Menopause

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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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 »

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.

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.