menstrual disorders and associated factors among adolescent girls visiting a youth clinic. Acta Obstet Gynecol Scand. 2007;86(1):65-72.

16. Weiner CL, Primeau M, Ehrmann DA. Androgens and mood dysfunction in women: comparison of women with polycystic ovarian syndrome to healthy controls. Psychosom Med. 2004;66(3):356-362.

17. Adali E, Yildizhan R, Kurdoglu M, et al. The relationship between clinico-biochemical characteristics and psychiatric distress in young women with polycystic ovary syndrome. J Int Med Res. 2008;36(6):1188-1196.

18. Hoeger KM. Obesity and lifestyle management in polycystic ovary syndrome. Clin Obstet Gynecol. 2007;50(1):277-294.

19. Zidenberg N, Wright S. Care of the overweight adolescent including polycystic ovarian syndrome. Clin Obstet Gynecol. 2008;51(2):249-256.

20. Drosdzol A, Skrzypulec V, Plinta R. Quality of life, mental health and self-esteem in hirsute adolescent females. J Psychosom Obstet Gynaecol. 2010;31(3):168-175.

21. Bhattacharya SM, Ghosh M. Insulin resistance and adolescent girls with polycystic ovary syndrome. J Pediatr Adolesc Gynecol. 2010;23(3):158-161.

22. Steinmetz S, ed. Feminine. In: Random House Webster’s Unabridged Dictionary. 2nd ed. New York, NY: Random House, Inc; 1997:708.

23. Wiksten-Almstromer M, Linden-Hirschberg A, Hagenfeldt K. Menstrual disorders and associated factors among adolescent girls visiting a youth clinic. Acta Obstet Gynecol Scand. 2007;86(1):65-72.

24. Jasik CB, Lustig RH. Adolescent obesity and puberty: the “perfect storm.” Ann N Y Acad Sci. 2008; 1135(1):265-279.

25. Jones GL, Balen AH, Ledger WL. Health-related quality of life in PCOS and related infertility: how can we assess this? Hum Fertil. 2008;11(3):173-185.

26. Jones GL, Benes K, Clark TL, et al. The polycystic ovary syndrome health-related quality of life questionnaire (PCOSQ): a validation. Hum Reprod. 2004;19(2):371-377.

27. Cronin L, Guyatt G, Griffith L, et al. Development of a health-related quality-of-life questionnaire (PCOSQ) for women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab. 1998;83(6):1976-1987.

28. Mastorakos G, Lambrinoudaki I, Creatsas G. Polycystic ovary syndrome in adolescents: Current and future treatment options. Paediatr Drugs, 2006;8(5):311-318.

29. Nicandri KF, Hoeger K. Diagnosis and treatment of polycystic ovarian syndrome in adolescents. Curr Opin Endocrinol Diabetes Obes. 2012;19(6):497-504.

30. Yii MF, Lim CED, Luo X, et al. Polycystic ovarian syndrome in adolescence. Gynecol Endocrinol. 2009;25(10):634-639.

31. Wild RA, Carmina E, Diamanti-Kandarakis E, et al. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society. J Clin Endocrinol Metab. 2010;95(5):2038-2049.

32. Eleftheriadou M, Michala L, Stefanidis K, et al. Exercise and sedentary habits among adolescents with PCOS. J Pediatr Adolesc Gynecol. 2012;21(3):172-174.

33. Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Effect of yoga program on quality of life in adolescent polycystic ovarian syndrome: a randomized control trial. Appl Res Qual Life. 2013;8(3):373-383.

34. Williams RM, Ong KK, Dunger DB. Polycystic ovarian syndrome during puberty and adolescence. Mol Cell Endocrinol. 2013;373(1-2):61-67.

35. Salmi DJ, Zisser HC, Jovanovic L. Screening for and treatment of polycystic ovary syndrome in teenagers. Exp Biol Med. 2004;229(5):369-377.

36. Arslanian S, Warren-Ulanch J. Treatment of PCOS in adolescence. Best Pract Res Clin Endocrinol Metab. 2006;20(2):311-330.

37. Wild RA. Dyslipidemia in PCOS. Steroids. 2012;77(4):295-299.

Barriers to care for sexual assault survivors of childbearing age: An integrative review

Research indicates that only a small fraction of sexual assault survivors seek comprehensive care—including physical and mental healthcare, forensic evidence collection, victim services, and legal support—after the assault. This integrative review was conducted to identify barriers that may be keeping sexual assault survivors of childbearing age from receiving such comprehensive care.

Key words: sexual assault, barriers to care, comprehensive care

For women in the United States, one of the most likely causes of severe psychological trauma is sexual assault, defined as unwanted sexual contact in any form that occurs without a person’s consent.1,2 Survivors of a completed rape have a 32%-80% incidence of posttraumatic stress disorder (PTSD), versus a rate of 9%-15% in the general population.3-6 In addition to psychological harm, sexual assault survivors may experience physical consequences such as bodily injury, sexually transmitted infections (STIs), and pregnancy. In the immediate aftermath of a sexual assault, about half of survivors show evidence of physical trauma, up to 30% contract an STI, and 5% become pregnant.7,8 Furthermore, survivors are up to 9 times more likely than the average woman to attempt suicide.9 Despite these potential health risks, a major gap exists between reported rates of sexual assault and rates of comprehensive care seeking following the assault.

Statement of the problem

In this country, 1 of every 4-5 women is raped in college,10,11 and lifetime prevalence of rape is 1 in 6-10 women.1,12 Following sexual assault, women may have a need for comprehensive care provided at a rape crisis center or hospital emergency department (ED)—ideally by a specially trained sexual assault nurse examiner (SANE). Recommended comprehensive care following a sexual assault includes treatment of physical injuries and other sequelae, pregnancy prevention, STI screening and treatment, psychological support and care for potential PTSD, forensic evidence collection, victim services, and legal support.1,13-16

Many sexual assault survivors do not receive the comprehensive care they need. In one analysis of post-assault care seeking, only one-third of rape survivors sought assistance from one or more of the following: the legal system, the medical system, the mental healthcare system, a rape crisis center, and/or the religious communi­ty.17 Another report indicated that 4 million U.S. women have not received medical attention focused on preventing or treating the physical and emotional effects of rape.8

The study

The author conducted an integrative literature review to ascertain the barriers that may be keeping childbearing-age women from seeking comprehensive care following sexual assault. The review was focused on survivor, advocate, healthcare provider (HCP), police, and student perspectives.

Method—Five steps were used: problem identification, literature search, data evaluation, data analysis, and presentation.18 An integrative review was appropriate because of the mix of quantitative and qualitative data that were available.18,19Problem identification. The author analyzed empirical studies and national surveys completed between 1990 and 2012. The research question guiding the review was “What are the barriers that may prevent sexual assault survivors of childbearing age from receiving comprehensive care?”

Literature search. The review was conducted at a university library using the search terms sexual assault, rape, barriers to care, barriers, inhibitors, impede, comprehensive care, health care, and health care access. The search utilized a variety of databases. National surveys were identified separately by searching national websites. Only studies whose purpose was to identify barriers to care for sexual assault survivors of childbearing age were included. These studies had to be written in English in the form of scholarly works, dissertations, or qualitative or quantitative research. Excluded were papers unrelated to the research question, commentaries, literature reviews, and papers not written in English.

The initial search elicited 220 articles with the following distribution: Cochrane Database of Systematic Reviews (n = 3), CINAHL (n = 12), EMBASE (n = 101), ISI Web of Knowledge (n = 52), PubMed (n = 37), and PsycINFO (n = 15). Many of these 220 articles were duplicates, and only 11 met all inclusion criteria. By hand-searching the references of these 11 articles, the author found 1 additional article for inclusion, resulting in a total of 12 empirical articles. In addition, 4 national surveys described in 6 different reports met inclusion criteria.

Data evaluation and analysis. Data extraction for the 4 national surveys and 12 empirical studies was conducted with use of a table to identify key components. The author extracted data about the sample, study design, outcomes measured, instruments utilized, results related to the research question, validity, and notes. Results related to the research question were reviewed for common themes using a technique similar to the constant comparative method of analysis outlined by Glaser.20 This technique entailed reading through the results to glean general thoughts, followed by a line-by-line review to evaluate for general themes using a color-coding system. Further review elicited core themes. The data were reviewed again to find commonalities in themes among the studies. Finally, the data were compiled into over­arching themes related to the research question and assessed for the information they represented.

Whittemore and Knafl18 noted that the diverse array of primary sources in an integrative literature review increases the complexity in evaluating the quality of the literature. Also, in an integrative review with a diverse collection of studies, various threats to internal validity must be addressed.19,21 These threats were determined by assessing the studies’ methodology and data relevance.

Results—
National surveys. Four national surveys were reported in 6 different studies (Table 1).1,2,8,10,22,2Empirical studies. Table 2 lists the 12 empirical research studies that met inclusion criteria. As shown in Table 3, these studies used a cross-sectional methodology24-29 or a descriptive or exploratory qualitative method­ology.30-35 All of the studies’ research questions elicited the barriers that prevented sexual assault survivors of childbearing age from accessing community services such as police re­porting,24 mental healthcare,27 medical care,25 and sexual assault centers.26,29Themes. Several themes describing barriers to care emerged. These themes, subdivided into personal and environmental factors, are described in detail using the results from all 18 studies—that is, the 6 reports on national survey data and the 12 empirical studies.

PERSONAL FACTORS. The overarching theme of personal factors encompassed barriers to care inherent to a survivor herself. This broad theme included three subfactors: emotional states, fear of external exposure, and lack of knowledge.

Emotional states. Certain emotional states experienced by a woman after a sexual assault could preclude her from seeking physical, mental, or legal care. These emotional states were identified in 11 (61%) of the 18 studies.1,22,24,26-32,35 Emotional states most commonly cited as barriers were shame,24,28-31 embarrassment or humiliation,1,24,26-29,32,35 guilt,26,28,30,35 and self-blame.22,26Fear of external exposure. Fear of external exposure was described in 12 studies (67%).1,2,8,10,23,24,26,28,29,31,32,35 Fears cited by survivors included bad treatment by the criminal justice system,2,10,23 not being believed,24,28,29 lack of confidentiality,22,24,26,28,29,31,32 going to trial,24 the assailant,1,2,10,23,24,28,31,32,35 and public exposure.8,29 Fears related to the assailant involved fear of retaliation1,10,23,24,28,31,32,35 and, conversely, the possibility of jail for the assailant because the survivor had some type of relationship with the assailant.24 Fear of public exposure was often cited by members of groups such as immigrants, persons with disabilities, sexual minority members, and racial minority members.28 Many of these women feared that their minority status would bring them greater stigma and potentially unfair treatment.

Lack of knowledge. Lack of knowledge regarding post-assault services was identified as a barrier to care in 6 studies (33%).2,23,27,28,31,32 This knowledge deficit encompassed factors such as not knowing which services were needed,31,32 where or how to get services,2,23,28,31,32 and how to pay for services.27,31,32

ENVIRONMENTAL FACTORS. The broad theme of environmental factors captured barriers to care due to outside forces and not within a survivor’s immediate control. These factors were noted in 11 of the 18 studies and included themes of structural/organizational barriers and societal rape myths.

Structural or organizational barriers. Barriers to comprehensive care can include factors related to how these services are accessed. Structural/organization barriers were elicited from 6 studies (33%).25,31-35 For instance, many survivors cited a lack of availability or limited services as a barrier to receiving care.31-33,35 Organizational barriers reported by HCPs included inexperience in treating sexual assault survivors, inadequate time, and personal discomfort.27 Rape victim advocates noted insufficient funding resources as barriers that might compromise survivors’ ability to receive support.33,34Societal myths. Twelve studies (67%) noted the perpetuation of rape myths by society as a factor in preventing survivors from accessing care.1,10,23,24,25,27,29-32,34,35 Many of these myths are propagated through biases related to race, gender, disability, sexual orientation, and class.34 Subsumed within this category is survivors’ perception of the social stigma attached to naming the incident and the belief that the assault was not serious enough to warrant using services.1,10,23,27,29 Societal myths noted by persons in the service sector included police attitudes, including blame and insensitivity24,31,32 and doubt about the validity of the sexual assault accusations.35 Some HCPs perceived that survivors would return to partners who had perpetrated the assault.25Discussion—This review has shown that from survivor, advocate, HCP, police, and student perspectives, numerous barriers to care—encompassing both personal and environmental factors—may prohibit a woman of childbearing age from seeking care after a sexual assault. The overarching theme of personal factors comprised the survivor’s emotional state, her fear as it related to external exposure of the survivor and the assailant, and a lack of knowledge about post-assault services. These results coincide with past research, which has shown that many survivors, especially members of ethnic minorities, lack awareness about post-assault services such as rape crisis centers.17 The broad theme of environmental factors included subthemes of structural/organizational barriers and societal myths. Past research has shown that survivors needed to sit for extended periods of time while they waited to be seen by HCPs who did not have training on the physical or mental aspects of performing a forensic exam.36 In addition, rape myths are known to affect how a survivor deals with an assault, including acquisition of care.37,38 The themes subsumed under environmental factors are long-standing issues that must be addressed using a team approach to improve acquisition of comprehensive care by sexual assault survivors.

Limitations. This review could not completely separate the research articles that dealt with sexual assault and intimate partner violence. One person may be a survivor of both crimes within the same relationship; therefore, many researchers combine the topics. All data were collected via cross-sectional surveys or qualitative interviews and are thus correlational in nature. These data are subject to the possible weaknesses of responses affected by social desirability bias (wherein a respondent wishes to please a researcher) and complicated by the stigma of the topic itself and by problems of recall of traumatic events post-assault.

A limitation specific to the studies in this review was the potential for limited generalizability due to homogenous samples, small sample sizes, and failure to expound on study characteristics. However, the four studies that enrolled college students had fairly heterogeneous samples in terms of age and ethnicity,26,27,29 and most qualitative studies had heterogeneous samples as evidenced by demographic variables and identified themes consistently reported within their study samples.31,32,34

Because a validated and psychometrically sound barriers-to-care scale for sexual assault survivors does not exist, all of the cross-sectional studies used questionnaires specifically created for the purposes of their study. These surveys may not have captured the full range of barriers to care perceived by these survivors.

Strengths. This integrative review demonstrates many strengths within this body of literature. The barriers identified within each individual study, when compared as a group, were consistent. Furthermore, the studies sampled a wide range of individuals. This broad range of participants, coupled with the large geographic region they represent, provides strong evidence for the overall generalizability of the results. Finally, the exploratory and descriptive natures of the included studies have served the purpose of identifying which barriers to care exist for sexual assault survivors of childbearing age.

Implications for practice and research

For nurse practitioners (NPs) working on the front line with survivors of sexual assault, one way to begin to overcome barriers to care is to change the societal atmosphere that perpetuates rape myths. Underlying this atmosphere are patriarchal attitudes and a history of male dominance, both of which support the perpetuation of sexually violent behaviors.

Nurse practitioners need to identify and treat survivors of sexual assault, an all-too-common crime. NPs should consider using screening techniques to identify these survivors, which could simply involve asking about sexual trauma in childhood and adulthood. NPs must also be aware of potential psychological and physical manifestations of past sexual assault, including increased mental health complaints and somatic symptoms, in order to identify hidden survivors who may not freely disclose their history. Universal screening for sexual assault is controversial because of the paucity of research regarding the benefits of early identification and of treatment once a survivor is identified.39 However, NPs do have a responsibility to understand their patients’ histories and their healthcare needs.

In addition, NPs and other HCPs, mental HCPs, and members of the legal system need to know about structural barriers that may exist within their professional realm. One way to surmount these barriers is to promote and expand the use of SANE programs in all EDs. These programs, in which specially trained nurses address survivors’ emotional and medical needs while performing high-quality evidence collection, are a viable alternative to the traditional medical system.13

Nurse practitioners need to advise survivors of their options for pregnancy prevention, STI testing, care of physical injuries, and mental healthcare. And for survivors who have not yet sought post-assault care, NPs can place useful, easy-to-read brochures in public locations such as lavatories, homeless shelters, and community centers. NPs can get brochures and pamphlets from organizations such as the National Sexual Violence Resource Center or the Rape, Abuse & Incest National Network. Additional research is needed to determine the resources that survivors would find most valuable, as well as the easiest ways in which these resources could be provided. For instance, would survivors prefer to receive information about community resources at HCP visits, when they fill prescriptions (e.g., for contraceptives), or through other sources?

Conclusion

Educating women about available resources and recommended care after a sexual assault can help remove personal barriers to care. However, NPs must keep in mind that the community is responsible for minimizing structural barriers. Community members must work together to prevent the occurrence of sexual assault; to provide resources on care, social support, and legal advocacy for instances in which sexual assault has occurred; and to continue to speak with community allies and survivors to determine their needs.

Michelle L. Munro is a research fellow at the University of Michigan School of Nursing in Ann Arbor. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author thanks Dr. Julia Seng and Dr. Kimberlee Gretebeck for the comments and support they provided on this manuscript. The author also gratefully acknowledges grant support by the National Institutes of Health and National Institute of Nursing Research, 5 T32 NR007073-19.

References
1. Tjaden PG, Thoennes N. Extent, Nature, and Consequences of Rape Victimization: Findings from the National Violence Against Women Survey. Washington, DC: U.S. Dept. of Justice, Office of Justice Programs, National Institute of Justice; 2006.

2. Wolitzky-Taylor KB, Resnick HS, McCauley JL, et al. Is reporting of rape on the rise? A comparison of women with reported versus unreported rape experiences in the National Women’s Study – replication. J Interpers Violence. 2011;26(4):807-832.

3. Breslau N, Peterson EL, Schultz LR. A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: a pro­spect­ive epidemiological study. Arch Gen Psychiatry. 2008;65(4):431-437.

4. Foa EB, Rothbaum BO. Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD. New York, NY: The Guilford Press; 1998.

5. Kilpatrick DG, Saunders BE, Amick-McMullan A, et al. Victim and crime factors associated with the development of crime-related post-traumatic stress disorder. Behav Ther. 1998;20:199-214.

6. Resnick HS, Kilpatrick DG, Dansky BS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol. 1993;61(6):984-991.

7. Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175(2):320-325.

8. Resnick HS, Holmes MM, Kilpatrick DG, et al. Predictors of post-rape medical care in a national sample of women. Am J Prev Med. 2000;19(4):214-219.

9. Goodman LA, Koss MP, Russo NF. Violence against women: physical and mental health effects. Part I: research findings. Appl Prevent Psychol. 1993;2(2):79-89.

10. Fisher BS, Cullen FT, Turner MG. The Sexual Victimization of College Women. (No. NCJ 182369). Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2000.

11. Koss MP, Gidycz CA, Wisniewski N. The scope of rape: incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psychol. 1987;55(2):162-170.

12. Basile KC, Chen J, Black MC, Saltzman LE. Prevalence and characteristics of sexual violence victimization among U.S. adults, 2001-2003. Violence Vict. 2007;22(4):437-338.

13. Ahrens CE, Campbell R, Wasco SM, et al. Sexual assault nurse examiner (SANE) programs: alternative systems for service delivery for sexual assault victims. J Interpers Violence. 2000;15:921-943.

14. Campbell R, Bybee D, Ford K, Patterson D. Systems Change Analysis of SANE Programs: Identifying the Mediating Mechanisms of Criminal Justice System Impact. (No. 226497). Washington, DC: U.S. Department of Justice; 2008.

15. Campbell R, Patterson D, Lichty LF. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes. Trauma Violence Abuse. 2005;6:313-329.

16. U.S. Department of Justice, Office on Violence Against Women. A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents. (NCJ 206554); 2004. http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf

17. Campbell R, Wasco SM, Ahrens CE, et al. Preventing the “second rape”: Rape survivors’ experience with community service providers. J Interpers Violence. 2001;16(12):1239-1259.

18. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-553.

19. Cooper HM. Synthesizing Research: A Guide for Literature Reviews. 3rd ed. Thousand Oaks, CA: Sage Publications; 1998.

20. Glaser BG. Advances in the Methodology of Grounded Theory: Theoretical Sensitivity. Mill Valley, CA: Sociology Press; 1978.

21. Kirkevold M. Integrative nursing research—an important strategy to further the development of nursing science and nursing practice. J Adv Nurs. 1997;25:977-984.

22. Kilpatrick DG, Edmunds C, Seymour A. Rape in America: A Report to the Nation. Charleston, SC: National Victim Center & the Crime Victims Research and Treatment Center, Medical University of South Carolina; 1992.

23. Kilpatrick DG, Resnick HS, Ruggiero KJ, et al. Drug-Facilitated, Incapacitated, and Forcible Rape: A National Study. (Document No. 219181); 2007. https://www.ncjrs.gov/pdffiles1/nij/grants/219181.pdf

24. Jones JS, Alexander C, Wynn BN, et al. Why women don’t report sexual assault to the police: The influence of psychosocial variables and traumatic injury. J Emerg Med. 2009;36(4):417-424.

25. McGrath ME, Bettacchi A, Duffy SJ, et al. Violence against women: provider barriers to intervention in emergency departments. Acad Emerg Med. 1997;4(4):297-300.

26. Nasta A, Shah B, Brahmanandam S, et al. Sexual victimization: incidence, knowledge and resource use among a population of college women. J Pediatr Adolesc Gynecol. 2005;18(2):91-96.

27. Prospero M, Vohra-Gupta S. The use of mental health services among victims of partner violence on college campuses. J Aggression Maltreat Trauma. 2008;16(4):376-390.

28. Sable MR, Danis F, Mauzy DL, Gallagher SK. Barriers to reporting sexual assault for women and men: Perspectives of college students. J Am Coll Health. 2006;55(3):157-162.

29. Walsh W, Banyard V, Moynihan M, et al. Disclosure and service use on a college campus after an unwanted sexual experience. J Trauma Dissociation. 2010;11(2):134-151.

30. Kelleher C, McGilloway S. ‘Nobody ever chooses this …’: a qualitative study of service providers working in the sexual violence sector – key issues and challenges. Health Soc Care Community. 2009;17(3):295-303.

31. Logan TK, Evans L, Stevenson E, Jordan C. Barriers to services for rural and urban survivors of rape. J Interpers Violence. 2005;20(5):591-616.

32. Logan TK, Stevenson E, Evans L, Leukefeld C. Rural and urban wom­en’s perceptions of barriers to health, mental health, and criminal justice services: implications for victim services. Violence Vict. 2004;19(1):37-62.

33. Muganyizi PS, Nyström L, Axemo P, Emmelin M. Managing in the contemporary world: Rape victims’ and supporters’ experiences of barriers within the police and the health care system in Tanzania. J Interpers Violence. 2011;26(16):3187-3209.

34. Ullman S, Townsend S. Barriers to working with sexual assault survivors: a qualitative study of rape crisis center workers. Violence Against Women. 2007;13(4):412-443.

35. Young CL. Barriers to reporting sexual assault as identified by sexual assault service providers: a qualitative study. Unpublished Doctor of Nursing Science Dissertation. Memphis, TN: University of Tennessee Health Science Center; 2002.

36. Ledray LE. Sexual Assault Nurse Examiner Development & Operation Guide. NCJ 170609; 1999. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf

37. DuMont J, Miller KL, Myhr TL. The role of “real rape” and “real victim” stereotypes in the police reporting practices of sexually assaulted women. Violence Against Women. 2003;9(4):466-486.

38. McGee H, O’Higgins M. Garavan R, Conroy R. Rape and child sexual abuse: what beliefs persist about motives, perpetrators, and survivors? J Interpers Violence. 2011;26(17):3580-3593.

39. Basile KC, Smith SG. Sexual violence victimization of women: prevalence, characteristics, and the role of public health prevention. Am J Lifestyle Med. 2011;5:407-417.

Motivational interviewing and adherence to osteoporosis regimens

Osteoporosis is associated with increased morbidity, mortality, and healthcare costs—billions of dollars annually. Although many types of pharmacotherapy are available to prevent or treat the disease, many patients, for various reasons, do not adhere to their prevention or treatment regimen. In this article the authors show how motivational interviewing, initially created for patients with substance abuse problems, can be used to help patients with osteoporosis overcome their ambivalence toward positive behavior change and better adhere to their prevention or treatment plan.

Key words: osteoporosis, adherence, motivational interviewing, osteoporosis management, osteoporosis drug regimen

Osteoporosis is a chronic metabolic disease of the skeletal system wherein bone resorption exceeds bone formation, leading to low bone mass, marked skeletal fragility, and an increased risk for fracture.1,2 In postmenopausal wo­men, bone loss is related to the effects of aging and the low estrogen state, but it can be exacerbated by immobilization, use of medications such as corticosteroids or gonadotropin-releasing hormones, overexposure to alcohol or tobacco, or nutritional deficiencies related to diet or caused by various malabsorption syndromes.3

In 2010, 10 million persons in the United States and 75 million persons in the Americas, Europe, and Japan were estimated to have osteoporosis.4 Worldwide, the presence of osteoporosis contributes to 9 million fractures annually.4 Osteoporosis-related fractures, particularly those of the hip, are associated with major increases in morbidity, mortality, and healthcare costs.2,5 Risk for such a fracture rises dramatically in women aged 70 years or older.5

Sequelae of hip fracture include declines in physical, mental, and functional health. In many cases, a hip fracture signals the downward spiral of an otherwise healthy and independent elder. In fact, fractures are considered life-threatening events in the elderly.5 In the U.S., osteoporosis-related fractures lead to approximately 4 million days of hospitalization and more than 3 million outpatient and emergency department visits per year.6 About one-half of women who develop a hip fracture rely on others for help with daily activities, one-fifth need long-term care, and one-fifth die within a year.1 The economic burden of osteoporosis in the U.S. is $13-$17 billion a year,1,4,6,7 a figure that is expected to rise to $25 billion by 2025.4,7

Osteoporosis management approaches

Although these statistics provide a grim outlook on the future of osteoporosis, recent scientific advances in the management of patients with osteoporosis may be able to prevent fractures. A wide array of pharmacologic and nonpharmacologic options is already available.6

Pharmacologic interventions work either by accelerating bone regeneration or decreasing bone resorption, resulting in a decreased risk for fracture.1,2 Teriparatide (parathyroid hormone) is the only agent that increases bone mineral density (BMD) anabolically by enhancing bone formation via the osteoblasts. Other osteoporosis medications decrease bone resorption; these antiresorptive agents include the bisphosphonates, the selective estrogen receptor modulators, and denosumab, a monoclonal antibody that limits activation of nuclear factor kappa B ligands, a component of osteoclasts that is important to their formation, function, and survival.4,5 Calcitonin, another antiresorptive agent, is mildly effective in improving BMD of the spine.4

In addition to drug therapy, patients with osteoporosis need to ingest adequate amounts of calcium and vitamin D. Obtaining the recommended 1200-1500 mg of elemental calcium and 1000 IU of vitamin D is difficult for persons following a typical Western diet, so calcium and vitamin D supplementation is often required.3

An important nonpharmacologic intervention for patients with osteoporosis is exercise. Exercise improves muscle efficiency, flexibility, and balance, which results in a decreased risk for falls and, ultimately a decreased risk for fall-related fractures.8 In a randomized controlled trial (RCT), researchers tested the effects of a 44-week exercise program on bone mass, bone quality, and functional capacity in subjects with low BMD.8 The exercise program included a combination of land (weight-bearing) and water (non–weight-bearing) exercises aimed at improving muscle strength, endurance, balance, and joint mobility. Pre- and post-treatment testing showed that bone quality and BMD in the intervention group remained the same and functional capacity improved. Results for the controls, who did not participate in the exercise program, showed a significant decline in bone quality and a decrease in physical function capacity. A meta-analysis of four RCTs on the effects of exercise in postmenopausal women with osteoporosis or osteopenia showed improvements in quality of life, physical function, vitality, and pain.9

Both pharmacologic and nonpharmacologic treatments for osteoporosis have been shown to be effective in reducing bone loss and fracture risk. However, efficacy can be realized only if patients adhere to their management regimen.9 Based on reports in the literature, only about 60% of patients with osteoporosis adhere to their drug regimens.1,2,7 To improve this low rate, nurse practitioners (NPs) first need to understand the reasons for lack of adherence in osteoporosis management.

Adherence in osteoporosis management

Adherence involves a combination of compliance and persistence.2 Compliance refers to the use of medications or other treatments exactly as instructed by a healthcare provider (HCP).1,2,10 With regard to medications, this process includes taking the proper dose at the prescribed frequency and time of day and following specific instructions (eg, taking the medication with food).2 Persistence is defined as following a treatment regimen for as long as it is prescribed.1,2,10 Nonadherence is the failure to comply with precise instructions and/or the premature discontinuation of treatment.

A review of the literature shows various reasons for nonadherence to osteoporosis regimens. A main reason is that osteoporosis is asymptomatic until a fracture occurs; patients are less likely to adhere to a regimen that prevents something from occurring than to a regimen that relieves acute symptoms. In addition, a belief that one’s illness is not serious or life-threatening may result in poor adherence.1,6 Other reasons cited for low adherence among patients with osteoporosis include complexity of the regimen, high frequency of dosing, high cost of medications, adverse side effects, poor understanding about osteoporosis and its chronic nature, and a poor patient–HCP relationship.1,2,6,7,11-13

Nonadherence to osteoporosis regimens results in a significant increase in fracture risk.13 By contrast, even a slight improvement in adherence may result in reduced fracture rates, hospitalization, and general costs of care and lost productivity.1,2,12 In light of the forecast on the personal and financial implications of osteoporosis-related fractures, HCPs must develop strategies that increase adherence to osteoporosis regimens.1,7

Interventions to improve adherence

A post hoc analysis of the results of an RCT was done to ascertain whether patient adherence to osteoporosis regimens would be improved with the use of educational interventions.12 Patients were randomized to an intervention group, who received physician-directed education and additional information about osteoporosis, or a control group, who received usual care without the additional education. Results showed that the additional education on osteoporosis did not improve adherence in the intervention group versus the control group.

A systematic literature review of seven studies focused on various interventions to improve adherence to osteoporosis regimens.7 In two of the studies, the intervention was to provide feedback to subjects regarding their bone turnover markers in response to treatment. Participants in the other five studies received educational material either in person or by brochures, letters, or telephone calls. In the seven studies, the intervention resulting in the greatest improvement in patient adherence was a patient-centered telephonic counseling style used in a nonrandomized investigation by Cook et al.6 This counseling style is similar to motivational interviewing (MI), a technique that facilitates patient self-motivation for treatment and equips patients with information and insight to overcome their own barriers to adherence so that they may improve their ability to manage their condition. Results of the study by Cook et al6 showed that participants who received the intervention had better adherence rates than did those who did not participate. These results suggest the need for further investigation; a blinded RCT is now testing the use of MI to improve adherence to osteoporosis regimens.13

Motivational interviewing

Background—MI was initially developed in the 1980s to help patients reduce substance abuse behaviors (click here for more information).14,15 This patient-centered method of communication aims to evoke one’s own intrinsic motivation for behavior change.16 The philosophy behind the use of MI is that behavior change is complex, and that simply advising patients or prescribing orders to make a change results in temporary change or no change at all.14 Instead, patients are recognized as having the answers they seek and as being experts about their own being.17,18 What impedes motivation, a necessary ingredient for behavior change, is unrecognized ambivalence.17,19 The role of the HCP is to facilitate identification and resolution of this ambivalence,14,16-19 which oftentimes leads to the desired behavior change.

Since its inception, MI has become increasingly used to modify behavior in healthcare domains such as intimate partner violence, smoking cessation during pregnancy, and dialysis adherence in chronic kidney disease.6,18,20,21 MI has a strong theoretical foundation.19 In a review of four meta-analyses on MI, Lundahl and Burke19 concluded that this technique builds on cognitive dissonance theory and self-perception theory to reduce ambivalence and increase motivation needed for change. The patient-centered focus of MI, evident in its therapeutic approach of reflective listening and empathy, is said to be derived from Carl Rogers’ patient-centered therapy.17 MI has been hailed as the clinical application of self-determination theory,18 which states that individuals are innately motivated to improve their own condition and that they are much more likely to adhere to a proposed behavior change if they believe that change is necessary and has personal significance.15 In addition, the self-determination theory suggests that autonomy is ingrained, and that individuals tend to succeed at change when the motivation to do so is of their own volition, as opposed to being influenced from elsewhere.18Learning the MI technique—Successful use of MI in clinical practice requires a certain level of training, but HCPs need not have a background in psychology or counseling.14,22 In a review of meta-analyses on the clinical applicability of MI, Lundahl and Burke19 concluded that the credentials and specific profession of the practitioner had no noteworthy impact on MI outcomes.

Training for MI includes practical exercises in a format wherein MI responses can be checked and modified if needed.22 In a pilot study, researchers aimed to teach a brief version of MI (brief MI) to third-year medical students.23 The researchers first developed a curriculum called CHANGE, a mnemonic that captures the essentials of brief MI: Check patients’ perspective regarding their health and health behaviors; Hear what patients say by using reflective listening skills; Avoid behaviors that are not in alignment with MI; Note patients’ priorities with regard to behavior change; Give feedback to patients only when requested or after permission has been granted; and End the interview by summarizing patients’ own plan for behavior change and healthcare follow-up. These researchers taught six instructors in two 4-hour sessions how to teach CHANGE. The instructors then taught CHANGE to the medical students during one 2-hour session. During the teaching session, students had an opportunity to practice brief MI skills and receive immediate feedback from the instructors, who had been “acting” as patients. In a posttest given right after the training, students showed an increase in their use of brief MI skills, a positive change that held true at a 4-week follow-up.23Applying MI to clinical practice—Practitioners of MI must embrace four key principles and acquire certain therapeutic skills. If properly applied, these principles and skills can help achieve the goal of MI, which is the identification and eradication of patients’ ambivalence toward the desired change.15

Key principles. The first principle of MI is to express empathy for patients’ challenges. In doing so, HCPs show respect for and a nonjudgmental attitude toward patients’ concerns, which fosters a collaborative relationship.15,24 Patients and HCPs work together as equal partners, with HCPs giving direction and support14 while patients supply expertise on their own being.17

The second principle is to develop a discrepancy between patients’ behavior and their personal goals.15,24 To develop this discrepancy, patients are encouraged to outline their own reasons for behavior change. Once this change talk develops, inconsistencies between patients’ current behavior and their stated goal can be identified. It is crucial that patients speak of the inconsistencies; HCPs merely guide them toward recognizing the difference between current action and desire.23 The greater and more obvious the discrepancy, the stronger the motivation to initiate a change.14,15

The third principle is to roll with resistance.24 Patients’ expressions of resistance, whether overt or covert, are indications of ambivalence about change.15 If their ambivalence is ignored or undermined, and HCPs push harder toward change, patients will defend themselves and resist.14 Instead, HCPs must remain nonjudgmental and gently suggest new perspectives for patients to ponder,15,24 which avoids conflict and keeps the lines of communication open.15

The final principle is to support self-efficacy. To achieve this goal, HCPs express belief in patients and their ability to plan and execute change.24 HCPs’ encouragement and positive reinforcement are ongoing. Continued support for self-efficacy empowers patients to believe that they are in control of their own behavior change.15Basic therapeutic skills. To carry out the key principles of MI, certain basic therapeutic skills are utilized.24 An important skill is avoidance of the righting reflex.15 Although HCPs may have certain goals for their patients, accompanied by a powerful drive to see these goals come to fruition,22 they must resist their natural knee-jerk reaction to right or fix things.14,15,22 Instead, they should encourage patients to search within themselves for their own ideas on how to create a change.15

Another important skill to hone is reflective listening,15 which entails summarizing patients’ statements in order to allow patients to correct any misunderstanding. This process enhances understanding between the two parties. In addition, HCPs can selectively reflect on patients’ own statements in favor of change, which encourages further discussion and elicits further change talk by patients.24

Another important therapeutic skill required in MI is asking open-ended questions.15,24 This type of questioning allows patients to do most of the talking while HCPs listen. This practice is especially important in the early stages of communication.24 Responses from open-ended questions can shed light on patients’ goals and values and guide HCPs regarding where to take the conversation next.17,24

The ask-provide-ask approach is yet another useful MI skill. Using this technique, HCPs ask patients to explain what they already know about their behavior or condition. If HCPs deem that additional information is needed, they ask patients for permission to present the information (providing unwanted information can build resistance).14,15 The information is prefaced with permission for patients to disregard it, and is provided in a neutral manner.14 Following the provision of information, patients are given an opportunity to discuss their interpretation of it.14,15

The final therapeutic skill, affirming and summarizing, is used throughout the MI process. Affirmations allow for acknowledgment and compliments for any success, recognition of difficulties, and support and encouragement for positive change. Summaries are used to reiterate statements made by patients during the interview, including those made regarding desire for change and HCPs’ support for fostering this change.14,24

Use of MI precludes HCPs from expressing their own ideas regarding desirable outcomes for patients. This approach does not equate to a lack of care on HCPs’ part, but, rather, represents a realization that within patients is the intrinsic motivation to change their lives.17 Three distinct styles of communication are evident in MI: (1) guiding rather than badgering, (2) encouraging rather than shaming, and (3) negotiating rather than dictating. According to MI’s founding fathers, “it is within the spirit of motivational interviewing that these three styles of communication come together.”22 With adequate MI training and inclusion of key principles and therapeutic skills, HCPs can help patients achieve positive behavior change.

Implications for NPs

With the aging of the U.S. population, the incidence of osteoporosis will increase rapidly in the coming years. Many of these patients will be seen by NPs in primary care and women’s health practices. Ample effective medications are available, along with well-studied exercise regimens. Use of a combination of pharmacologic and nonpharmacologic interventions can help re­duce the risk for osteoporosis-related falls and fractures. However, adherence rates among patients with osteoporosis are historically low. MI has been shown to be effective in helping patients implement favorable behavioral changes, including improved adherence to osteoporosis regimens. The versatility and nearly universal applicability of MI makes this technique fairly easy for NPs to learn and implement in practice, which may significantly alter the course of osteoporosis and osteoporotic fractures in this country.

Conclusion

The foundations of MI are deeply rooted in sound evidence-based theories such as cognitive dissonance theory, self-perception theory, and self-determination theory. This decade-old, patient-centered therapeutic style of communication has been assisting patients in overcoming their ambivalence toward behavior change. MI is not a clever set of tricks used to manipulate patients but, rather, a respectful appreciation of the fact that patients have tools within themselves to create their own change. HCPs’ only objective is to evoke change talk from patients, which then creates a discrepancy between current and desired actions. Finally, gentle guidance toward recognition of the discrepancy heightens patients’ own innate motivation for the sought-after change.

Racquel S. Maccagno is a nurse practitioner at the MinuteClinic in Tampa, Florida. Cathy R. Kessenich is a professor of nursing at the University of Tampa in Tampa, Florida. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

Note to readers: An older version of this article was published in the January/February 2013 issue of AJNP Online.

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12. Shu AD, Stedman MR, Polinski JM, et al. Adherence to osteoporosis medications after patient and physician brief education: post hoc analysis of a randomized controlled trial. Am J Manag Care. 2009;15(7):417-424.

13. Solomon DH, Gleeson T, Iversen M, et al. A blinded randomized controlled trial of motivational interviewing to improve adherence osteoporosis medication: design of the OPTIMA trial. Osteoporosis Int. 2010;21(1):137-144.

14. Shannon R, Hillsdon M. Motivational interviewing and musculoskeletal care. Musculoskeletal Care. 2007; 5(4):206-215.

15. McCarley P. Patient empowerment and motivational interviewing: engaging patients to self-manage their own care. Nephrol Nurs J. 2009;36(4):409-413.

16. Apodaca TR, Longbaugh R. Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction. 2009;104(5):705-715.

17. Croston M. Motivational interviewing: an overview. HIV Nurs. Autumn 2010;15-18.

18. Neighbors C, Walker DD, Roffman RA, et al. Self-determination theory and motivational interviewing: complementary models to elicit voluntary engagement by partner-abusive men. Am J Fam Ther. 2008;36(2):126-136.

19. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009;65(11):1232-1245.

20. Karatay G, Kublay G, Emiroglu ON. Effect of motivational interviewing on smoking cessation and pregnant wo­m­en. J Adv Nurs. 2010;66(6):1328-1337.

21. Russell CL, Cronk NJ, Herron M. Motivational interviewing and dialysis adherence study (MIDAS). Nephrol Nurs J. 2011;38(3):229-236.

22. Wilson H. Implementing motivational interviewing in practice: issues and challenges. HIV Nurs. Autumn 2010;19-21.

23. Martino S, Haeseler F, Belitsky R, et al. Teaching brief motivational interviewing to year three medical students. Med Educ. 2007;41(2):160-167.

24. Levensky ER, Forcehimes A, O’Donohue WT, Beitz K. Motivational interviewing: anevidence-based approach to counseling helps patients follow treatment recommendations. Am J Nurs. 2007;107(10):50-58.

Treating women with osteoporosis: Review and NPWH survey results

The author reviews osteoporosis, including basic facts about the disease, risk factors, prevention, diagnosis, and treatment. In addition, the author presents findings of a National Association of Nurse Practitioners in Women’s Health (NPWH) survey* in which 361 nurse practitioners answered questions about different aspects of caring for their patients with osteoporosis, particularly with regard to treatment options and their benefits and risks.

*This survey was conducted with funding from Mission Pharmacal.

In the United States, 40-52 million adults have either osteoporosis or the low bone mass (LBM) that puts them at increased risk for developing osteoporosis.1,2 Among the 10 million U.S. adults with osteoporosis, about 8 million (80%) are wom­en.3 Data from the 2005-2008 National Health and Nutrition Examination Survey showed that 16% of wom­en aged 50 or older have osteoporosis, and that an additional 61% have LBM at the femur neck or lumbar spine.4 According to the National Osteoporosis Foundation (NOF), osteoporosis is responsible for 2 million broken bones and $19 billion in related costs each year.2 The NOF predicts that the number of osteoporosis-related fractures will rise to about 3 million by 2025, at an annual cost of more than $25 billion.2

Nurse practitioners who care for women are key to helping change the course of osteoporosis-related fractures in the future. By gaining up-to-date knowledge about osteoporosis and its prevention and treatment, NPs can teach patients at risk for LBM and osteoporosis how to protect their bones. And if either LBM or osteoporosis is identified in any of their patients, NPs can implement optimal treatment to prevent further bone loss and avert fractures. This article not only covers the basics about osteoporosis, but it also provides the results of NPWH’s survey of NPs who are already treating women with osteoporosis. The aims of the survey were to…
• Gain additional insight into how NPs treat osteoporosis in their practice;
• Identify NPs’ educational needs with regard to treatment of patients with osteoporosis; and
• Gather feedback that can be used to design or improve the education provided by NPWH about the care of patients with osteoporosis.

Bone and osteoporosis—the basics

Bone consists primarily of collagen, a tough, elastic protein that forms its framework, and calcium phosphate deposits, which harden and strengthen that framework. As a dynamic tissue, bone is constantly being remodeled; new bone is continuously being formed by osteoblasts and old bone is removed by osteoclasts.5 Most people attain their peak bone mass at about age 30, after which the resorption of existing bone slowly begins to exceed the formation of new bone, leading to a decrease in bone mass.1

Osteoporosis literally means porous bone, which describes the LBM and deterioration that characterize this disease.1 Risk for osteoporosis and its related fractures becomes much higher in women at about age 50, when the level of estrogen, which protects against excessive bone loss, declines and bone loss accelerates.3 Osteoporosis is frequently undetected until one or more vertebrae collapse or a fragility fracture occurs.5

Risk factors

Nonmodifiable risk factors for osteoporosis include female gender, increasing age, and having a small, thin-boned body type.1 Caucasian and Asian women are at higher risk than African American and Hispanic women, although the risk is substantial for all women. Heredity may partially account for an increased risk of LBM and a tendency for fractures.

Modifiable risk factors for osteoporosis include having a treatable condition that raises osteoporosis risk, including amenorrhea in younger women, hypoestrogenemia in older women, anorexia nervosa, and a long history of low calcium and vitamin D intake. Long-term use of glucocorticoids or certain anticonvulsants leads to a loss of bone mineral density (BMD). Other risk factors for osteoporosis that can be altered include physical inactivity, extended bed rest, smoking, and excessive alcohol intake.1

Prevention

Preventive measures against osteoporosis must be taken across a lifetime. Women need to build optimal peak bone mass by getting enough calcium and vitamin D and exercising when they are young, while avoiding cigarette smoking and excessive alcohol consumption. NPs need to be aware of medications that can decrease BMD and contribute to increased fracture risk.1 These medications include
• Glucocorticoids: used to treat arthritis, asthma, Crohn’s disease, lupus, and other diseases of the lungs, kidneys, and liver;
• Antiseizure drugs, such as phenytoin and barbiturates;
• Gonadotropin-releasing hormone agents used to treat
endometriosis;
• Excessive use of aluminum-containing antacids;
• Certain cancer treatments; and
• Excessive thyroid hormone treatment.

Following a healthful diet and performing regular exercise remain important even after LBM or osteoporosis has developed. NPs need to assess patients’ daily intake of calcium and vitamin D.6 NPs should recommend that women older than 50 receive calcium 1,200 mg/day and vitamin D 800-1,000 IU/day from food, and supplement their diet only as needed to make up for any shortfall. Every precaution must be taken to keep living and working areas safe so as to prevent falls, a major cause of fractures.1

Diagnosis

Several factors in a woman’s health history are key in terms of ultimately identifying LBM and osteoporosis. In addition to basic information such as age and menopausal status, NPs should check for a personal history of broken bones during adulthood, a family history of osteoporosis and fractures, an adequate intake of calcium and vitamin D, regular exercise and physical activity, smoking and/or drinking alcohol, a history of eating disorders or irregular periods, and any health conditions and/or medications that might affect bone mass. Regular thorough physical examinations can document any height loss and identify spinal changes.7

If osteoporosis is suspected, NPs can order a central dual-energy x-ray absorptiometry (DXA) scan to measure a patient’s BMD. Diagnosis of osteoporosis is made if a woman aged 50 or older has a T-score less than or equal to –2.5 or if a woman has a history of fragility fractures—regardless of BMD. The T-score represents a way of comparing a patient’s BMD with that of a normal reference person aged 30. Low bone mass is defined as a T-score between –1.0 and –2.5; BMD is considered normal if it is –1.0 or higher. In premenopausal wom­en and younger men, a Z-score is used to evaluate BMD; this score compares the person’s BMD to a reference matched for age. Either score is given as a standard deviation from the BMD used as the norm.6 Medicare covers the cost of a DXA scan every 2 years, or more often if deemed necessary.8

A tool to aid practitioners in developing a treatment plan is the World Health Organization fracture risk assessment, or FRAX®, which helps estimate 10-year fracture risk.9 The tool uses an established set of clinical risk factors to compute 10-year fracture risk. FRAX can be used with or without BMD scores. In the U.S., FRAX is especially helpful when determining the best treatment plan for women with LBM but not established osteoporosis. Treatment should be considered for women with low BMD and a 10-year risk of hip fracture of at least 3%, as assessed by FRAX, or a 10-year risk of a major osteoporosis-related fracture of at least 20%, as assessed by FRAX.10

Treatment

Medications prescribed for prevention and/or treatment of osteoporosis include bisphosphonates, selective estrogen receptor modulators (SERMs), calcitonin, parathyroid hormone (PTH), estrogen, other types of hormone therapy, and an osteoclast or RANK ligand (RANKL) inhibitor.1 Some bisphosphonates, the RANKL inhibitor denosumab, and teriparatide, the PTH agent, have indications for both women and men, whereas calcitonin, estrogen and other hormone therapies, SERMs, and certain bisphosphonates are approved only for use in women.11 Bisphosphonates are the most common type of anti-osteoporosis medication currently being prescribed.6

Because many of the NPWH survey questions dealt specifically with bisphosphonate therapy, the remaining discussion of medications focuses on this class. Bisphosphonates have a great affinity for bone mineral, which helps increase BMD. These agents also inhibit osteoclast activity, thereby slowing bone turnover.12 Bisphosphonates have proven efficacy in reducing the risk of fractures of the spine, hip, and other nonvertebral sites. In addition, use of these agents has been associated with a significant reduction in morbidity and an increase in survival.13

Bisphosphonate products with an FDA indication include alendronate (Fosamax®, Binosto®),14,15 risedronate (Actonel®, Atelvia®),16,17 ibandronate (Boniva®),18,19 and zoledronic acid (Reclast®).20 Alendronate, ibandronate, zoledronic acid, and risedronate as Actonel® are approved for both prevention and treatment of osteoporosis14-16,18-20; delayed-release risedronate (Atelvia®) is approved only for treatment.17 Ibandronate and delayed-release risedronate have indications for women only17-19; alendronate, risedronate in Actonel®, and zoledronic acid are approved for both women and men.14-16,20 Both formulations of alendronate are taken orally on a weekly basis.14,15 Risedronate is an oral agent that can be taken weekly, monthly, or on 2 consecutive days each month; dosing differs by product.16,17 Ibandronate is taken orally on a monthly basis or given intra­ve­nous­ly (IV) every 3 months.18,19 Zoledronic acid is given IV once a year.20

Oral bisphosphonates are poorly absorbed and, when taken with food, form complexes that cannot be absorbed. Because of this problem, oral bisphosphonates usually must be taken on an empty stomach with plain water,21 followed by a 30- to 60-minute delay before ingestion of any food or beverage.14-16,18 Because of this inconvenient routine, some patients eat and/or drink too soon, thereby negating some or all of the medication effect, or they abandon treatment altogether. Use of IV bisphosphonates can be associated with short-term flu-like symptoms, which occur more often with zoledronic acid than with ibandronate.22

Two newer bisphosphonate products were developed to avoid or minimize the original problems associated with oral dosing. For patients who do not want to wait to eat or drink, delayed-release risedronate (Atelvia),17 which also contains a calcium chelator,21 is taken immediately after breakfast. For patients who do not want to swallow a pill, an alendronate sodium effervescent tablet (Binosto) has been developed15; the tablet is dropped into a small glass of water to create a strawberry-flavored oral solution.

Rare adverse effects of the bisphosphonates

Over the past several years, a growing body of research has identified an increased risk for atypical femoral fracture (AFF) and osteonecrosis of the jaw (ONJ) in bisphosphonate users. It is important for NPs prescribing these medications—or hesitating to do so because of the headlines—to know the facts.

Atypical femoral fracture—Most fractures of the femoral shaft are caused by a major trauma. However, a 2005 report initially raised concern about unusual fractures associated with bisphosphonate use.23 A task force of the American Society for Bone and Mineral research established a list of major features that must be present to classify a femoral fracture as atypical:
• Location anywhere along the femur from just distal to the lesser trochanter to just proximal to the supracondylar flare;
• Association with no or minimal trauma (e.g., a fall from a standing height or less);
• Transverse or short oblique configuration;
• Noncomminuted (not crushed or broken into small pieces); and
• Complete fractures that extend through both cortices and that may be associated with a medial spike; incomplete fractures that involve only the lateral cortex.24

Minor features that are not required for this diagnosis but are sometimes present include bilateral fractures and symptoms, delayed healing, co-morbid conditions (e.g., vitamin D deficiency, rheumatoid arthritis, hypophosphatasia), and use of agents such as bisphosphonates, glucocorticoids, and proton-pump inhibitors, among others.24

Data from a population-based nationwide analysis in Sweden found that the age-adjusted relative risk for AFF in bisphosphonate users was 47.3 and the multivariable-adjusted odds ratio was 33.3.25 However, absolute risk was increased by only 5 cases/10,000 patient-years. A 12-year study showed that although AFF incidence was low, it increased with longer bisphosphonate use.26 A systematic review from the Research on Adverse Drug Events And Reports (RADAR) Project showed that up to 26% of the published cases of AFF in bisphosphonate users had delayed healing or did not heal.27

As a rule, bisphosphonate therapy is considered safe when used for the length of time in the original trials—less than 5 years. Risk for AFFs is increased in patients who have used bisphosphonates for more than 5 years.28 A systematic review of clinical studies of bisphosphonate use in postmenopausal women with osteoporosis found persistent anti-fracture efficacy and increases in BMD beyond 3 years of treatment.29 Some studies in the review showed continuing fracture benefits when patients who had used alendronate or zoledronic acid for 3-5 years discontinued treatment for 3-5 years.

Bisphosphonates are incorporated into bone, allowing them to exert an effect for a time after treatment is discontinued.13 Although there is no formal recommendation for patients at low risk of fracture to take a drug holiday from bisphosphonate therapy, some clinicians think that treatment suspension is appropriate after 5 years.30 However, the benefits of continuing therapy probably outweigh any risk of harm in patients at high risk for fracture—that is, in those with BMD indicating osteoporosis or in those who have sustained a previous fragility fracture.13 Once a patient has been identified as having an AFF, bisphosphonate therapy should be discontinued. Initiating teriparatide therapy may help enhance healing of the fractures.28Osteonecrosis of the jaw—Bisphosphonate-related ONJ occurs when the jaw bone is exposed and begins to die because of a lack of a blood supply.31 One proposed mechanism has to do with the antiangiogenic effect of bisphosphonates. These agents may limit the angiogenesis that is vital to the development of blood vessels in bone, which has a high turnover rate.32 Prevalence of bisphosphonate-related ONJ is between 1/1000 and 1/100,000 for each year of exposure.31 Risk may depend on the bisphosphonate dose, the length of time it has been taken, and the condition for which it has been prescribed. For example, patients with cancer who take IV bisphosphonates are at higher risk for this adverse effect than are patients with osteoporosis taking oral bisphosphonates.31

NPWH survey results

In 2013, NPWH surveyed 411 NPs about different aspects of caring for their patients with osteoporosis. These NPs were located in many different areas of the country, including Western (23.8%), Northeastern (21.9%), Great Lakes (20.0%), Southeastern (16.3%), South Central (14.6%), and North Atlantic (3.4%) regions. Among NPs surveyed, almost two-thirds (63.6%) reported working in an obstetrics/gynecology practice. The group had a great deal of experience; 31.9% had been in practice 11-20 years and 26.8% had been in practice more than 20 years. A total of 361 NPs (87.8%) who replied that they treat patients with osteoporosis completed the survey.

Of these 361 survey respondents, 75.6% first counseled their patients about osteoporosis risk as a routine part of well-woman visits, and 18.0% first addressed this risk when a woman became perimenopausal. Of the 361 NPs, more than three-fourths (75.9%) used a BMD test to make the diagnosis of osteoporosis and 23.5% treated patients who had been diagnosed by another healthcare practitioner. In addition to prescribing medication to reduce their patients’ fracture risk, the NPs recommended adequate calcium and vitamin D intake (97.2%), regular weight-bearing exercise (95.3%), cessation of tobacco use (84.2%), and avoidance of excessive alcohol intake (70.9%). The vast majority of the respondents (90.3%) stated that they wanted to receive more education about the diagnosis and treatment of this disease.

As reflected in the literature, most of these NPs (84.8%) prescribed a bisphosphonate as first-line treatment for osteoporosis. The group was almost evenly split between those who felt oral bisphosphonates were of great value as a treatment option (50.4%) and those who felt these agents were of moderate value (47.9%). Although 53.7% of the NPs have maintained their previous level of prescribing bisphosphonates in the past 2 years, 28.3% had decreased their level. Common concerns about prescribing oral bisphosphonates included patient noncompliance (33.8%), gastrointestinal (GI) problems (28.0%), rare side effects such as ONJ (14.4%), and patients’ failure to fill their prescriptions (10.5%). Only 4.7% of the NPs had no concerns about prescribing these agents. About half of the survey group (51.0%) planned to keep patients on bisphosphonate therapy for 3-5 years; 32.4% of the group were not sure.

The NPs were asked to compare different aspects of alendronate, ibandronate, and rised­ronate. Most respondents (73.1%) thought that all three agents had equal efficacy, whereas 18.6% favored alendronate, 6.1% chose risedronate, and 2.2% selected ibandronate as being more efficacious. When asked to compare the agents with respect to the incidence of GI side effects, 76.7% thought that the agents did not differ in this regard and 11.4%, 9.1%, and 2.8% of the group identified alendronate, rised­ronate, and ibandronate, respectively, as having the lowest incidence of GI side effects. Most respondents (80.6%) thought that branded and generic bisphosphonates did not differ in tolerability, whereas 19.4% favored branded products.

The NPs reported several common patient complaints about oral bisphosphonate therapy. The main problems were having to take the pill in the morning on an empty stomach (35.5%), GI side effects (26.3%), dislike of needing to stay upright after taking the tablet (13.0%), difficulty remembering to take the tablets (12.5%), and feeling that the drug was having no impact (5%).

Almost two-thirds of the respondents (63.4%) said that a monthly tablet would likely improve their patient’s adherence to an oral bisphosphonate regimen; 17.5% suggested a weekly tablet and 11.1% chose a daily tablet. Among respondents who favored weekly dosing, 40% preferred a weekly tablet and 60%, a weekly tablet that dissolves into a drinkable strawberry-flavored solution. When asked specifically about the value of this bisphosphonate solution as a treatment option, 61.5% thought that it would be of moderate value, 27.1% felt it would be of great value, and 11.4% saw it has having no value. Among the 361 NPs surveyed, 79.2% were aware of Binosto alendronate sodium effervescent tablets; however, 93.8% of the 145 NPs who replied to this question had never prescribed this product.

Conclusion

Nurse practitioners who treat women with osteoporosis need to be aware of all the treatment options available. Bisphosphonates are still the first-line choice for patients with low BMD and osteoporosis. New formulations have been developed to address concerns that affect adherence to the regimen. Although NPs need to be aware of the rare adverse effects associated with bisphosphonate use, they also need to keep the low absolute risk in mind when deciding whether or not to prescribe these medications.

Susan Rawlins is Director of Education at the National Association of Nurse Practitioners in Women’s Health and practices at the Greater Texoma Health Clinic in Denison, Texas. Ms. Rawlins is a consultant to Mission Pharmacal.

References
1. NIH Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis overview. www.niams.nih.gov/Health_Info/Bone/osteoporosis/overview.pdf

2. National Osteoporosis Foundation. What is osteoporosis? http://nof.org/articles/7

3. National Osteoporosis Foundation. What women need to know. http://nof.org/articles/235

4. Looker AC, Borrud LG, Dawson-Hughes B, et al. Osteoporosis or low bone mass at the femur neck or lumbar spine in older adults: United States, 2005-2008. NCHS Data Brief. 2012(93):1-8.

5. NIH Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis handout on health. www.niams.nih.gov/Health_Info/Bone/Osteoporosis/osteoporosis
_hoh.asp

6. Warriner AH, Saag KG. Osteoporosis diagnosis and medical treatment. Orthop Clin North Am. 2013;44(2):125-135.

7. National Osteoporosis Foundation. Making a diagnosis. http://nof.org/
articles/8

8. Medicare & You 2014. Centers for Medicare & Medicaid Services: Baltimore, MD. www.medicare.gov/Pubs/pdf/10050.pdf

9. FRAX® WHO Fracture Risk Assessment Tool. www.shef.ac.uk/FRAX/tool.jsp

10. Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. J Bone Joint Surg Am. 2010;92(3):743-753.

11. National Osteoporosis Foundation. Treatment with osteoporosis medication. http://nof.org/articles/21

12. Verron E, Bouler JM. Is bisphosphonate therapy compromised by the emergence of adverse bone disorders? Drug Discov Today. August 22, 2013. Epub ahead of print.

13. McClung M, Harris ST, Miller PD, et al. Bisphosphonate therapy for osteoporosis: benefits, risks, and drug holiday. Am J Med. 2013;126(1):13-20.

14. Fosamax® alendronate sodium tablets and oral solution. Prescribing information. Merck & Co., Inc., Whitehouse Station, NJ. 2013. www.merck.com/product/usa/pi_
circulars/f/fosamax/fosamax_pi.pdf

15. Binosto® alendronate sodium effervescent tablets for oral solution. Prescribing information. Mission Pharmacal, San Antonio, TX. Rev 2012. http://binosto.com/sites/
binosto.com/themes/danlandBinosto/images/binostoPI.pdf

16. Actonel® risedronate sodium tablets. Prescribing information. Procter & Gamble Pharmaceuticals, Inc., Cincinnati, OH. Revised 2013. www.actonel.com/global/prescribing
_information.pdf

17. Atelvia® risedronate sodium delayed-release tablets. Prescribing information. Norwich Pharmaceuticals, Inc., North Norwich, NY. Revised 2013. www.wcrx.com/pdfs/pi/pi_
atelvia.pdf

18. Boniva® ibandronate sodium tablets. Prescribing information. Roche Laboratories Inc., Nutley, NJ. Revised 2013. www.gene.com/download/pdf/boniva_tablets_prescribing.pdf

19. Boniva® ibandronate injection. Prescribing information. Genentech USA. Inc., South San Francisco, CA. Revised 2013. www.gene.com/download/pdf/boniva_injection_prescribing.pdf

20. Reclast® zoledronic acid injection. Prescribing information. Novartis Pharmaceuticals Corporation, East Hanover, NJ. Revised 2013. www.pharma.us.novartis.com/product/pi/pdf/reclast.pdf

21. Pazianas M, Abrahamsen B, Ferrari S, Russell RG. Eliminating the need for fasting with oral administration of bisphosphonates. Ther Clin Risk Manag. 2013;9:395-402.

22. Sieber P, Lardelli P, Kraenzlin CA, et al. Intravenous bisphosphonates for postmenopausal osteoporosis: safety profiles of zoledronic acid and ibandronate in clinical practice. Clin Drug Investig. 2013;33(2):117-122.

23. Tripto-Shkolnik L. Atypical femoral fractures and their relation to bisphosphonate use. Isr Med Assoc J. 2013;15(8):447-450.

24. Shane E, Burr D, Ebeling PR, et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010;25(11):2267-2294.

25. Schilcher J, Michaelsson K, Aspenberg P. Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med. 2011;364(18):1728-1737.

26. Meier RP, Perneger TV, Stern R, et al. Increasing occurrence of atypical femoral fractures associated with bisphosphonate use. Arch Intern Med. 2012;172(12):930-936.

27. Edwards BJ, Bunta AD, Lane J, et al. Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project. J Bone Joint Surg Am. 2013;95(4):297-307.

28. Saleh A, Hegde VV, Potty AG, Lane JM. Bisphosphonate therapy and atypical fractures. Orthop Clin North Am. 2013;44(2):137-151.

29. Eriksen EF, Diez-Perez A, Boonen S. Update on long-term treatment with bisphosphonates for postmenopausal osteoporosis: A systematic review. Bone. 2014;58:126-135.

30. Suresh E, Pazianas M, Abrahamsen B. Safety issues with bisphosphonate therapy for osteoporosis. Rheumatology (Oxford). 2014;53:19-

31. American College of Rheumatology. Osteonecrosis of the jaw (ONJ). www.rheumatology.org/Practice/Clinical/Patients/Diseases_and_
Conditions/Osteonecrosis_of_the_Jaw_(ONJ)/

32. Sharma D, Ivanovski S, Slevin M, et al. Bisphosphonate-related osteo­necrosis of jaw (BRONJ): diagnostic criteria and possible pathogenic mechanisms of an unexpected anti-angiogenic side effect. Vasc Cell. 2013;5(1):1. www.vascularcell.com/content/5/1/1

Healthy bones for women*

 

Osteoporosis is a disease known for slow, silent loss of bone. (In this case, the word “silent” means that you won’t feel anything as the disease starts or worsens.) Bones become thinner and weaker, so they are more likely to fracture—that is, to break. Women are more likely than men to get osteoporosis. Your risk is also higher if someone in your family has had osteoporosis or if at least one of your parents has had a broken hip. More than 1.5 million fractures each year are related, at least in part, to osteoporosis.

Your healthcare professional (HCP) can help you assess your bone health at routine visits by…

Measuring your height.
A loss in height may mean that you have had silent spine fractures. Any loss in height from year to year should be checked further.
Using your height and weight measures together to compute your body mass index (BMI).
A low BMI or a weight less than 127 pounds (thinner women) is a risk factor for osteoporosis.
Reviewing all the medicines you are taking, including prescription and over-the-counter medicines and supplements.
Medicines such as prednisone, some anti depressants, some heartburn/ulcer drugs, and others may increase bone loss.
Discussing whether you should have a blood test to measure your vitamin D level.
Vitamin D is needed to absorb calcium in your bones. A normal blood level of vitamin D is 30 ng/mL or higher. Risk factors for having a low vitamin D level include being older than 60, being obese, having a disease of the kidney or bowel, getting too little sun, having very
dark skin, having had gastric bypass surgery, and using certain medicines. If your vitamin D level is too low, your HCP will prescribe vitamin D supplements and retest your vitamin D level in a few months.
Discussing whether you should have a bone density test.
A bone density test measures bone mass in places such as the lower spine, hip, and forearm. The most common bone density test done is a DXA (dual energy x-ray absorptiometry) scan. You should have this test if you are 65 or older, if you are older
than 50 and have risk factors for osteoporosis, if you broke a bone after age 50, or if you are past menopause and are stopping the use of estrogen. Depending on your test results and your risk factors, and whether you’ve had any osteoporosis treatment, you may need another DXA scan every 2 or more years.

Using a tool called FRAX to see whether you should have a bone density test (if
you are past menopause but not yet 65).
Your HCP may also use FRAX if your bone density test shows low bone mass (but not osteoporosis) to see if you need to be on an osteoporosis prevention medicine. FRAX shows your risk of having a bone fracture in the next 10 years by looking at your risk factors and, if done, your bone density test scores.

You can maintain or improve your bone health by…

Eating the right foods and taking supplements if needed.
You need calcium to make and keep your bones strong. Adult women up to age 50 need 1,000 mg/day and women older than 50 need 1,200 mg/day. Good food sources of calcium are low-fat dairy products, calcium-fortified foods (e.g., cereals, orange juice),
kale, bok choy, halibut, and sardines with bones. Know your usual dietary intake of calcium to decide how much supplement is needed to meet daily requirements. If you take a supplement, it’s best to divide your dose so you take no more than 500 mg of calcium at one time. Calcium carbonate costs the least and is taken with meals to work best. Calcium citrate need not be taken with meals.  You need vitamin D for calcium to be absorbed by your bones. Women younger than 50 need 400-800 IU/day and women older than 50 need 800-1,000 IU/day. Most women do not stay out in the sun long enough for their bodies to make vitamin D. Good food sources of vitamin D are wild salmon, halibut, trout, sardines, and vitamin Dfortified foods (e.g., milk, yogurt, cereals, orange juice). Know your usual dietaryintake of vitamin D to decide how much supplement is needed to meet daily requirements.
Limiting your intake of sodium, which reduces calcium absorption.
Look for sodium content on food labels. Avoid processed and canned foods and
salted snack foods and nuts. Eat fresh or frozen fruits and vegetables and fresh
lean meats, poultry, and fish.
Getting regular exercise, which helps make your bones strong.
Plan to get at least 30 minutes of moderate weight-bearing exercise on most
days of the week. Weight-bearing exercises include brisk walking, running/jogging, dancing, stair climbing, tennis, and use of exercise equipment such as elliptical training and stair-step machines and treadmills. Plan to do muscle strengthening exercises 2 or 3 days each week. You can lift weights, use weight machines, or use elastic exercise bands. Yoga and Pilates can improve strength, flexibility, and balance.
Not smoking.
Smoking decreases calcium absorption and speeds up bone breakdown.
Drinking alcohol in moderation.
For women, this is no more than 2 drinks each day. One drink = 10 ounces of beer, 4 ounces of wine,or 1 ounce of liquor. Drinking heavily can lead to bone loss.

Resources for more information

National Osteoporosis Foundation
4BoneHealth
FRAX calculator

*Readers are invited to photocopy Patient education pages in the journal and distribute them to their patients.