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

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

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

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

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

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

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

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

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

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

Dear Colleagues,

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

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

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

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

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

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

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

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

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

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.

Infertility evaluation and treatment

How common is infertility?

After 1 year of having unprotected sex, 15% of couples are unable to conceive—that is, to get pregnant. After 2 years, 10% of couples still have not had a successful pregnancy.

What are the causes of female infertility?

For about a third of couples who have difficulty conceiving, the woman is found to have the problem. In order for a woman to conceive, she needs to ovulate (produce and release eggs from your ovaries), have patent Fallopian tubes (that is, tubes free of blockages), and have a healthy uterus that can support a pregnancy. Fertility can be affected by problems with the menstrual cycle, by a disease or a condition, by lifestyle factors, and/or by age-related factors.

What are the causes of male infertility?

For more than a third of couples who have difficulty conceiving, the man is found to have the problem. To impregnate a woman, a man must have sperm that can reach and combine with a woman’s egg. Sperm are made and stored in the testicles. During sex, sperm mix with seminal fluid, or semen, and are ejaculated by the penis into the woman’s reproductive tract. Infertility in a man is often related to low sperm production, which may be due to a varicocele, an enlarged vein in the testicle. Other causes of male infertility are hormone imbalances, medication or steroid use, and blockages in the reproductive organs.

How is female infertility evaluated?

In addition to a health history and physical exam, your healthcare provider will likely order blood tests to check for conditions such as a thyroid disorder or a high level of the hormone prolactin. Other blood tests may check:

A progesterone level late in the second half of your menstrual cycle to tell if ovulation has occurred and if your ovaries are producing a normal amount of this hormone.

Follicle-stimulating hormone and estradiol levels in the first few days of the menstrual cycle to evaluate ovarian function.

Anti-Müllerian hormone (AMH) level to evaluate ovarian reserve (your remaining egg supply).

Because some of these tests must be done at specific times in the menstrual cycle and repeated for accuracy, this part of your evaluation may take several weeks.

Other tests may be done to examine your Fallopian tubes and determine if a blockage is preventing movement of the egg from the ovaries or preventing the egg and sperm from reaching each other. These tests include a hysterosalpingogram, transvaginal ultrasound (TVUS), and laparoscopy. TVUS can also be used to assess your ovaries, including the number of remaining follicles you have, and it can be used to assess the uterus.

How is male infertility evaluated?

A health history and physical exam are also part of the man’s evaluation. The most common lab test for male infertility is a semen analysis to assess the quantity and quality of the sperm. A man may need to provide a semen sample on more than one occasion because sperm production can vary over time, depending on his activities and stress level.

How is female infertility treated?

Treatment options depend on the cause. If you have a problem with ovulation, you may try a medication that will help your ovaries produce and release eggs. If you have a blockage in a Fallopian tube, you may need to undergo a minor surgical procedure to remove it. If neither medication nor surgery is an option or if the treatment does not work, you may be able to use an assisted reproductive technology (ART) such as in vitro fertilization.

How is male infertility treated?

Medication can treat problems such as hormone imbalances. Surgery can help repair blockages in the tubes that transport sperm from the testicles to the penis. Surgery can be used to repair a varicocele. If medication or surgery does not restore fertility, ART may be considered.

Resources: National Institutes of Health. Eunice Kennedy Shriver National Institute of Child Health and Human Development. When should I consult a healthcare provider? How is infertility diagnosed?

* Readers are invited to photocopy or download a PDF Patient Education pages in the journal and distribute them to their patients.

Incorporating features of the Bedsider website into contraceptive counseling

Key words: contraception counseling, bedsider.org, family planning, long-acting reversible contraceptives, LARC

In the United States, approximately 50% of pregnancies are unintended; the U.S. continues to have one of the highest rates of unintended pregnancy among all developed countries. Although unintended pregnancies occur among women of all demographic groups, those who are young, unmarried, poor, and from an ethnic or racial minority group have the highest rates of unintended pregnancy.For women aged 18-29 years, high unintended pregnancy rates have been associated with a low level of contraceptive knowledge, low use, and fear of side effects, as well as ambivalence regarding pregnancy and mistrust of government-supported family planning services.3,4 To reduce these high rates, the CDC now recommends counseling patients about the use of long-acting reversible contraceptives (LARC), including intrauterine contraceptives (IUCs) and the subdermal implant, as first-line, highly effective options for pregnancy prevention.5,6

Researchers have documented the superiority of LARC methods over short-acting methods (pills, patches, rings, barrier methods) in lowering rates of unintended pregnancy.7,8 The short-acting contraceptives are less effective than LARC methods because they are more likely to be used incorrectly or inconsistently or to not be used at all.9 If 10% of women aged 20-29 years switched from oral contraceptives to LARC, total costs would be reduced by about $288 million per year.10 Also, LARC methods could reduce disparities associated with unintended pregnancy by enabling women to have greater control over the timing of their pregnancies.11

According to researchers who analyzed data from the 2011-2013 cycle of the National Survey of Family Growth, LARC use increased five-fold over the past decade among females aged 15-44 years.12 Even with this increase, overall rates of LARC use are low, with only 7.2% of women choosing them. For females aged 15-24, LARC use is even lower, accounting for only 5% of the contraceptive methods in this age group.12 Low utilization has been ascribed to a variety of barriers, including high cost (especially higher initial cost), lack of awareness and knowledge about LARC, lack of access to a healthcare provider (HCP) trained in LARC insertion, and restrictive clinic protocols.13-16

With recent advances in technology and new approaches to healthcare delivery, patient education has moved from passive delivery of healthcare information to a more interactive approach. These changes allow patients to be more knowledgeable and active participants in the healthcare decision-making process. This model of patient education has resulted in technology-based patient decisional-aid tools and a plethora of Internet-based applications (apps) and mobile health apps, including apps focused on contraceptive methods and choices. These decisional-aid tools can assist HCPs in delivering health education content that is visible, colorful, auditory, and interactive, facilitating the transfer and retention of information.17

Based on learning theories, the most effective decisional-aid tools are available in multiple languages, are suitable for patients with low literacy, are readily available for repeated use, and require limited knowledge of technology.18 Researchers have demonstrated that these decisional-aid tools are effective, increase patient knowledge, are acceptable both to patients and HCPs, and are cost effective.19-22

Considering the low rate of LARC use and the consistently high rate of unintended pregnancy in the U.S., the authors sought to implement a pilot trial of technology-enhanced contraceptive counseling to increase LARC use among young women who sought care at a Title X family planning clinic in the northeastern U.S. For the purpose of this study, LARC methods were defined as either the subdermal implant or an IUC (progesterone or copper).

Purpose

Specific aims of the study were (1) to incorporate a technology-enhanced counseling intervention utilizing features of the Bedsider website23 at family planning visits to increase LARC use, (2) to determine the feasibility and acceptability of the technology-enhanced counseling intervention for both patients and HCPs, and (3) to measure the difference in LARC use between the intervention and control groups.

Methods

Setting

The participating clinic in this study was Health Quarters, Inc., a non-profit, Title X provider of confidential reproductive healthcare. Services include contraceptive care, testing and treatment of sexually transmitted infections, gynecologic examinations, and sexual health education services for adolescents, women, and men in northeastern Massachusetts. This clinic provides care to uninsured and underinsured patients regardless of their ability to pay for services. Approximately 93% of patients who seek care at this site are at 250% below the federal poverty level. The clinic is located in a city in which nearly 75% of residents identify as Hispanic or Latino. It employs multilingual and multicultural staff members who reflect the community: the medical director is fluent in Spanish and the medical assistants (MAs), office assistant, and nurse practitioner (NP) are bilingual in English and Spanish.

Institutional Review Board approval to conduct the study was granted through the university of the principal investigator and supported by the clinic’s board of directors. All clinic staff members who interacted with study participants were trained in the ethical conduct of research. Data were collected from February 2015 through December 2015.

Sample

A convenience sample who met inclusion criteria—female gender; age, 18-29 years; a person seeking contraceptive services; and an English speaker—were asked to participate. At the time of the study, the Bedsider website was in English only, so women who could not read, speak, or understand English were excluded. Because the study incorporated features of the Bedsider website into contraceptive counseling, women who were pregnant or seeking pregnancy were excluded. Females younger than 18 years were excluded to ensure delivery of confidential services without parental notification of study participation.

Measures

Limited demographic information was collected to increase participant confidentiality. Contraceptive information, including history, use, and questions relating to reproductive and pregnancy coercion, were assessed via standardized questions adapted from the CDC.24,25

Procedure

Women who met inclusion criteria were recruited at the time of registration for their clinic visit and were asked by a front desk staff member if they wanted to participate in a study about contraceptive methods. Those who were interested were referred to the MA, who provided a brief overview of the study, obtained informed consent, and allowed the participant to join either the intervention group or the control group. All participants completed a pre-test study questionnaire on an iPad® prior to receiving any contraceptive counseling.

Women in the intervention group received the Bedsider website-based intervention. Specific Bedsider website features used in this intervention included the Method Explorer page, with emphasis on the most effective methods—that is, LARC—and the Compare Methods page, a side-by-side comparison of methods with respect to effectiveness, side effects, hormones, and cost. Participants were instructed to view information about the different methods while they waited for the NP to begin the visit (typical wait, 10-15 minutes). The NP reviewed the webpages with the patient as part of the contraceptive counseling process, which also included a discussion about the effectiveness, risks, benefits, method of action, medical eligibility, and instructions on use for the various contraceptives. The final choice of method was recorded. Post-intervention study questionnaires that measured contraceptive behaviors were completed at a 6-week follow-up appointment.

Women in the control group received usual care, which entailed a brief discussion with the MA about contraceptive methods and then face-to-face counseling with the NP, who discussed the effectiveness, risks, benefits, method of action, medical eligibility, and instructions on use for the various contraceptives. The final choice of method was recorded. Post-study questionnaires were completed at the 6-week follow-up.

Results

A total of 44 women enrolled in the study, 24 in the Bedsider intervention group and 20 in the control group. Twenty-five women completed the 6-week follow-up measures. Mean age for all participants was 22.2 years. Most participants self-identified as white/Caucasian (n = 24; 54.5%) or multiracial (n = 13; 29.5%). All participants reported their ethnicity as Hispanic, which is representative of the city and clinic populations. At enrollment, 20 participants (45.4%) reported using no contraceptive. In the previous year, 13 participants (29.5%) reported using emergency contraception one or more times. The Table provides demographic and contraceptive history information.

Aim 1

At the beginning of the study, 11% of the women were using an IUC or implant. Regardless of whether women chose to join the intervention group or to receive usual care, LARC use increased during the study. Of the 25 women who returned for the 6-week follow-up, 29% of those in the intervention group and 36.6% of those in the control group had chosen a LARC method. Overall contraceptive use increased. At enrollment, 45.4% of the participants reported not using any form of contraception. At the 6-week follow-up, only 12% of the 25 women were still undecided about their contraceptive method.

Aim 2

Technology-enhanced counseling using the Bedsider website was both feasible and acceptable. Although no formal qualitative interviews were conducted, study meetings with the clinic staff (MAs and NP) elicited positive feedback and no reports of technology-related problems from staff or participants. Staff members thought that the Bedsider website was a helpful adjunct to counseling. It neither shortened nor lengthened the total amount of time spent discussing contraceptive methods.

Aim 3

Overall LARC use increased with contraceptive counseling, regardless of whether it was traditional face-to-face counseling by the NP or traditional counseling enhanced by use of the Bedsider website. The intervention and control groups did not differ significantly with respect to LARC use.

Clinical implications

Although the results of this small pilot study were not statistically significant for an increase in LARC use, they are clinically interesting and have important implications for NPs who work with women at risk for unintended pregnancy. Of note, almost half the participants were not using any form of contraception at study enrollment even though they were sexually active and at risk for pregnancy. At follow-up, only 12% of participants were still undecided about their contraceptive method. Contraceptive counseling, whether done in a traditional face-to-face format with the NP or enhanced with technology, was effective in helping women choose a method.

Initial aims of this study were to incorporate technology-enhanced contraceptive counseling into practice and determine the feasibility and acceptability of this process. Use of digital media as an adjunct to traditional conversations about contraception has been noted to fill gaps that women experience when trying to access contraceptive information.26 The clinic did not previously use any technology-based counseling for patients who were trying to choose a contraceptive method. Because of their ease of use, iPads were the electronic devices chosen to access the Bedsider website. To eliminate possible distractions, all preloaded applications were removed; only a shortcut to the Bedsider website was visible to participants. The Methods Explorer and Compare Methods webpages were chosen for inclusion in the study because of their application to clinical practice in helping patients understand available methods, as well as the benefits and limitations of each method. These webpages are colorful and easy to understand, and provide pictures and brief text describing the main features of each method.

No technology-related problems were reported during the study. Prior to data collection, the iPads were connected to the clinic’s password-protected wireless Internet. Webpages loaded quickly, and participants were able to navigate the Bedsider website easily after orientation by the MA. Tablets were stored in a locked cabinet when not in use and the MAs were responsible for distributing and collecting the devices when participants were done with their visit. Although clinic staff initially expressed concerns about damaged or stolen tablets, no instances of theft or breakage occurred during the study.

Consistent with existing research, the participants were receptive to using the Bedsider website. In the past, patients have found the website convenient and easy to navigate and appreciated feature formats such as videos and pictures.27 Decisions about contraceptives are complex, multifaceted, and personal. Aids such as the Bedsider website can facilitate contraceptive decision making by allowing women to consider their own needs, values, and personal preferences, and may be particularly useful in low-resource settings.28

At enrollment, LARC use was low (11%). The authors noted an increase in LARC use for both the intervention group (29%) and the control group (36.6%)—the difference between groups was not significant—highlighting that either technology-enhanced counseling or usual care delivered by an NP favorably affected LARC use rates. The control group had slightly higher LARC uptake, but the reasons for this difference are unclear. It may have been related to individual women’s preferences or selection bias (the women self-selected into the intervention or control group). Other researchers have reported that use of the Bedsider website over a 12-month period increased the likelihood that women would use a more effective birth control method.29 Those findings were not statistically supported by this study, but the small sample size and shorter (6-week) measurement point must be considered when interpreting the results.

Although the overarching aim of the study was to increase the use of LARC methods by women attending a family planning clinic, attention was paid to each woman’s preferences and concerns. HCPs need to ensure that all contraceptive counseling is provided in a respectful manner that supports each woman in identifying the method that best suits her needs, whether or not it is a LARC method. In this study, participants received non-biased contraceptive counseling regardless of whether they joined the intervention group or the control group. Their final choice of method was supported irrespective of the method selected.

Limitations

Results of this pilot study must be viewed in terms of several limitations. The study was conducted at one clinical site. At the time of the study, the Bedsider website was in English only, thereby excluding women who were not English proficient. Likewise, in order to complete the questionnaires, participants needed to be proficient in reading English, another limitation. The final sample was small, and included only women aged 18-29 years. Also, only 57% of the participants returned for 6-week follow-up measures.

Additional recruitment difficulties revolved around the weather and the political climate at the time. In January and February 2015, the northeastern Massachusetts region of the country received historic snowfall amounts, resulting in multiple canceled clinic sessions and transportation challenges that extended into March. Most women who attended the study clinic were of Hispanic descent; some were also undocumented. In addition to the language barrier, some of these women may have been reluctant to participate in the study because of the heated rhetoric regarding Hispanic and Mexican immigrants that was dominating the media at the time.

The ensuing sample characteristics and limited follow-up data restricted generalizability beyond this sample. In addition, as with all self-report measures, issues of social desirability must be considered.

Despite these limitations, important insights were gained. The clinic that served as the research site provides low-cost healthcare, quick-start contraception, and flexible, open-access scheduling. Even with removal of access and cost barriers and the liberal policies for starting the contraceptive methods, women who enrolled in the study reported low levels of contraceptive use. The reasons for this low level of use are unclear. However, NP counseling, with or without the addition of technology, increased LARC use and overall use of contraception.

Conclusion

Providers of today encounter complex and challenging health problems within a multicultural and multilingual patient population. In this environment, patient education can be challenging. Given the move toward greater patient involvement in the healthcare decision-making process, technology-based decisional-aid tools offer an effective and acceptable adjunct for patient health education. The women who participated in this study were receptive to using the Bedsider website as an adjunct to contraceptive counseling with the NP. Participants easily navigated the webpages and did not encounter technology-related problems. Although LARC use did not differ significantly between women who received traditional face-to-face contraceptive counseling and those who received technology-enhanced counseling, the use of online/digital media to enhance contraceptive counseling was both feasible and acceptable to patients. Practice settings should consider novel ways to deliver and reinforce contraceptive teaching that will help women choose the most effective method that reflects their individual needs.

Heidi Collins Fantasia is Assistant Professor at the University of Massachusetts Lowell College of Health Sciences, School of Nursing, in Lowell, Massachusetts. Allyssa L. Harris and Holly B. Fontenot are Assistant Professors at Boston College, William F. Connell School of Nursing, in Chestnut Hill, Massachusetts. All authors practice clinically as women’s health nurse practitioners. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

Funding

This study was funded by a grant from Bedsider awarded to Dr. Fantasia and Health Quarters, Inc.

Acknowledgment

The authors thank the staff and patients of Health Quarters, Inc., who graciously agreed to take part in this study.

References

  1. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-485.
  2. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.
  3. Frost JJ, Lindberg LD, Finer LB. Young adults’ contraceptive knowledge, norms and attitudes: associations with risk of unintended pregnancy. Perspect Sex Reprod Health. 2012;44(2):107-116.
  4. Zolna M. Lindberg L. Unintended Pregnancy: Incidence and Outcomes Among Young Adult Unmarried Women in the United States, 2001 and 2008. New York, NY: Guttmacher Institute; 2012.
  5. CDC. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(4):1-66.
  6. CDC. Providing quality family planning services: recommendations of CDC and U.S. Office of Population Affairs. MMWR. 2014;63(4):1-54.
  7. Lotke PS. Increasing use of long-acting reversible contraception to decrease unplanned pregnancy. Obstet Gynecol Clin N Am. 2015;42(4):557-567.
  8. Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception. 2008;78(3):197-200.
  9. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health. 2008;40(2):94-104.
  10. Trussell J, Henry N, Hassan F, et al. Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception. Contraception. 2013;87(2):154-161.
  11. Parks C, Peipert JF. Eliminating health disparities in unintended pregnancy with long-acting reversible contraception. Am J Obstet Gynecol. 2016;214(6):681-688.
  12. Branum AM, Jones J. Trends in long-acting reversible contraception use among U.S. women aged 15-44. NCHS Data Brief. 2015;(188):1-8.
  13. Secura GM, Allsworth JE, Madden T, et al. The contraceptive CHOICE project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010;203(2):115.e1-7.
  14. Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. J Adolesc Health. 2013;52(4 suppl):S59-S63.
  15. Biggs MA, Arons A, Turner R, et al. Same-day LARC insertion attitudes and practices. Contraception. 2013;88(5):629-635.
  16. Thompson KMJ, Rocca CH, Kohn JE, et al. Public finding for contraception, provider training, and use of highly effective contraceptives: a cluster randomized trial. Am J Public Health. 2016;106:541-546.
  17. Fox MP. A systematic review of the literature reporting on studies that examined the impact of interactive, computer-based patient education programs. Patient Educ Couns. 2009;77(1):6-13.
  18. Wofford JL, Smith ED, Miller DP. The multimedia computer for office-based patient education: a systematic review. Patient Educ Couns. 2005;59(2):148-157.
  19. Evans AE, Edmundson-Drane EW, Harris KK. Computer-assisted instruction: an effective instructional method for HIV prevention education? J Adolesc Health. 2000;26(4):244-251.
  20. Homer C, Susskind O, Alpert HR, et al. An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Pediatrics. 2000;106(1 pt 2):210-215.
  21. Martin JT, Hoffman MK, Kaminski PF. NPs vs. IT for effective colposcopy patient education. Nurse Pract. 2005;30(4):52 -57.
  22. Shaw MJ, Beebe TJ, Tomshine PA, et al. A randomized, controlled trial of interactive, multimedia software for patient colonoscopy education. J Clin Gastroenterol. 2001;32(2):142-147.
  23. Bedsider website. 2015.
  24. Groves RM, Mosher WD, Lepkowski J, Kirgis NG. Planning and development of the continuous National Survey of Family Growth. National Center for Vital Health Statistics. Vital Health Stat 1. 2009;(48):1-64.
  25. CDC. Sexual and reproductive health of persons aged 10-24 years – United States, 2002- 2007. MMWR Surveill Summ. 2009;58(6):1-58.
  26. Strasburger VC, Brown SS. Sex education in the 21st century. JAMA. 2014;312(2):125-126.
  27. Gressel GM, Lundsberg LS, Illuzzi JL, et al. Patient and provider perspectives on Bedsider.org, an online contraceptive information tool, in a low income, racially diverse clinic population. Contraception. 2014;90(6):588-593.
  28. Wyatt KD, Anderson RT, Creedon D, et al. Women’s values in contraceptive choice: a systematic review of relevant attributes included in decision aids. BMC Women’s Health. 2014;14(1):1-13.
  29. Antonishak J, Kaye K, Swiader L. Impact of an online birth control support network on unintended pregnancy. Soc Market Q. 2015;21(1):23-36.

Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle

In 2015, the Council on Patient Safety in Women’s Health Care convened an interdisciplinary workgroup to develop an evidence-based patient safety bundle addressing maternal mental health. The 13-member workgroup was co-chaired by NPWH Director of Policy Susan Kendig, JD, MSN, WHNP-BC, FAANP, and American Congress of Obstetricians and Gynecologists representative John P. Keats, MD. The workgroup collaborated over several months, reaching consensus and approval of the Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle in 2016.

The bundle has four key components: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning (Box). Rather than introducing new guidance, the bundle summarizes existing recommendations and matches them with specific resources to facilitate the implementation of best practices in all maternity care settings. The bundle is designed to be applicable in any setting where prenatal and/or postpartum care is provided. It can be adapted for implementation in preconception/interconception care as well.

Why is a maternal mental health bundle important?

First, healthcare providers (HCPs) need to know what is meant by the term bundle as it applies to healthcare. A bundle is a small set of evidence-based interventions that combines medical and improvement science to achieve improved outcomes. When care processes are grouped into simple bundles, HCPs are more likely to implement them by making fundamental changes in how the work is done. When the care processes are evidence based, subsequent outcomes will improve. Bundled interventions encourage interdisciplinary teams to organize work, adapt the delivery system, and deliver all of the bundle components. An emphasis is placed on improving process reliability. The endpoint is improvement of clinical outcomes.1 

Second, HCPs need to recognize the scope of maternal mental health safety issues. Perinatal mood and anxiety disorders are among the most common complications of pregnancy. Perinatal depression affects one in seven women.2,3 Anxiety disorders affect 13%-21% of women during pregnancy and 11%-17% postpartum.4 When unrecognized or untreated, these conditions can have a devastating effect on women, their infants, and their families. The spectrum of adverse effects includes poor adherence to healthcare recommendations, smoking, substance abuse, loss of financial and interpersonal resources, and a potential adverse effect on maternal–infant bonding/attachment. Depressive psychosis, an extreme form of perinatal depression, can lead to maternal suicide and/or infanticide. In fact, maternal suicide within a year of delivery is emerging as a major cause of maternal mortality and is probably underreported. Because perinatal mood and anxiety disorders are associated with increased risks for maternal and infant morbidity and mortality, they represent a vital patient safety issue.5

Where can HCPs find information about the bundle?

A commentary, Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety, published in the March 2017 issue of the journal Obstetrics and Gynecology, provides information to assist with bundle implementation. This commentary includes a discussion concerning each item within the four key bundle components. In addition, it provides a table listing useful patient/provider educational resources and the websites where these resources can be obtained. Because NPWH provided leadership both in the development of the bundle and in the writing of the commentary (Susan Kendig is the lead author), we at Women’s Healthcare are able to provide you with a link to the full article in Obstetrics and Gynecology.

What is the Council on Patient Safety in Women’s Health Care?

The Council on Patient Safety in Women’s Health Care is a broad consortium of organizations across the spectrum of women’s health established for the promotion of safe healthcare for every woman. The council has a mission to “continually improve patient safety in women’s healthcare through multidisciplinary collaboration that drives culture change” and a vision of “safe healthcare for every woman.” The council membership comprises 19 organizations, including NPWH, as well as patient advocates. NPWH participates in a number of workgroups convened by the council.

One of the major accomplishments of the council has been the development and dissemination of evidence-based patient safety bundles to support ongoing improvement of clinical care and patient outcomes. The council website provides access to live and archived webinars on a variety of topics relevant to promoting a culture of safety in women’s healthcare. The website also provides information on all of the patient safety bundles along with safety resources and tools.

Recommendations

I strongly encourage you to read the commentary, Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety, and to share the information with colleagues who provide prenatal, postpartum, and pre/interconception care. If you provide this care in your own clinical setting, consider using the bundle to facilitate a standardized process to ensure that maternal mental health is always addressed. The bundle is not intended to dictate practice. It is, as described previously, a set of evidence-based interventions that combines medical and improvement science to achieve improved outcomes. The interventions can be adapted in consideration of local resources, but standardization within an institution is important for consistent and safe care.

If you have implemented the bundle in your healthcare setting, please consider writing a short commentary for our journal on the process and outcomes thus far. You can submit your commentaries to me at bkelsey@healthcommedia.com. By sharing our experiences, we can strengthen the resolve to make sure that maternal mental health is always regarded as a safety issue and that it is addressed in an evidence-based manner.

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 and NPWH Director of Publications. 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. Reser R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243-248.
  2. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ). 2005;(119):1-8.
  3. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490-498.
  4. Fairbrother N, Young AH, Janssen P, et al. Depression and anxiety during the perinatal period. BMC Psychiatry. 2015;15:206.
  5. Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on maternal mental health: perinatal depression and anxiety. Obstet Gynecol. 2017;129(3):422-430.

Human Sex Trafficking

The National Association of Nurse Practitioners in Women’s Health (NPWH) recognizes the critical role of women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for adolescent and adult females in terms of identifying, assessing, and responding to the needs of trafficked female individuals. Adolescent and young adult females comprise the majority of trafficked persons in the United States and globally, most specifically as victims of sex trafficking. NPs must be well prepared to identify, assess, and provide care for these individuals and have access to the resources to do so.

Many trafficked persons are seen in healthcare settings, yet they remain unidentified.2 Healthcare providers (HCPs) either are not aware of or do not respond to signs, when present, that a patient may be a victim of sex trafficking. A validated screening tool is not yet available. However, NPs can draw from existing evidence in related areas—especially intimate partner violence, sexual assault, homeless and runaway youth, child abuse and neglect, and individuals experiencing trauma in general—for clinical guidance. In addition, NPs can consider practice recommendations from colleagues in social service, advocacy, healthcare, and law enforcement who have expertise in human trafficking identification and intervention.

NPWH supports a comprehensive, coordinated, multidisciplinary approach to meet sex-trafficked individuals’ complex needs and help them address the challenges they face. To that end, NPWH supports research initiatives to develop a validated screening tool to better identify patients who are victims of sex trafficking, as well as to better understand the most effective manner in which to meet their emergency, short-term, and long-term healthcare needs.

Legislation and regulatory policies should focus on eliminating the demand for trafficked individuals in the first place, and on targeting persons and agencies that condone human trafficking. NPWH supports the development of legislation, regulatory policies, and advocacy efforts that protect the safety, rights, dignity, and cultural values of trafficked individuals.

NPWH will provide leadership and collaborate with other organizations and agencies to deliver NP education, develop policies, and conduct or support research in a concerted effort to increase knowledge and provide resources for NPs to identify, assess, and respond to the needs of trafficked female individuals.

Background

In 2000, the U.S. Trafficking Victims Protection Act (TVPA) updated post-Civil War slavery statutes to further guarantee freedom from slavery and involuntary servitude.3 For this purpose, sex trafficking was defined as the recruitment, harboring, transportation, provision, or obtaining of a person, through force, fraud, or coercion, for the purpose of commercial sex act.3 Severe forms of trafficking in persons was defined as sex trafficking in which the person induced to perform such act has not attained 18 years of age or sex trafficking for the purpose of subjection to involuntary services, servitude, peonage, debt bondage, or slavery.3 The TVPA was re-authorized most recently in 2013.4 Today, the terms modern slavery, trafficking in persons, and human trafficking are used as umbrella terms meeting the TVPA definition.

Accurate statistics for the incidence and prevalence of human trafficking are elusive because of the clandestine nature of the crime and trafficked individuals’ reluctance to identify themselves. Worldwide, it is estimated that 20.9 million persons are victims of trafficking and that among this group, 4.5 million (22%) are victims of forced sexual exploitation.5 Within the U.S., trafficked individuals may be transported across borders from other countries or they may already reside here. Data from a Bureau of Justice Statistics report for January 2008 through June 2010 identified 527 confirmed victims of trafficking, with 80% of these cases being classified as sex trafficking, 10% as labor trafficking, and 10% as undetermined.1 Eighty-three percent of the sex-trafficked individuals in this report were U.S. citizens, with 94% of them being female. The commercial sexual exploitation of minors comprised 64% of the cases. Of note, these data reflect only reported and investigated cases; the numbers may greatly under-represent the true extent of the problem. In 2015, the National Human Trafficking Resource Center (NHTRC) hotline received 21,957 calls across all states, with 4,314 calls reporting sex trafficking.6 

Females at high risk for being victims of sex trafficking include those who are young, live in extreme poverty, have limited education and work opportunities, engage in drug use, and/or have a history of instability or abuse in their families of origin. They may be more vulnerable if they have mental or physical disabilities. Adolescent females who are runaways and/or homeless are particularly vulnerable.2,7

Trafficked individuals face numerous barriers to disclosing their situation to HCPs. They may fear harm to themselves, family members, or friends; fear deportation if not legally in the U.S.; have language barriers; distrust authority figures; feel they do not have any options; be ashamed of their situation and the stigma they believe it carries; or have a criminal record. Traffickers may use monitoring devices to track these individuals’ every move to deter them from seeking help. In addition, some trafficked individuals may not under-stand the concept of coercion or that they are victims of an illegal activity.2

Patients who have been trafficked are at high risk for long-term physical and mental health con-sequences related to inflicted trauma and depriva-tion of their basic needs for survival. Health conse-quences may include unintended pregnancies; sexually transmitted infections (STIs), including HIV; poor dentition compounding malnutrition; depression; post-traumatic stress disorder (PTSD); and suicidal ideation. Commonly reported physi-cal symptoms include fatigue, headaches, back pain, and weight loss.8

Implications for women’s healthcare and WHNP practice

WHNPs and other NPs who provide women’s healthcare should be aware of indicators that raise suspicion that an individual presenting to a healthcare setting may be in an exploitative circumstance. Warning signs identified by anti-trafficking experts include:

Hypervigilant, fearful, or submissive demeanor; evidence of being controlled;

Provision of vague answers to questions or a script-like recitation of her history;

Delay between the onset of an injury or illness and the seeking of healthcare, in context with other indicators;

Discrepancies between an individual’s explained cause and the clinical presentation of her injuries;

Accompaniment by another person who answers questions for the individual and refuses to leave her alone during the visit;

Inability to produce identification documents;

Signs of physical abuse (e.g., cigarette burns, bruising), sexual abuse, medical neglect, torture, depression, PTSD, and/or alcohol or substance use disorder;

Tattoos or other markings indicating a claim of ownership by another;

Recurrent STIs;

Trauma to her genitals or rectum; and/or

History of repetitive abortions or miscarriages.2,7,9,10

WHNPs are particularly qualified through their educational preparation to recognize and provide needed healthcare services and referrals for adolescent and adult females who are victims of sexual, physical, and/or emotional abuse. Trauma-informed care for these patients places an emphasis on helping the individual feel safe and reclaim control of her life and decisions. Goals of a trauma-informed approach in care are to avoid re-traumatization, to emphasize the patient’s strengths and resilience, to support development of healthy short- and long-term coping mechanisms, and to promote healing and recovery.2

No official guidelines are available regarding the most effective manner in which to provide for the emergency, short-term, and long-term healthcare needs of trafficked patients. However, expert opinion supports these approaches:

Foster trust and relationship building, which includes an assurance of confidentiality.

Ensure privacy prior to discussing potential trafficking with the patient.

Recognize potential danger to the patient and/or her family members if she reports the crime.

Incorporate safety planning for both the patient and staff.

Use a trauma-informed approach in assessment and treatment.

Provide care for any immediate needs (e.g., treat STIs, diagnose a pregnancy).

Provide culturally appropriate services.

Mitigate language barriers; provide a professional interpreter when needed.

Establish a list of local resources for collaboration that provides wraparound services for the individual.

Contact the NHTRC hotline at 1-888-373-7888 for guidance on the next steps and referrals if needed.2,7,11

The NHTRC provides detailed information for HCPs concerning identification, assessment, and response to the needs of patients who have been trafficked.

Recommendations

WHNPs and other NPs who provide healthcare for adolescent and adult females should:

Be familiar with and educate staff about warning signs indicating that a patient may be a victim of sex trafficking;

Establish a plan in the healthcare setting for safety of both the patient and staff;

Establish partnerships with local social service providers, mental health providers, religious leaders, legal advocates, and law enforcement representatives for comprehensive services;

Serve as change agents in their communities through mentoring programs for at-risk youth, advocacy for policy changes to aid recovery of trafficked individuals, and engagement in activities that will promote greater cultural awareness of gender inequalities; and

Assess their own learning needs with regard to the unique and complex needs of trafficked individuals and seek continuing education as appropriate.

NPWH will provide leadership and resources to ensure that:

Educational programs for NP students with a population focus that includes adolescent and adult females impart evidence-based knowledge and skill building for the development of competencies to identify trafficked individuals and provide healthcare and appropriate referrals for them; and

Continuing education programs are available for NPs to obtain evidence-based knowledge and competencies to identify and provide healthcare and appropriate referrals for trafficked individuals.

References

1. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008-2010. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2011. 

2. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. Waltham, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, and Committee on Violence Intervention and Preven-tion, Massachusetts Medical Society; 2014.

3. 106th U.S. Congress. Victims of Trafficking and Violence Protection Act of 2000, Public Law 106-386. 2000. 

4. U.S. Department of State. U.S. Laws on Trafficking in Persons. 2016. 

5. International Labor Organization. ILO 2012 Global Estimate of Forced Labor: Executive Summary. 2012. 

6. National Human Trafficking Resource Center. 2015 NHTRC Annual Report. 2016. 

7. Clawson H, Dutch N, Solomon A, Grace L. Human Trafficking Into and Within the United States: A Review of the Literature. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Planning and Evaluation; 2009. 

8. World Health Organization. Understanding and Addressing Violence Against Women: Human Trafficking. 2012. 

9. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human sex trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49. 

10. National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting. 2016. 

11. Dovydaitis T. Human trafficking: the role of the health care provider. J Midwifery Womens Health. 2010;55(5):462-467. 

Perinatal anxiety disorders: Assessment and management

Key words: pregnancy, perinatal period, perinatal anxiety, generalized anxiety disorder, perinatal anxiety screening scale

An anxiety disorder can disrupt a woman’s abilities to enjoy life and to self-care. When an anxiety disorder is present during the perinatal period—that is, during pregnancy and/or the first year postpartum—it can change how a woman experiences her pregnancy and how she interacts with and cares for her child.Limited data suggest a possible association between severe perinatal anxiety disorders and adverse pregnancy outcomes such as preterm birth, low birth weight, and postpartum depression.2,3 In addition, maternal anxiety disorders have been linked to developmental and mental health problems in offspring.2-4 Healthcare providers (HCPs) who see women during pregnancy and postpartum need to know the risk factors and signs and symptoms associated with perinatal anxiety disorders so that these disorders can be identified early and treated as needed. This article focuses primarily on assessment for and management of a common anxiety disorder—generalized anxiety disorder (GAD)—in this patient population.

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is a mental disorder characterized by frequent and intense worry or anxiety about many aspects of one’s life (e.g., health, work, family), even if these aspects of life are going well.A person with GAD has difficulty controlling this anxiety, which can interfere with daily functioning.

Prevalence

Approximately 40 million adults in the United States, or 18% of the adult U.S. population, are diagnosed with an anxiety disorder each year, with 22.8% of these cases classified as severe.In addition to GAD, anxiety disorders include phobias, social anxiety disorder, post-traumatic stress disorder (PTSD), panic disorder, and obsessive-compulsive disorder. Many adults have more than one anxiety disorder.GAD, with a prevalence of 3.1% and an average age of onset of 31 years, is twice as common in women as in men,7 Anxiety disorders affect 4%-39% of women during pregnancy and up to 18% during the postpartum period.8

Risk factors

Perceived lack of partner and/or social support, a history of intimate partner violence or other abuse, a personal history of mental illness, having an unplanned or unwanted pregnancy, past or present pregnancy complications, and past pregnancy loss are risk factors for perinatal GAD.Women experiencing a high-risk pregnancy are also at greater risk for developing GAD.10,11 Other risk factors for perinatal GAD include failure to complete high school, unemployment, and nicotine use.12

Symptoms

Some degree of anxiety is common during pregnancy and postpartum, so HCPs should aim to differentiate between “normal” anxiety and GAD. Persons in the general population with GAD may report trembling, twitching, shakiness, muscle aches, sweating, nausea, diarrhea, and an exaggerated startle response.7 In the perinatal period, GAD may manifest as excessive and persistent nervousness, worry, or even panic about pregnancy and childbirth, the infant’s health, and parenting. Physical features—in addition to those listed for GAD in general—may include stomach pain, headaches, dizziness, palpitations, and shortness of breath.13 GAD can exacerbate sleep disturbances and fatigue in women during the perinatal period. Because anxiety and depressive disorders often co-exist, a pregnant or postpartum woman with GAD may exhibit manifestations of depression as well.14

Screening for perinatal GAD

Routine screening is essential for early recognition of GAD, which may otherwise go undetected and untreated in pregnant and postpartum women. Some of the most common clinical features of GAD may be attributed to normal physiologic changes of pregnancy or expected psychosocial adjustments to pregnancy and child care. A woman may be reluctant to report signs/symptoms of GAD for fear of being perceived as an excessive worrier or a hypochondriac.

The American College of Obstetricians and Gynecologists (ACOG) advises screening women at least once during the perinatal period for anxiety and depression using a standardized, validated tool.15 Although ACOG does not provide a recommendation for timing or frequency of this screening, the organization does advise HCPs to closely monitor women who have a history of, or risk factors for, anxiety or depressive disorders.

Two anxiety screening instruments used in both pregnant and postpartum women are the Generalized Anxiety Disorder-7 (GAD-7) and the Perinatal Anxiety Screening Scale (PASS). The GAD-7 is a 7-item self-report questionnaire created to identify essential areas of anxiety (worry, restlessness, irritability, and fear) and its severity in the previous 2 weeks.16,17 The reported internal consistency of the GAD-7 is excellent (Cronbach’s α, .92), and its test/retest reliability is good (intraclass correlation coefficient [ICC], .83). The PASS is useful throughout the perinatal period to assess for a range of anxiety symptoms.18,19 Principal component analyses suggested a 4-factor structure addressing symptoms of acute anxiety and adjustment; general worry and specific fears; perfectionism, control, and trauma; and social anxiety. The PASS is validated for use in hospital, mental health, and community samples and has excellent reliability (Cronbach’s α, .96) and test/retest reliability (ICC, .74). The Box lists various anxiety screens and provides links to them for easy access.

Validated anxiety screening instruments with a postpartum focus include the Postpartum Worry Scale-R (PWS-R) and the Penn State Worry Questionnaire-10 (PSWQ-10). The PWS-R was developed to identify the degree of uncontrollable worry, a major symptom of GAD in postpartum women.20 This revised format of the original PWS includes items related to the mother’s perception of the infant’s well-being in terms of health and development and the mother’s relationship with her child.21,22 The PSWQ-10 measures worry, often described as the cardinal feature of GAD.23  Although the PSWQ-10 cannot distinguish GAD from major depressive disorder, it can track worry, which may affect both treatment and recovery. The Edinburgh Postnatal Depression Scale (EPDS) has an anxiety subscale (EPDS-3A) and can reliably differentiate between depression and anxiety.24 

Making the diagnosis

Establishing rapport with patients facilitates a discussion of the clinical features of anxiety, screening test results, and treatment options.

HCPs need to determine the extent to which anxiety, worry, and/or the physical manifestations of anxiety are causing impairment in social, occupational, or other areas of functioning.

Once perinatal anxiety is identified and diagnosed, the next step is to determine whether an underlying condition might be causing the signs/symptoms or exacerbating their severity (e.g., substance misuse/abuse, a physical health condition), as well as whether co-existing psychiatric conditions such as depression, substance abuse, bipolar disorder, psychosis, schizophrenia, or PTSD might be complicating the picture. Referral to a mental health specialist is imperative when a pregnant woman has suicidal ideation, a co-existing psychiatric condition, or need for a complex medication regimen. HCPs providing perinatal care should have resources available for initiating a multidisciplinary team approach in treating perinatal anxiety.25,26 

Management

If perinatal anxiety is determined to be the primary problem, cognitive behavioral therapy (CBT), the first-line treatment for anxiety in the general population, is a reasonable first approach.27  Although less studied in women with perinatal anxiety, CBT has been shown to be effective in treating postpartum depression.28,29 Additional nonpharmacologic options include mindfulness-based cognitive therapy, interpersonal therapy, psychodynamic therapy, acupuncture, and massage.30 When nondrug therapies are ineffective or only partially effective, medication may be indicated. In these cases, HCPs and patients should weigh the risks of not fully treating the anxiety disorder, the potential risks to a fetus exposed to the medications chosen, and the potential benefits of easing the anxiety disorder.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line drugs for the treatment of moderate or severe anxiety disorders.31 The Table lists commonly prescribed SSRIs and SNRIs, as well as their recommended daily doses and side effects.31 Taken together, data obtained over several years suggest that SSRIs and SNRIs are not teratogenic or associated with adverse pregnancy outcomes. Studies of the use of the SSRIs sertraline, fluoxetine, and citalopram during pregnancy provide the largest databases indicating no teratogenic effects.32,33 Although study results are conflicting, some reports have suggested a small increased risk for congenital heart defects associated with use of paroxetine during pregnancy.34,35 No teratogenic effects have been reported with use of SNRIs during pregnancy, although these agents may be associated with a small increased risk for pre-eclampsia.36

The SSRIs fluoxetine and paroxetine and the SNRI venlafaxine, if taken around the time of birth, have been most closely associated with postnatal adaptation syndrome (PNAS).37 However, a recent study found that these agents did not cross the placenta to a greater extent than other antidepressants.37 Maternal use of SSRIs in late pregnancy may also be associated with a potentially increased risk of persistent pulmonary hypertension of the newborn.38 The absolute risk is small, and, according to a recent study, the increased risk appears more modest than that suggested in previous studies.38

Both SSRIs and SNRIs may be used for treatment of an anxiety disorder in a woman who is breastfeeding.34,39 Infants whose mothers are using the SSRIs fluvoxamine, paroxetine, or sertraline or the SNRI venlafaxine have been found to have low or undetectable serum drug levels, and no adverse effects have been reported.40

In the general population, use of benzodiazepines should be reserved for acute anxiety on a short-term basis because of the multiple associated risks: worsening of depressive symptoms, possible dependence, and possible overdose.32 Benzodiazepine use should be avoided in pregnancy because of these risks. Some data show a small increased risk for preterm birth, low birth weight, and floppy infant syndrome (hypotonia) in infants whose mothers used benzodiazepines during pregnancy. Data are inconclusive in terms of any teratogenic effect. If benzodiazepines are considered for women who are breastfeeding, those with a shorter half-life such as lorazepam and oxazepam are preferred because they are reported to result in low levels in breast milk and because they do not cause adverse effects in breastfed infants.34,41 Alprazolam and diazepam, with longer half-lives than some of the other benzodiazepines, should be avoided because of reports of infant sedation.34,41

Implications for practice

Perinatal anxiety is fairly common, and, when severe, has been linked to adverse pregnancy outcomes and to developmental and mental health problems in offspring. Early identification of and intervention for perinatal anxiety can help alleviate signs and symptoms, improve the perinatal experience, and reduce the risk for adverse outcomes. HCPs need to screen women for anxiety both during pregnancy and postpartum. When anxiety is identified, HCPs should conduct further assessment to determine whether the patient has a co-existing psychiatric disorder that merits referral and collaboration with a mental health specialist. Nonpharmacologic treatments such as CBT should be considered as first-line treatment, although some women may require medication to manage symptoms adequately. Risks and benefits of using medications to treat anxiety during the perinatal period should be considered on an individualized and ongoing basis.

Marian L. Farrell is Professor of Nursing at the University of Scranton in Scranton, Pennsylvania. She is also in private practice as a psychiatric nurse practitioner and clinical nurse specialist. 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. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry. 2006; 67(8):1285-1298.

2. Bauer A, Knapp M, Parsonage M. Lifetime costs of perinatal anxiety and depression. J Affect Disord. 2016;192:83-90.

3. Bayrampour H, Al E, McNeil DA, et al. Pregnancy-related anxiety: a concept analysis. Int J Nurs Stud. 2015;55:115-130.

4. Rubertsson C, Hellström J, Cross M, Sydsjö G. Anxiety in early pregnancy: prevalence and contributing factors. Arch Womens Ment Health. 2014;17(3):221-228.

5. National Institute of Mental Health (NIMH). Generalized Anxiety Disorder Among Adults.

6. National Institute of Mental Health. Any Anxiety Disorder Among Adults.

7. American Psychiatric Association. Anxiety disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: APA; 2013:222-226.

8. Marchesi C, Ossola P, Amerio A, et al. Clinical management of perinatal anxiety disorders: a systematic review. J Affect Disord. 2016;190:543-550.

9. Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: a systematic review. J Affect Disord. 2016;191:62-77.

10. O’Hara MW, Stuart S, Watson D, et al. Brief scales to detect postpartum depression and anxiety symptoms. J Womens Health. 2012;21(12):1237-1243.

11. Zadeh MA, Khajehei M, Sharif F, Hadzic M. High-risk pregnancy: effects on postpartum depression and anxiety. Br J Midwifery. 2012;20(2):104-113.

12. Fairbrother N, Janssen P, Antony MM, et al. Perinatal anxiety disorder prevalence and incidence. J Affect Disord. 2016;200:148-155.

13. Hoang S. Pregnancy and anxiety. Int J Childbirth Educ. 2014;29(1):67-70.

14. Grigoriadis S, de Camps Meschino D, Barrons E, et al. Mood and anxiety disorders in a sample of Canadian perinatal women referred for psychiatric care. Arch Womens Ment Health. 2011;14(4):325-333.

15. American College of Obstetricians and Gynecologists. Screening for perinatal depression. Washington, DC: ACOG; 2015.

16. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.

17. Simpson W, Glazer M, Michalski N, et al. Comparative efficacy of the generalized anxiety disorder 7-item scale and the Edinburgh Postnatal Depression Scale as screening tools for generalized anxiety disorder in pregnancy and the postpartum period. Can J Psychiatry. 2014;59(8):434-440.

18. Somerville S, Dedman K, Hagan R, et al. The perinatal anxiety screening scale: development and preliminary validation. Arch Womens Ment Health. 2013;17(5):443-454.

19. Somerville S, Byrne SL, Dedman K, et al. Detecting the severity of perinatal anxiety with the Perinatal Anxiety Screening Scale (PASS). J Affect Disord. 2015;186:18-25.

20. Wenzel A, Haugen EN, Jackson LC, Robinson K. Prevalence of generalized anxiety at eight weeks postpartum. Arch Womens Ment Health. 2002;6(1):43-49.

21. Moran TE, Polanin JR, Wenzel A. The Postpartum Worry Scale-Revised: an initial validation of a measure of postpartum worry. Arch Womens Ment Health. 2014;17(1):41-48.

22. Moran TE, Polanin JR, Segre L, Wenzel A. The Postpartum Worry Scale-Revised: continuing validation with a sample of NICU mothers. Arch Womens Ment Health. 2015;18(2):221-228.

23. Yao B, Sripada RK, Klumpp H, et al. Penn State Worry Questionnaire-10: a new tool for measurement-based care. Psychiatry Res. 2016;239:62-67.

24. Matthey S, Fisher J, Rowe H. Using the Edinburgh postnatal depression scale to screen for anxiety disorders: conceptual and methodological consideration. J Affect Disord. 2013;146(2):224-230.

25. Ali NS, Azam IS, Ali BS, et al. Frequency and associated factors for anxiety and depression in pregnant women: a hospital-based cross-sectional study. Scientific World Journal. 2012;2012:653098.

26. Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr Opin Psychiatry. 2012;25(2):141-148.

27. Otte C. Cognitive behavior therapy in anxiety disorders: current state of the evidence. Dialogues Clin Neurosci. 2011;13(4):413-421.

28. Sockol LE, Epperson CN, Barber JP. A meta-analysis of treatments for perinatal depression. Clin Psychol Rev. 2011;31(5):839-849.

29. Stuart S, Koleva H. Psychological treatments for perinatal depression. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):61-70.

30. Kittel-Schneider S, Reif A. Treatment of mental disorders in pregnancy and lactation: psychotherapy and other non-drug therapies. Neurologist. 2016;87(9):967-973.

31. Stahle S. Stahl’s Essential Psychopharmacology Prescriber’s Guide. 5th ed. New York, NY: Cambridge University Press; 2014.

32. Woo TM, Robinson MV. Pharmacotherapeutics for Advanced Practice Nurse Prescribers. Philadelphia, PA: F.A. Davis; 2016.

33. Rubinchik SM, Kablinger AS, Gardner JS. Medications for panic disorder and generalized anxiety disorder during pregnancy. Prim Care Companion J Clin Psychiatry. 2005;7(3):100-105.

34. Malm H, Artama M, Gissler M, Ritvanen A. Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstet Gynecol. 2011;118(1):111-120.

35. Stephansson O, Kieler H, Haglund B, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of stillbirth and infant mortality. JAMA. 2013;309(1):48-54.

36. Palmsten K, Setoguchi S, Margulis AV, et al. Elevated risk of preeclampsia in pregnant women with depression: depression or antidepressants? Am J Epidemiol. 2012;175(10):988-997.

37. Ewing G, Tatarchuk Y, Appleby D, et al. Placental transfer of antidepressant medications: implications for postnatal adaptation syndrome. Clin Pharmacokinet. 2015;54(4):359-370.

38. Huybrechts KF, Bateman BT, Palmsten K, et al. Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn. JAMA. 2015;313(21):2142-2151.

39. Ellfolk M, Malm H. Risks associated with in utero and lactation exposure to selective serotonin reuptake inhibitors. Reprod Toxicol. 2010;30(2):249-260.

40. LactMed: A Toxnet Database.

41. Brucker MC, King TL. Pharmacology for Women’s Health. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2017.

Web resources

A. integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf

B. drsarahallen.com/wp-content/uploads/2015/10/PerinatalAnxietyScreeningScale2.pdf

C. link.springer.com/article/10.1007/s00737-013-0380-9

D. outcometracker.org/library/PSWQ.pdf

Evaluation of women with infertility

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

Key words: infertility, infertility evaluation, ovulatory dysfunction, ovarian reserve, tubal patency

Advanced practice nurses (APNs) may be the first point of contact in a woman’s lengthy fertility journey. Although caring for a patient with infertility is within the scope of practice of APNs, this process can be intimidating and complex. APNs need to set realistic expectations, educate patients, and provide initial management. The author discusses the initial evaluation of a woman with infertility prior to a referral to a reproductive endocrinology and infertility specialist if necessary.

As many as 15% of couples trying to conceive a child are diagnosed with infertility, defined as the inability to conceive within 1 year despite unprotected intercourse.1 Because advancing maternal age is a driving force in the decline of fertility, the time span in the definition may reasonably be altered to 6 months for women older than 35 years. Overall fertility rates, which peak between the ages of 20 and 24 years, are 4%-8% lower in women aged 24-29, 15%-19% lower in those aged 30-34, 26%-46% lower in those aged 35-39, and as much as 95% lower in those aged 40-45.1 

Infertility is a complex diagnosis that can greatly affect physical, mental, and financial aspects of a couple’s life together.2 In general, infertility is considered a couple’s diagnosis because 35%-40% of cases are due to male factors, 30%-40% to female factors, and up to 30% to a combination of male and female factors or unexplained factors.1 Common causes of infertility in women are ovulatory dysfunction and tubal/peritoneal pathology, and a common cause of infertility in men is a sperm abnormality.3 

Referral to a specialist in reproductive endocrinology and infertility (REI) is considered early in the assessment of infertility in a woman with endometriosis, tubal disease, a history of three or more spontaneous abortions, or previous ovulation induction, or in a case of male factor infertility. When known risk factors exist, or when a woman is older than 35 years, APNs should not wait to initiate assessment and referral until a couple has tried to conceive for a full year. However, women who have not previously tried ovulation induction medications, are anovulatory, have polycystic ovary syndrome (PCOS), or have unexplained infertility may be treated by an APN for 3-6 months prior to referral.4 Male factor infertility may be addressed with an intrauterine insemination if an andrology laboratory is available. Knowing the appropriate components and timing of an infertility assessment is essential.

History

The APN takes a thorough history from each partner. The APN needs to learn how long the couple has been trying to conceive and the results of any previous evaluation to ensure that testing is not repeated unnecessarily.

The woman

A full menstrual history is obtained, including age at menarche, cycle length, characteristics of bleeding, and presence or absence of moliminal symptoms (e.g., bloating, breast tenderness). Absence of moliminal symptoms may suggest anovulation.1 The woman is asked about prior contraception use; her obstetric history, including pregnancy outcomes and complications (e.g., ectopic pregnancy, cesarean delivery, dilation and curettage procedures); past surgeries; current medications; recent weight changes; signs and symptoms of thyroid disease; pelvic or abdominal pain; galactorrhea; hirsutism; and dyspareunia. A history of chlamydia, gonorrhea, or pelvic inflammatory disease (PID) increases the potential for tubal damage and raises suspicion of tubal infertility disease.1,5 

A thorough family history includes a discussion of reproductive outcomes and the existence of birth defects, mental retardation, early menopause, and/or genetic abnormalities.1 The American Congress of Obstetricians and Gynecologists recommends taking a detailed family history and, depending on a woman’s ethnicity, performing preconception carrier screening for cystic fibrosis, sickle cell disease, Tay-Sachs disease, thalassemia, familial dysautonomia, and Canavan disease.6 

The man

Male infertility may be influenced by lifestyle factors (e.g., obesity; use of certain medications, alcohol, or tobacco) or a genetic condition (e.g., cystic fibrosis) or it may be idiopathic. Evaluation begins with a thorough reproductive history to assess for coital frequency and timing, duration of infertility, results of any past evaluations, childhood illnesses (e.g., mumps), systemic illness (e.g., diabetes mellitus, hypertension), past genitourinary surgery (e.g., orchiectomy, hernia repair), sexual history (e.g., erectile dysfunction, history of sexually transmitted infections), and exposure to environmental toxins.7 The history entails a thorough review of systems, a complete family reproductive history, and a social history, including use of recreational drugs, steroids, tobacco, or alcohol (these substances can affect semen parameters).

Physical examination

The woman

The APN performs a targeted physical examination to explore causes of infertility. Weight and body mass index (BMI) are calculated. Ovulatory dysfunction may occur at any BMI level but is more common when it falls outside the healthy range (20-24 kg/m2).1  The thyroid is assessed for enlargement, presence of nodules, or tenderness. Signs of androgen excess (e.g., hirsutism, acne) are noted, as are characteristics of any breast/nipple discharge. Abdominal and bimanual exams are performed to assess for tenderness, organ enlargement, and masses. Pelvic tenderness in the posterior cul-de-sac or uterosacral ligaments may indicate endometriosis. The uterus is palpated for enlargement or immobility, which may indicate fibroids, uterine anomaly, endometriosis, or pelvic adhesions.8 A speculum exam is done to assess the cervix for the presence of abnormalities, secretions, or discharge, which may suggest a pelvic infection.

The man

In the absence of a history of trauma, surgery, genital abnormality, or sexual dysfunction, the physical exam of the man may be deferred pending a semen analysis. An abnormal history or semen analysis finding warrants a physical exam by a urologist or an REI specialist. If a physical exam by the APN is deemed appropriate in a given case, it consists of an inspection of the penis, noting the location of the urethral meatus and the presence of hypospadias; palpation of the testes; ascertainment of the presence and consistency of the vas deferens and the epididymis; and determination of the presence of a varicocele. The APN notes the presence of secondary sex characteristics such as stature, hair distribution, and breast tissue distribution. A digital rectal exam may be considered to evaluate the prostate.1 

Diagnostic testing

Ovulatory function

In order for a woman to conceive, several components are necessary: ovulation, patent Fallopian tubes, a suitable uterine environment, and motile sperm capable of fertilization. Ovulatory dysfunction accounts for up to 40% of female infertility cases and is identified in about 15% of couples.1  Ovulation may be assessed by a mid-luteal progesterone level, an ovulation predictor kit, basal body temperature (BBT) measurements, or mid-cycle ultrasound. In some cases, a menstrual history may be sufficient. If a woman does not have regular and predictable menstrual cycles occurring every 21-35 days, further evaluation is necessary.

A mid-luteal progesterone level is assessed 7 days before expected menses; for a woman with a regular 28-day cycle, progesterone is assessed on cycle day 21.8 For a woman with irregular cycles, this assessment may occur later in the menstrual cycle. A progesterone level greater than 3 ng/mL provides evidence of recent ovulation, although levels greater than 10 ng/mL better reflect good luteal function.9 If the progesterone level is less than 3 ng/mL, the level is rechecked 5-7 days later. If the level remains low, the woman is further evaluated for anovulation.

A woman may choose to use an ovulation predictor kit, also known as a urine luteinizing hormone (LH) kit, to track her ovulation. A woman begins using daily test strips several days before anticipated ovulation to identify the mid-cycle LH surge that precedes ovulation by about 36 hours. The test kit identifies peak fertility as the day of the surge and the following day. The kit is not reliable for all women, particularly those with premature ovarian failure or PCOS, because LH levels may already be elevated.

Although not widely recommended, another option for ovulation detection is the BBT method, an inexpensive way to look retrospectively at the ovulation time frame. An oral temperature is taken at the same time every morning before rising. About 2 days following ovulation, a woman’s temperature rises roughly 0.5° F. Charting this temperature shift can help a woman better identify her ovulation pattern and peak fertility in subsequent months. Of note, evaluating an increase in cervical mucus or using an ovulation predictor kit has been found to be more reliable than BBT in terms of attempting to achieve a pregnancy in the current cycle.10

Ovarian reserve

Oocytes decrease in quantity and quality as women age and are incapable of regenerating. The number of human oocytes peaks at 6-7 million at 20 weeks’ gestation; by the time a female reaches puberty, only 300,000-500,000 oocytes remain. During her lifetime, a woman will ovulate 400-500 eggs. To assess a woman’s fertility potential and determine a treatment plan, the APN must first assess ovarian reserve, which is done by measuring basal follicle-stimulating hormone (FSH), estradiol, and anti-Müllerian hormone (AMH) levels and performing ovarian imaging early in the follicular phase to evaluate the antral follicle count (AFC).

There is debate regarding the age at which to begin ovarian reserve testing. Current thinking is to recommend such testing for women older than 35 years who have not conceived after 6 months of regular unprotected intercourse.11 The APN may consider testing a woman at an earlier age if certain risk factors are present: anovulation, family history of early menopause, certain genetic conditions such as fragile X or Turner syndrome, history of endometriosis or pelvic infection, previous ovarian surgery, history of cancer treated by gonadotoxic therapy or pelvic radiation, and tobacco use.

Ovarian reserve testing is not infallible and it does not determine the end of a woman’s reproductive capability, nor does it predict the rate in which reproductive potential will diminish. The purpose is to assess the quality and quantity of the remaining oocytes to predict reproductive potential and, for the APN, the time to refer to a specialist. When results fall outside the normal range, the APN can encourage the patient to pursue more aggressive treatment options, which often include referral to an infertility specialist. Ovarian reserve can be assessed by measuring/doing the following:

Basal follicle-stimulating hormone/estradiol

Low estradiol levels early in each menstrual cycle trigger increased secretion of gonadotropin-releasing hormone, leading to increased release of FSH. Then, as the developing cohort of follicles produces estradiol and inhibin B, the increased FSH is suppressed by negative feedback. As a woman ages, a smaller cohort of follicles is available to produce estradiol and inhibin B, which increases secretion of FSH. The robust secretion of FSH stimulates rapid follicular growth and higher estradiol levels, resulting in a shorter follicular phase.11

Estradiol and FSH levels are measured on menstrual cycle days 2-4. FSH values greater than 10 mIU/ mL are associated with diminished ovarian reserve and poor response to ovarian stimulation. Because each menstrual cycle can vary, a single elevated FSH level does not predict an inability to conceive and, therefore, has limited reliability.12 During follicular development, estradiol is released from the developing follicles. In the early follicular phase (typically, cycle day 2-4), the estrogen level is usually less than 50 pg/mL. An elevated value (>60-80 pg/mL) may indicate oocyte depletion.13 For measurements to be meaningful, both FSH and estradiol levels are drawn on menstrual cycle days 2-4.

Clomiphene citrate challenge test

The CCCT may be considered for ovarian reserve testing, although it does not clearly improve FSH and estradiol test accuracy for predicting poor ovarian response or pregnancy after in vitro fertilization (IVF).14 The test requires measurement of cycle day 3 FSH and estradiol levels, followed by administration of clomiphene citrate 100 mg on cycle days 5-9. An FSH level is drawn again on cycle day 10; it should remain below 10 mIU/mL. If either the FSH or the estradiol level on day 3 or the FSH on day 10 is elevated, the patient likely has impaired ovarian function and a referral is warranted. Use of the CCCT has declined because newer tests such as AMH and AFC are simpler and have high predictive values.11

Serum anti-Müllerian hormone

Anti-Müllerian hormone is secreted by the granulosa cells of the pre-antral follicles and is reflective of the primordial oocyte pool.15 As women age and the number of oocytes decreases, the AMH level drops as well. The AMH level may be an earlier predictor of decreased ovarian reserve than FSH levels; it begins to decline early in the ovarian aging process, whereas elevated serum FSH levels are not found until cycles are already irregular.16 The advantage of determining the AMH level is that it remains constant throughout the menstrual cycle and may be drawn at any time.11 Evidence suggests that AMH levels may be diminished with oral contraceptive use and in women with obesity.17 By contrast, women with PCOS have been noted to have AMH levels 2-3 times higher than unaffected women. Overall, an AMH value of 1.0 mg/mL predicts an FSH value of 10.0 mIU/mL. Higher AMH levels suggest normal ovarian function, whereas lower levels have been associated with poor ovarian stimulation and poor pregnancy outcomes.18 Women whose levels fall outside the normal range should be referred to an REI specialist.

Antral follicle count

Ultrasound, although expensive, is another useful tool in evaluating ovarian reserve. AFC is the sum of the antral follicles in both ovaries early in the follicular phase (cycle days 1-4). Antral follicles have been defined as measuring 2-10 mm in diameter. A total of 3-6 antral follicles is considered low, and is associated with poor response in IVF. However, a low value is not predictive of a patient’s ability to conceive.19 No single test has 100% specificity and sensitivity; biochemical assays and imaging should be used in combination to most accurately evaluate ovarian reserve.

Tubal patency

Impaired tubal patency is another common cause of infertility. When tubal disease is suspected by patient history (e.g., chlamydia, gonorrhea, PID, previous ectopic pregnancy, tubal surgery), a hysterosalpingogram (HSG) is considered.8 An HSG can evaluate tubal patency and may have some therapeutic benefit. HSG is typically performed in the late follicular phase, or 2-5 days after the end of menstruation. An HSG can document tubal patency and uterine abnormalities, including filling defects (polyps and fibroids) and uterine malformations (e.g., septum, bicornuate uterus). If an abnormality is noted, a referral is warranted.

Semen analysis

For the male partner, a semen analysis is considered early in the evaluation. This analysis is the most accurate evaluation of male fertility and can be used as a cost-effective way to quickly exclude male factors as the cause of a couple’s infertility. If the semen analysis yields normal results, attention is then focused on the female partner.

Prior to semen collection, the male partner should have an abstinence window of 2-5 days (2-3 days is preferred).20 The analysis may be performed in a fertility center or a urology office where an andrology lab is available. The semen sample is collected in a sterile container provided by the lab. If the man chooses to collect the sample outside the lab, it must be kept warm and delivered within 1 hour of collecting. Normal results for a semen analysis include a volume of 1.5 mL or greater, more than 39 million sperm per ejaculate, total motility of 40%, progressive motility (linear movement) of 32%, and 4% normal forms. If the analysis yields abnormal findings, efforts are made to identify modifiable factors to improve the natural ability of the man’s sperm to fertilize an ovum. Because semen samples can fluctuate, the semen analysis is repeated in 4-6 weeks. If results remain abnormal on repeat evaluation, referral to an infertility specialist is advised.7 

Conclusion

A diagnosis of infertility is life altering for many couples, with lasting psychological impact. The cause of infertility is often multifactorial and complex, leading to frustration in both providers and patients. Because of the substantial emotional, financial, and physical burden to patients, providers must practice with a holistic and therapeutic approach. APNs are in an excellent position to provide this holistic care for their patients, addressing aspects of both physical and emotional well-being. Resources for patients are listed in the Box.

Much of fertility testing is cycle dependent and cannot be completed at a single visit. Therefore, a month or more may be spent completing diagnostic testing before treatment takes place. The APN must assess patient expectations and explain that the evaluation takes time. Once test results are received, the APN may decide to treat with ovulation induction medication (e.g., clomiphene citrate) and timed intercourse for several months or refer to an REI specialist. Because of the length and intimacy of the evaluation, patients may feel more comfortable working with an APN with whom they have already established a trusting relationship before referral to a specialist.

References

  1. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
  2. Benyamini Y, Gozlan M, Kokia E. Variability in the difficulties experienced by women undergoing infertility treatments. Fertil Steril. 2005;83(2):275-283.
  3. Hull M, Glazener C, Kelly NJ, et al. Population study of causes, treatment, and outcome of infertility. BMJ. 1985;291:1693-1697.
  4. Devine KS. Caring for the infertile woman. MCN Am J Matern Child Nurs. 2003;28(2):100-105.
  5. Akande VA, Hunt LP, Cahill DJ, et al. A cohort study of the prediction of Chlamydia infection causing subfertility, the value of treatment independent management and prognosis for pregnancy in 1119 women following laparoscopy. Presented at: British Congress of Obstetrics and Gynaecology; 2011; Birmingham, UK.
  6. American Congress of Obstetricians and Gynecologists. Preconception Carrier Screening. August 2012.
  7. Practice Committee for the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile male: a committee opinion. Fertil Steril. 2015;103(3):e18-e25.
  8. Practice Committee for the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2015;103(6):e44-e50.
  9. Quaas A, Dorkras A. Diagnosis and treatment of unexplained infertility. Rev Obstet Gynecol. 2008;1(2):69-76.
  10. Barron ML, Fehring RJ. Basal body temperature measurement: is it useful to couples seeking pregnancy? J Matern Child Nurs. 2005;30(5):290-296.
  11. Practice Committee of the American Society for Reproductive Medicine. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2015;103(3):e9-e17.
  12. Kwee J, Schats R, McDonnell J, et al. Intercycle variability of ovarian reserve tests: results of a randomized study. Hum Reprod. 2004;19(3):590-595.
  13. Cahill DJ, Wardle PG. Management of infertility. BMJ. 2002;325(7354):28-32.
  14. Hendriks DJ, Mol BW, Bancsi LF, et al. The clomiphene citrate challenge test for the prediction of poor ovarian response and nonpregnancy in patients undergoing in vitro fertilization: a systematic review. Fertil Steril 2006;86(4):807-818.
  15. Nelson SM. Biomarkers of ovarian response: current and future applications. Fertil Steril. 2013;99(4):963-969.
  16. de Vet A, Laven JS, de Jong FH, et al. Antimüllerian hormone serum levels: a putative marker for ovarian aging. Fertil Steril. 2002;77(2):357-362.
  17. Kallio S, Puurunen J, Ruokonen A, et al. Antimüllerian hormone levels decrease in women using combined contraception independently of administration route. Fertil Steril. 2013;99(5):1305-1310.
  18. Singer T, Barad DH, Weghofer A, Gleicher N. Correlation of antimüllerian hormone and baseline follicle stimulating hormone levels. Fertil Steril. 2009;91(6):2616-2619.
  19. Hendriks DJ. Mol BW, Bancsi LF, et al. Antral follicle count in the prediction of poor ovarian response and pregnancy after in vitro fertilization: a meta-analysis and comparison with basal follicle stimulating hormone level. Fertil Steril. 2005:83(2):291-301.
  20. Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human semen characteristics: Hum Reprod Update. 2010;16(3):231-245.

Web resources (for the Box)

B. reproductivefacts.org/Booklet_Infertility_An_Overview/

C. reproductivefacts.org/FACTSHEET_Diagnostic_Testing_for_Female_Infertility/

D. acog.org/Patients/FAQs/Evaluating-Infertility

E. brighamandwomens.org/Departments_and_Services/obgyn/Services/infertility-reproductive-surgery/infertility-services/education-consent-forms.aspx

F. aafp.org/afp/2015/0301/p308-s1.html

G. cdc.gov/reproductivehealth/Infertility/

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.

Best-practice recommendations for adoption planning and placement in the healthcare setting

Pregnant women considering or planning on adoption present a unique set of needs for healthcare providers who want to support them in their decision-making throughout their pregnancy, delivery, and beyond. Nurse practitioners (NPs) are well situated to provide the nuanced and empathetic care needed. The authors describe the current standard of care regarding adoption planning and placement and provide resources that NPs can use to increase their knowledge about ethical adoption.

Years ago, best-practice recommendations for healthcare providers (HCPs) reflected the realities of closed adoption, wherein birth parents and adoptive parents did not know each other’s identities. For HCPs, closed adoption placed greater emphasis on getting full health histories from the birth parents to pass on to the adoptive parents, and a greater focus on helping birth mothers cope with fully severing contact with their children.1 In the literature, birth mothers were typically described as being young, middle-class, and white, and experiencing their first pregnancy.2-7 Recommendations for these mothers’ care focused on their youth and on the involvement of their parents in their pregnancy and decision-making.2,8 As recently as 30 years ago, it was unusual to offer birth mothers the option of holding their infants after delivery.9

Adoption looks quite different today. Although peer-reviewed research lags behind, survey data and agency reports show that birth mothers have become much more diverse in terms of their racial and  ethnic background, age, and parenting status.10,11 In addition, research shows that open adoption, in which birth parents and adoptive parents have ongoing, meaningful contact before and after the adoption placement, results in better long-term outcomes for members of the adoption triad: birth parents, adoptive parents, and adoptee.12-17 Open adoption has become the preferred and accepted standard in the United States, with 90% of domestic infant adoptions having some degree of openness.10

Healthcare providers, including nurse practitioners (NPs), must be informed about current best practices regarding how to support pregnant women who are considering adoption and birth mothers who have placed a child for adoption. The authors provide recommendations for that standard of care and present resources for NPs who want to continue increasing their knowledge about ethical adoption. These recommendations are drawn from the literature and from the professional expertise of the second author, who has worked with and advocated for more than 500 women in the process of considering, planning, and living their adoptions.

Pregnancy decision-making

Although the pregnancy options of parenting, abortion, and adoption are often presented in parallel, they are undertaken at dramatically different rates. Over the course of their reproductive lives, nearly 85% of pregnant women parent the child,18 30% have an abortion,19 and fewer than 1% place the child for adoption.7,10,20 These percentages do not add up to 100 because these populations are not mutually exclusive. Many women who have abortions are already parenting children, and an even greater proportion will parent a child in the future.21 In addition, many women who place children for adoption will also raise children, suggesting that the diverse circumstances of pregnancy lead the same women to pursue different options at various points in their reproductive lives. Although placement of a child for adoption is rare, NPs should be prepared to handle the situation if a pregnant patient is considering or planning adoption. This preparation includes being ready to discuss all options—parenting, abortion, and adoption— in a productive, unbiased, non-judgmental way.

Parenting

Many pregnant women considering adoption would prefer to parent but feel they lack the resources and support needed.22,23 If a woman wants to parent, NPs should find out what is needed to help her assume that role. She and her child may be entitled to resources such as Medicaid; Women, Infants, and Children (WIC) food nutrition services; support from the child’s father; public childcare vouchers; and/or subsidized housing. Some women may need to address other aspects of their lives to prepare for parenthood (e.g., obtaining addiction treatment, job training, or services for persons leaving abusive relationships). Knowledge of available social services and local non-profit organizations can help these women prepare for parenthood if that is their preference.

Abortion

If a woman is considering abortion but remains unsure, NPs should help her assess her options. Is the pregnancy at a gestational age where abortion is still an option? Does she have an accurate understanding of what the procedure entails? Does she know where to get an abortion? Does she need help in accessing it? Because abortion is far more frequently chosen by pregnant women who do not have the desire, ability, resources, or support to parent at a given point in their lives,19 NPs should be able to provide information about and referrals for abortion care. They should be familiar with local abortion funds that can provide monetary or logistical support. The National Network of Abortion Funds is a good resource.

Ongoing counseling

If a pregnant woman needs further help in making a decision, she should be referred to a counselor or social worker with experience in this area. Backline provides free, unbiased, all-options pregnancy phone lines for callers anywhere in the U.S. who want to discuss pregnancy, parenting, abortion, and adoption. NPs should avoid referring patients to Crisis Pregnancy Centers affiliated with the anti-abortion movement. These centers mislead women, providing them with incorrect information about their pregnancies and misrepresenting the safety and impact of abortion.24-26 This “counseling” does not support all choices and can represent coercion.

Adoption planning

If a pregnant woman is strongly considering adoption or feels it is the right option for her, she must be referred to an ethical adoption agency or attorney. Ethical adoption providers:

offer counseling regarding all pregnancy options;

engage in concurrent adoption and parenting planning during the course of the pregnancy;

actively encourage and support open adoption plans;

have experience working with a diverse range of prospective adoptive families; and

offer post-adoption support to all members of the adoption triad.

These practices help ensure that adoptions are free of coercion and work toward the best long-term outcomes for birth and adoptive families.10 Agencies are generally better equipped than individual attorneys to meet these criteria. However, many adoption attorneys provide ethical legal services and are prepared with referrals for other forms of support. The American Academy of Adoption Attorneys is a good resource for identifying these professionals. NPs should be familiar with at least one adoption provider, either an agency or an attorney, to which or to whom they would feel comfortable referring patients.

The decision to make an adoption plan is considered an ongoing process throughout the pregnancy that should be handled with support and sensitivity. A pregnant woman’s final decision is not made until after delivery, when legal documents terminating her parental rights are signed. Until that point, she is the child’s parent and should be supported as a parent in her decision-making. Of note, a woman should not be lauded as selfless or virtuous because she is considering adoption. She should not be told she is a good mother because of the adoption plan. Her decision should be framed as an attempt to make the best choice for herself at this point in her life.

Legal considerations

A full understanding of the state-by-state legal complexities of adoption is beyond the scope of necessary care. However, the policies surrounding adoption affect how and when parental rights are ended, who is legally eligible to adopt, and which legal rights all participants will have post-adoption, thereby having a great effect on the expectant mother’s experience in planning an adoption. To that extent, and to theextent that they wish to advocate for a patient’s general well-being, NPs should be at least somewhat familiar with their state’s policies regarding adoption. As such, NPs need to consider these questions:27-30

Are open adoption agreements legally enforceable in their state or are they courtesy agreements?

When is the termination of parental rights document signed?

Does the state have an adoption revocation period during which birth parents can change their minds and regain their parental rights?

What are birth fathers’ rights as far as notification and relinquishment?

What is the status of open records? Can adopted persons have access to their original birth certificates, as is considered best practice?

The Child Welfare Information Gateway, a program of the U.S. Department of Health & Human Services, and the American Academy of Adoption Attorneys are good resources to explore for answers to these questions. An expectant mother needs to have her own legal counsel in the process of planning an adoption. She should not have the same lawyer as the prospective adoptive parents because she needs someone who will be advocating for her rights, without any conflict of interest.27-31

Prenatal care

In many ways, prenatal care for women considering adoption does not vary from that for women planning to parent. However, the conditions that make a woman more likely to plan an adoption may make prenatal care more difficult for her to access or more challenging for the NP to provide.

For example, a woman may be considering adoption because she feels ill-equipped to parent because of mental illness, addiction, or other health problems.10,32 For such a woman, particularly one abusing drugs or alcohol, NPs should have a harm-reduction and strengthbased perspective on prenatal substance exposure33,34 so that the woman is not deterred from seeking care.35 Oftentimes, this deterrence is rooted in the double stigma of both addiction and adoption. Yet, even in cases where an infant is born positive for illegal substances and Child Protection Services is contacted, the birth mother has the right to make a safe care plan for her infant, including adoption. NPs should view themselves as patient advocates, affirming that their paramount goal is to achieve healthy outcomes for both mother and infant.

In another scenario, a pregnant woman may be considering adoption because she does not have the support of her family or community. Such a woman may feel ashamed of her pregnancy and the sexual activity it reveals.10 NPs should provide judgment-free care and ongoing support.

The prospective adoptive parents may wish to be involved during the course of prenatal care. They may ask to be present at routine visits or even assume financial responsibility for the expectant mother’s care. They may ask the patient to undergo drug screening, genetic testing, or other healthcare interventions, but the patient is not obliged to honor their requests. NPs need to maintain the expectant mother’s privacy and ensure that any financial assistance does not represent an obligation to place her child with these, or any other, potential parents.10 All of a patient’s health-related privacy rights remain intact.

Labor and childbirth

In preparation for labor and childbirth, an expectant mother planning on adoption needs to have a clear birth plan, and all HCPs working with her must be familiar with the plan. Under ideal circumstances, the expectant mother is supported by a social worker—either from an ethical adoption agency or from the facility where she plans to deliver—in developing a birth plan that meets her needs.

In addition to aspects of labor and childbirth that any expectant mother wants to plan for (e.g., pain management strategies, support persons present), a woman making adoption plans may want to consider these questions:

Who will be in the room during labor and childbirth? Will the prospective adoptive parent(s) be present?

Are there other spaces for adoptive parents at the facility (e.g., another hospital room) where they may wait during labor and spend time with the infant after birth?

When would the birth mother like to invite the prospective adoptive parents to meet the infant?

Are the birth and adoptive parents in agreement on any routine healthcare procedures that the infant may face soon after birth (e.g., vaccinations, circumcision)?

Do the birth and adoptive parents have a plan for the child’s name? Birth mothers sign the original birth certificate and can name the infant, although adoptive parents have the right to re-name the infant once the adoption is finalized and the adoption birth certificate is issued.

Have the birth and adoptive parents discussed whether the infant will be breastfed following birth?

Adoption agencies usually help a pregnant woman navigate and negotiate the answers to these questions. However, some agencies may not provide this help, and private lawyers may not have the expertise or resources necessary to support their clients in this way. In these situations, NPs should be prepared to help their patient think through these scenarios.

A woman planning an adoption can benefit from the support of a birth doula, who can focus entirely on helping her through her birth experience without being especially involved in the adoption planning. NPs should discuss doula care with the patient and be able to provide referrals for compassionate caregivers who can fulfill this role.

Of note, the expectant mother is not only the primary patient but also—along with the birth father, if present—the child’s legal parent until she signs papers relinquishing her parental rights. In most states, this termination of rights cannot occur while she is on hospital grounds.27 Therefore, for the duration of her hospital stay, she is the infant’s parent. From a legal standpoint, she must make all decisions regarding the infant’s care, rooming arrangements, and birth certificate. All providers involved in the birth mother’s care should understand this situation and use respectful language, even if the birth mother allows the adoptive parents to help care for the infant while in the hospital.

Immediate postpartum care

Like all postpartum mothers, birth mothers need support in their physical recovery, with further attention paid to their mental and emotional well-being. Birth mothers experience grief that places them at increased risk for postpartum depression (PPD),36,37 especially because they are already more likely than other postpartum mothers to struggle with mental health problems and trauma histories.10 They should be informed about the range of normal emotional responses, to recognize if they are struggling beyond that threshold, and to know when and where to seek help. Most mothers are screened for PPD at their babies’ well-child visits.38 Because birth mothers will not have this opportunity, they should be screened before discharge, at their own postpartum visits, and at future wellness visits.

Birth mothers need additional support regarding lactation. A birth mother may want to breastfeed while she is with her infant, and should be supported in doing so. In addition, she may intend to supply her infant with expressed breast milk, either before or after the adoption. She should be counseled about pumping and given resources for how to maintain and manage a supply moving forward. However, many birth mothers may not intend to breastfeed, either via nursing or expression, for a substantial amount of time. In these cases, typical efforts to promote breastfeeding in the immediate postpartum setting are inappropriate. These mothers should receive information and support on how to comfortably manage and reduce their milk production in the weeks following birth. The emotional strain of not nursing after adoption warrants supportive care as well.

Some providers go to great lengths to ensure that adoptive parents are included in the infant’s early care. Some hospitals even offer adoptive parents a room to stay in overnight if space permits. Such measures are appropriate as long as they are first respectful to the birth mother’s desires and needs. The novelty of working with excited adoptive parents must never overshadow the careful consideration of a birth mother’s well-being.

The custody plan for the child after discharge should be clear to all parties, including HCPs involved in the care of the mother and the infant. NPs need to make sure that the infant’s health records are transferred to the pediatrician chosen by the adoptive parents, even though the baby’s legal status may be pending. Communication among all HCPs can help ensure continuity of care once all proper releases of information have been signed.

Long-term support

Adoption is a lifelong process, not just for adoptees and adoptive families, but for birth mothers as well. Many birth mothers deal with profound grief after an adoption as they mourn the loss of their parenting relationship with their child.39 Their feelings post-adoption may include sadness, relief, regret, pride, hopefulness, disappointment—the full range of complex human emotions. Some birth mothers report feeling traumatized by the adoption and by the lack of support that they receive throughout and after the adoption process.40 Some birth mothers may feel stigmatized by members of their family, as well as by their community, friends, the media, and even by HCPs.41-44

Such stigmatization may cause them to feel isolated and depressed.

Nurse practitioners should try to provide birth mothers with as much support as they need. Although adoption has changed greatly in the past few decades, the recommendation offered by Askren and Bloom45 in 1999 still holds true: Nurses involved with women at the time of relinquishment can be of significant help in the resolution of grief… Simple recognition of the loss and its significance to the woman will go a long way toward assisting with resolution.

In an ideal situation, the birth mother is further supported by the adoption agency with which she worked. The agency can refer her to individualized counseling with an adoption-competent mental health provider, ensure that she has ongoing support in maintaining an open relationship with her child’s adoptive family, and connect her with a group of other birth mothers with whom she can share her experience.

Some agencies provide some, but not all, of these services; others are unequipped to offer the types of post-adoption support many birth mothers need. Most lawyers who facilitate private adoptions are not able to provide any of these support services—an important reason to refer patients to ethical, full-service agencies during the adoption planning phase, as well as a reason for NPs to be able to make referrals to organizations that can offer post-adoption services.

For a birth mother who needs greater support post-adoption, the American Adoption Congress maintains a list of regional and local support groups on their website. Other organizations that work with birth mothers include the On Your Feet Foundation and Concerned United Birthparents, Inc.  

Conclusion

Despite its comparative rarity in the U.S., adoption, with all its legal and emotional complexity, necessitates that NPs understand how to best address the needs of pregnant women considering it and birth mothers who have chosen it. These situations are usually not medically complicated, but they demand a high level of sensitivity and compassion. When treating a woman who is considering or choosing adoption, NPs need to be able to provide her with a reliable source for nonjudgmental, unbiased pregnancy options counseling; have a working knowledge of their state’s adoption laws; be familiar with an ethical adoption provider; and know how to procure comprehensive post-adoption services. These resources can help ensure the best outcome for birth mothers during pregnancy, childbirth, adoption placement, and beyond.

Gretchen Sisson is a research sociologist at Advancing New Standards in Reproductive Health (ANSIRH) in the Department of Obstetrics, Gynecology, and Reproductive Science at the University of California, San Francisco. She serves on the Board of Directors for Backline. Rachel Herndon is the Director of Birth Parent Services at Adoption Connection, an adoption provider in San Francisco, and she serves on the Board of Directors for the On Your Feet Foundation. The authors state that they do not have a financial interest in or any other relationship with any commercial product named in this article.

References

1. Melina CM, Melina L. The physician’s responsibility in adoption: part 1, caring for the birthmother. J Am Board Fam Pract. 1988;1(1):50-54.

2. Namerow PB, Kalmuss DS, Cushman LF. The determinants of young women’s pregnancy-resolution choices. J Res Adolesc. 1993;3(2):193-215.

3. Namerow PB, Kalmuss D, Cushman nLF. The consequences of placing versus parenting among young unmarried women. Marriage Fam Rev. 1997;25:175-197.

4. Cushman LF, Kalmuss D, Namerow PB. Placing an infant for adoption: the experiences of young birthmothers. Soc Work. 1993;38(3):264-272.

5. Donnelly B, Voydanoff P. Factors associated with releasing for adoption among adolescent mothers. Fam Rel. 1991;40(4):404-410.

6. Bachrach CA, Stolley KS London LA. Relinquishment of premarital births: evidence from national survey data. Fam Plann Perspect. 1992;24(1):27-32, 48.

7. Chandra A, Abma J, Maza P, Bachrach C. Adoption, adoption seeking, and relinquishment for adoption in the United States. Adv Data. 1999;11(306):1-16.

8. Lauderdale JL, Boyle JS. Infant relinquishment through adoption. Image J Nurs Sch. 1994;26(3):213-217.

9. Kaunitz AM, Grimes DA, Kaunitz KK. A physician’s guide to adoption. JAMA. 1987;258(24):3537-3541.

10. Smith S. Safeguarding the Rights and Well-Being of Birthparents. New York, NY: The Evan B. Donaldson Adoption Institute; 2007.

11. Early Growth and Development Study. Agency Report: Birth Parent Summary Statistics from All Sites. 2006.

12. Ge X, Natsuaki MN, Martin DM, et al. Bridging the divide: openness in adoption and postadoption psychosocial adjustment among birth and adoptive parents. J Fam Psychol. 2008;22(4):529-540.

13. Grotevant HD, McRoy RG, Elde CL, Fravel DL. Adoptive family system dynamics: variations by the level of openness in the adoption. Fam Process. 1994;33(2):125-146.

14. Logan J, Smith C. Adoption and direct post-adoption contact. Adoption Fostering. 1999;23(4):58-59.

15. Siegel DH. Open adoption of infants: adoptive parents’ feelings seven years later. Soc Work. 2003;48(3):409-419.

16. Grotevant HD, McRoy RG. The Minnesota/Texas Adoption Research Project: implications of openness in adoption for development and relationship. Appl Devel Sci. 1997;1(4):168-186.

17. Grotevant HD, McRoy RG, Wrobel GM, Ayers-Lopez S. Contact between adoptive and birth families: perspectives from the Minnesota Texas Adoption Research Project. Child Devel Perspect. 2013;7(3):193-198.

18. Monte LM, Ellis RR. Fertility of Women in the United States: 2012. July 2014.

19. Jones RK, Kavanuagh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol. 2011;117(6):1358-1366.

20. Child Welfare Information Gateway. How many children were adopted in 2007 and 2008? September 2011.

21. Jones RK, Finer LB, Singh S. Characteristics of U.S. Abortion Patients, 2008.

22. Sisson G. “Choosing life”: birth mothers on abortion and reproductive choice. Womens Health Issues. 2015;25(4):349-354.

23. Ellison M. Authoritative knowledge and single women’s unintentional pregnancies, abortions, adoption, and single motherhood: socialstigma and structural violence. Med Anthropol Q. 2003;17(3):322-347.

24. Bryant AG, Levi EE. Abortion misinformation from crisis pregnancy centers in North Carolina. Contraception. 2012;86(6):752-756.

25. Bryant AG, Narasimhan S, Bryant- Comstock K, Levi EE. Crisis pregnancy center websites: information, misinformation, and disinformation. Contraception. 2014;90(6):601-605.

26. Kelly K. In the name of the mother: renegotiating conservative women’s authority in the crisis pregnancy center movement. Signs. 2012;38(1):203-230.

27. Samuels EJ. Time to decide? The laws governing mothers’ consents to the adoption of their newborn infants. Tennessee Law Rev. 2005;72:509-572.

28. Beck MM. Toward a national putative father registry database. Harvard J Law Public Policy. 2002;25(3).

29. Baumann C. Adoptive fathers and birthfathers: a study of attitudes. Child Adolesc Soc Work J. 1999;18(5):373-391.

30. Samuels E. The idea of adoption: an inquiry into the history of adult adoptee access to birth records. Rutgers Law Rev. 2001;53.

31. Samuels E. Legal representation of birth parents and adoptive parents. Adoption Q. 2008;9(4):73-80.

32. Kovalesky A, Flagler S. Child placement issues of women with addictions. J Obstet Gynecol Neonat Nurs. 1997;26(5):585-592.

33. Drabble L, Poole N, Magri R, et al. Conceiving risk, divergent responses: perspectives on the construction of risk of FASD in six countries. Substance Use Misuse. 2011;46(8):943-958.

34. Wong S, Ordean A, Kahan M. SOGC clinical practice guidelines: substance use in pregnancy: no. 256, April 2011. Int J Gynaecol Obstet. 2011;114(2):190-202.

35. Roberts SC, Pies C. Complex calculations: how drug use during pregnancy becomes a barrier to prenatal care. Matern Child Health J. 2011;15(3):333-341.

36. Aloi JA. Nursing the disenfranchised: women who have relinquished an infant for adoption. J Psychiatr Ment Health Nurs. 2009;16:27-31.

37. Foli KJ. Nursing care of the adoption triad. Perspect Psychiatr Care. 2012;48(4):208-217.

38. Gjerdingen DK, Yawn BP. Postpartum depression screening: importance, methods, barriers, and recommendations for practice. J Am Board Fam Med. 2007;20(3):280-288.

39. Henney SM, Ayers-Lopez S, McRoy R, Grotevant HD. Evolution and resolution: birthmothers’ experience of grief and loss at different levels of adoption openness. J Soc Pers Relat. 2007;24(6):875-889.

40. Memarnia N. ‘It felt like it was night all the time’: listening to the experiences of birth mothers whose children have been taken into care or adoption. Adoption Fostering. 2015;39(4):303-317.

41. Gustafson D, ed. Unbecoming Mothers: The Social Production of Maternal Absence. New York, NY: Routledge; 2005.

42. Romanchik B. Being a Birthparent: Finding Our Place. R-Squared Press; 1999.

43. Franklin LC. May the Circle Be Unbroken: An Intimate Journey into the Heart of Adoption. New York, NY: Authors Choice Press; 2005.

44. Weir KN. Developmental, familial, and peer deterrents to adoption placement. Adoption Q. 2000;3(3):25-50.

45. Askren H, Bloom K. Postadoptive reactions of the relinquishing mother: a review. J Obstet Gynecol Neonat Nurs. 1999;28(4):395-400.

Collaborative care in a rural setting for a pregnant woman with heroin addiction

ATa 23-year-old woman, presents to the obstetrician’s office in her rural hometown. As a nurse practitioner (NP) enters the examination room, AT cries out to her, “I can’t lose another baby!”

Three weeks previously, after learning that she was pregnant, AT voluntarily admitted herself to an inpatient treatment program at a regional medical center located 50 miles from her home. AT had been injecting heroin daily for the past 1.5 years. At the inpatient treatment program, AT insisted on undergoing detoxification from heroin because she knew that she would not be able to keep appointments for maintenance medication management.

She underwent medicated detoxification over 2.5 days. After a 5-day stay, she was discharged from the medical center and instructed to follow up with counseling services nearer to her home.

At the office visit, AT acknowledges to the NP that she has thought about heroin every minute since her discharge from the inpatient treatment program, and that her boyfriend, with whom she lives, is still using heroin. She admits that she has relapsed twice since the discharge, taking a hydrocodone/acetaminophen tablet one time and injecting methamphetamine one time. The NP wonders how she can best help AT safely carry her pregnancy to term and deliver a healthy infant.

How common is heroin addiction today?

Most heroin addictions begin with prescription opioid abuse. In 2010, approximately 210 million prescriptions were written for opioids in the United States.1 Twenty percent of the U.S. population have admitted using prescription opioids for nonmedical reasons. Opioid users who become addicted to the drugs but can no longer get them legally may turn to heroin because it is less costly on the black market.1 In 2013, more than 500,000 persons in this country admitted using heroin, an increase of 100% since 2006.1

Heroin has infiltrated small rural areas as well as urban areas because of its easy availability and relatively low cost.1-5 In fact, data indicate that heroin use has increased significantly in recent years among rural adolescents and young adults, with a report from the National Institute on Drug Abuse and the CDC describing a shift in heroin use from urban to rural areas.6-8

The demographics of heroin users are changing in other ways. Nowadays, a typical user may be a woman in a high income bracket living in a suburban area with private health insurance or she may be a woman living in poverty in a rural or urban area.1,5,8 In 2012, 34% of persons receiving treatment for heroin addiction in the U.S. were women.2,9 Women fortunate enough to be treated for heroin addiction will likely undergo psychological counseling, with or without maintenance therapy with an opioid agonist.2, 9-11 By contrast, many women living in rural areas have limited access to treatment.7

How can an NP providing care in a rural community meet the needs of AT?

The NP reviews AT’s health history, including her recent hospitalization information. She asks AT if they can have an honest conversation about her heroin use and her life situation so that they can plan for the best care for her and the fetus.

AT has complex health and social problems that have led to and complicated her current situation. Her health history includes depression and anxiety. She was the victim of a sexual assault at age 14. Her parents were both heavy drinkers, and her three siblings have addictions to alcohol, drugs, or both. At age 20, AT was prescribed hydrocodone/acetaminophen after a back injury and became addicted to the opioid, which eventually led to her heroin use. She has had many failed attempts to quit using heroin on her own. As a result, AT has not been able to get or keep a job. She has no home or car and has been charged with two felony possessions in the past year. The year before, the Division of Family Services removed her two children from her care because of her addiction—prompting her outcry to the NP about her fear of losing another child.

When she learned she was pregnant with her third child, AT and her boyfriend were homeless. It was only after AT’s detoxification and hospital stay that her boyfriend’s mother agreed to let them stay with her as long as they both remained drug free. Her boyfriend, who is the father of her other two children as well, can hold odd jobs, but he spends most of his income on drugs.

AT’s initial physical examination and routine prenatal laboratory test findings are all normal. Test results for HIV, hepatitis C, chlamydia, gonorrhea, and syphilis are negative. AT completed the hepatitis B vaccination series with her previous pregnancy. A urine drug screen is negative. Ultrasonography (USG) confirms that she is at 10 weeks’ gestation.

The NP tells AT about an outpatient treatment program at the local hospital that provides free transportation to and from visits. AT agrees to be evaluated at the program and to consider maintenance therapy. An appointment is made for the next day. The NP also describes the healthcare providers (HCPs) who will be important team members in AT’s care. She will receive chemical dependency counseling, other mental health counseling, and management of her maintenance medication dosage at the outpatient treatment program. The NP will collaborate with the obstetrician at the office to provide her prenatal care and will consult regularly with maternal–fetal healthcare specialists at the regional medical center where she was previously hospitalized. AT provides written consent for all healthcare team members to have access to her electronic health record so that her care can be coordinated.

How is heroin addiction treated during pregnancy?

Chronic heroin use during pregnancy is associated with spontaneous abortion, placental insufficiency, intrauterine growth restriction, premature labor and/or birth, chorioamnionitis, preeclampsia, abruption placentae, oligohydramnios, premature rupture of membranes, intrauterine death, higher rates of cesarean sections, postpartum hemorrhage, and longer hospital stays. Newborns are at risk for neonatal abstinence syndrome (NAS).12-14

Opioid-assisted maintenance therapy (OAMT), the standard treatment for heroin addiction during pregnancy, can reduce the risks for obstetric and neonatal complications.15 In addition, the use of OAMT during pregnancy can prevent complications of illicit opioid use, narcotic withdrawal, and relapse; encourage prenatal care and drug treatment; reduce criminal activity; and avoid risks to the patient of associating with a drug culture.15, 16

Methadone, a full opioid agonist, is the most commonly used medication for OAMT during pregnancy. Methadone maintenance must be prescribed and dispensed on a daily basis by an addiction treatment specialist in a registered methadone treatment program. Buprenorphine, a partial opioid agonist, is another option for treatment during pregnancy. Buprenorphine may be prescribed in an office setting by a physician or NP who has undergone specific credentialing and in accordance with federal and state regulations. Advantages of treatment with buprenorphine over methadone include lower risk of overdose, ability to have outpatient treatment without required daily visits to a treatment program, and evidence of less severe NAS.15,16 Disadvantages include higher discontinuation rates, risks for sharing or selling the drug, and lack of long-term data on the effects of the medication on children exposed to it in utero.15,16

Medication dosages may need to be adjusted during pregnancy to avoid withdrawal symptoms that can cause fetal stress and may lead to maternal heroin use relapse. This need is especially true in the third trimester, when the woman may have a more rapid metabolism.15,16

How does the NP manage AT’s ongoing care?

The NP sees AT every 2 weeks over the next 6 weeks to establish rapport, offer support, and evaluate concerns. The NP consults with maternal– fetal healthcare specialists at the regional medical center to discuss a plan to monitor fetal well-being throughout the pregnancy. A USG schedule is established to evaluate fetal anatomy at 19 weeks and then every 6 weeks in the third trimester to monitor fetal growth.

AT and her addiction specialist decide that buprenorphine is an appropriate maintenance medication for her. AT attends individual and group counseling sessions at the outpatient treatment program 5 days a week and sees the addiction specialist weekly for her buprenorphine prescription for the first month of her treatment. The psychiatrist at the treatment center evaluates AT for depression and anxiety and prescribes sertraline to treat depression and quetiapine to aid sleeping. Over time, AT is able to reduce her counseling sessions to 3 days a week and her appointments for buprenorphine prescription to once monthly.

After the first few weeks of frequent visits, AT sees the NP every 4 weeks until 26 weeks’ gestation, every 2 weeks until 36 weeks’ gestation, and then weekly. The USG at 19 weeks shows normal fetal anatomy and growth. USGs at 28 and 34 weeks show fetal growth within normal limits. All routine laboratory test results are normal.

The NP and obstetrician discuss birthing plans with AT. She decides to remain on buprenorphine through labor and delivery, with a planned epidural for pain management. The pediatrician is available to oversee management of any NAS in the newborn. The maternal–fetal healthcare specialists at the regional medical center remain available for consultation.

At 38 weeks’ gestation, AT has an uncomplicated labor and vaginal birth of a baby girl weighing 6 lb 15 oz. Although breastfeeding is encouraged, AT decides to bottle feed. A social worker from the division of family services approves AT to take her baby home. AT and her daughter are discharged after 48 hours to stay with her boyfriend at his mother’s home. She decides she will use an intrauterine contraceptive so that she can continue to get her life in order without worrying about another pregnancy.

Should AT be encouraged to breastfeed?

Breastfeeding is encouraged for mothers receiving OAMT as long as they abstain from the use of illicit substances.15,17 Breastfeeding supports mother–infant bonding and may reduce the severity and duration of NAS symptoms.18,19 Minimal levels of methadone or buprenorphine are found in breast milk, regardless of the maternal dosage.15,16 Both medications are considered safe during breastfeeding.15

The safety of illicit substances during breastfeeding is not possible to determine. Maintaining open lines of communication between the mother and her HCPs is essential so that she feels comfortable letting them know if she does relapse. If relapse does occur, the mother should be provided with assistance to transition to bottle feeding and guidance on how to taper milk production to prevent mastitis.17

Reflection

Although AT was successful in stopping heroin and staying drug free for most of her pregnancy, she admitted having two occasions of illegal drug use during treatment. Her boyfriend initiated treatment, but he stopped after 2 weeks and started using heroin again. AT moved into a shelter for homeless pregnant women for a month, until her boyfriend returned to treatment. The motivation to have a healthy baby she could keep and easy access to a treatment center near home were vital to AT’s success.

Implications for NPs

Nurse practitioners providing care for reproductive-aged women may encounter some with heroin addiction, including during a pregnancy. NPs need to screen all women for alcohol and drug abuse at least annually and all pregnant women early in pregnancy. A nonjudgmental and supportive approach is important. Goals for pregnant women are to encourage regular prenatal care and drug treatment that includes OAMT and counseling. A collaborative approach includes prenatal care providers, addiction treatment specialists, mental health professionals, maternal–fetal healthcare specialists, and neonatal specialists. Using this collaborative approach, NPs in rural health settings can safely manage the care of pregnant women with heroin or opioid addiction.

Corinne Ann Coppinger is a women’s health nurse practitioner atMercy Hospital-Washington in Washington, 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. Kane-Willis K, Schmitz SJ, Bazan M, Narloch VF. A multiple indicator analysis of heroin and opiate use in Missouri: 2001-2011. Missouri Recovery Network. March 2013.

2. Substance Abuse and Mental Health Services Administration. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. September 2015.

3. Kane-Willis K, Schmitz SJ, Bazan M, Narloch VF. Heroin use: National and Illinois Perspectives, 2008-2010. Roosevelt University. Institute for Metropolitan Affairs. August 2012.

4. U.S. Department of Justice Drug Enforcement Administration. National Drug Threat Assessment Summary. November 2014. info.

5. Substance Abuse and Mental Health Service Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. September 2014.

6. Havens JR, Young AM, Havens CE. Nonmedical prescription drug use in a nationally representative sample of adolescents: evidence of greater use among rural adolescents. Arch Pediatr Adolesc Med. 2011;165(3):250-255.

7. Keyes KM, Cerdá M, Brady JE, et al. Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States. Am J Public Health. 2014;104(2):e52-e59.

8. CDC. Today’s Heroin Epidemic. Updated July 7, 2015.

9. Substance Abuse and Mental Health Service Administration. Substance Abuse Treatment Admissions by Primary Substance of Abuse, According to Sex, Age Group, Race, and Ethnicity. 2013.

10. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med. 2015;9(5):358-367.

11. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Updated December 2012.

12. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2004.

13. Kaltenbach K, Berghella V, Finnegan L. Opioid dependence during pregnancy. Effects and management. Obstet Gynecol Clin North Am. 1998;25(1):139-151.

14. Maeda A, Bateman BT, Clancy CR, et al. Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes. Anesthesiology. 2014;121(6):1158-1165.

15. American College of Obstetricians and Gynecologists. Committee Opinion. Opioid Abuse, Dependence, and Addiction in Pregnancy. May 2012.

16. Wong S, Ordean A, Kahan M;Society of Obstetricians and Gynecologists of Canada. SOGC clinical practice guideline: substance use in pregnancy. Int J Gynaecol Obstet. 2011;114(2):190-202.

17. Reece-Stremtan S, Marinelli KA.ABM clinical protocol # 21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015;10(3):135-141.

18. McQueen KA, Murphy-Oikonen J, Gerlach K, Montelpare W. The impact of infant feeding method on neonatal abstinence scores of methadone- exposed infants. Adv Neonat Care. 2011;11(4):282-290.

19. Pritham UA. Breastfeeding promotion for management of neonatal abstinence syndrome. J Obstet Gynecol Neonat Nurs. 2013;42(5):517-526.

Prevention and Management of Opioid Misuse and Opioid Use Disorder Among Women Across the Lifespan

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports

 the role of women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for women across the lifespan in the provision of safe and effective treatment of pain. In certain cases, this treatment may include the prescription of opioid pain relievers (OPR). NPWH acknowledges that NPs must use evidencebased strategies to reduce harm from the misuse of OPR and to prevent the development of opioid use disorder (OUD). These strategies include screening for opioid use/misuse/abuse, educating patients about the risks associated with OPR misuse, and following evidence-based guidelines when prescribing OPR.1,2 In addition, when OUD is identified, NPs qualified to provide medication-assisted treatment (MAT) should follow evidence-based guidelines and prescribe within federal and state regulations.

Use of OPR in general should be reserved for acute pain resulting from severe injuries, medical conditions, or surgical procedures, and only when non-opioid alternatives are ineffective or contraindicated. When OPR are prescribed, they should be given at the lowest necessary dose for the shortest duration (usually <14 days).2 Although many NPs in primary care treat acute pain, the treatment of chronic pain is best achieved through a multimodal and multidisciplinary approach that includes a team member with expertise in pain management. This approach is particularly advantageous when chronic pain management includes OPR use.1,2 NPs should consider evidence-based nonpharmacologic therapies and non-opioid medications as first-line treatment for chronic pain. Primary care NPs with adequate training who prescribe OPR for chronic pain should follow evidence-based guidelines such as those provided by the CDC.1

Whether prescribing OPR for acute or chronic pain, NPs should use risk-mitigation strategies to reduce the potential for harm from misuse or abuse. These strategies include checking state prescription drug monitoring programs when available to assess a patient’s history of controlled substance use, avoiding concurrent prescription of benzodiazepines, and establishing realistic treatment goals with patients. In addition, overdose mitigation includes consideration of co-prescribing the opioid antagonist naloxone when appropriate, along with education about its use to reverse respiratory depression from OPR overdose.1-3

For individuals with OUD, MAT has proven to be clinically effective.4-7 MAT entails the use of medications along with counseling and behavioral therapies to treat OUD and to prevent opioid overdose.4 This recovery-oriented treatment approach has been shown to improve patient survival, increase retention in treatment, decrease drug-related criminal activity, increase patients’ ability to gain and maintain employment, and improve birth outcomes among pregnant women with OUD.The Comprehensive Addiction and Recovery Act (CARA) was signed into law in July 2016.The law includes a section authorizing NPs who meet certain criteria, including participation in a mandatory 24-hour education program, to receive a waiver to prescribe the opioid agonist buprenorphine as a crucial component of treatment for OUD. NPs who receive this education and waiver are able to work within their individual state prescribing laws to provide increased access to OUD treatment.

NPWH will provide leadership and collaborate with other organizations and agencies to deliver NP education, develop policies, and conduct and/or support research, all in a concerted effort to increase knowledge and provide resources for NPs to prevent and reduce harm from OPR misuse. NPWH will actively monitor and engage in the process needed to implement CARA so that access to treatment for OUD can reach all women in need.

Background

Pain can be acute or chronic in nature. Acute pain may be related to disease, injury, or recent surgery and typically diminishes with tissue healing. Chronic pain is consistent pain that lasts more than 3 months; usually has neurologic, emotional, and behavioral components; and often affects function, social roles, and quality of life.1,2 At least 116 million adults in the United States have chronic pain conditions.9

Some efforts to improve pain management, despite clinicians’ best of intentions, have had adverse effects. The number of prescriptions for OPR quadrupled between 1999 and 2013.10,11 During this same time period, deaths from opioid use/misuse have also quadrupled.10 In 2014, more than 28,000 persons in the U.S. died of opioid overdoses, with at least half of these overdoses involving prescription OPR.10 These overdose death rates are highest among persons aged 25-54 years.10 

Lethal overdose is not the only risk associated with prescription OPR. Every day, more than 1,000 persons are seen in emergency departments (EDs) for reasons related to misusing prescription OPR.12 Hospital admissions for nonfatal overdoses are on the rise. Other serious consequences include falls and fractures in older adults, sleep-disordered breathing, cardiac arrhythmias related to methadone use, and immunosuppression.2

More than 4 million persons in this country abuse or are dependent on opioids.13 In fact, as many as 1 in 4 persons receiving prescription OPR in primary care settings for chronic noncancer pain struggles with addiction.14 More than 60% of persons taking OPR for at least 3 months are still taking them 5 years later.2 Abuse of OPR results in more than $72 billion in medical costs each year, which is similar to the cost of chronic diseases such as asthma and HIV infection.3

About 25% of persons who abuse OPR obtain them through their own prescriptions, and about 50% of persons who abuse prescription OPR obtain them for free or buy them from friends or relatives.15 Others get OPR by stealing from friends or relatives or from drug dealers.15 If unable to obtain prescription OPR, persons with OUD may turn to heroin. In fact, dependence on or abuse of prescription OPR has been associated with a 40-fold increased risk of dependence on or abuse of heroin.16

The increase in OPR prescriptions has not been accompanied by an overall change in the amount of pain reported. Recent systematic reviews have shown at most only modest benefits of OPR for chronic pain when balanced with potential risk of harm.17,18

The use of safer and more effective treatments for chronic pain could reduce the number of persons who develop OUD or experience an overdose or other adverse event related to opioid use. Studies have supported a range of effectiveness for nonpharmacologic approaches to chronic pain management that include behavioral, psychological, and physical-based therapies and non-opioid pharmacologic treatments such as acetaminophen, non-steroidal anti-inflammatory drugs, and selected anticonvulsants and antidepressants. Use of multiple modalities is likely to be more effective than a single modality.1,2 Because of the complexities involved, the initiation of treatment and the ongoing care for patients with chronic pain are most safely and effectively directed by a multidisciplinary team that includes pain management specialists.1,2

The CDC’s OPR prescribing guidelines include a recommendation for clinicians to offer or facilitate MAT for patients with OUD.1 MAT is underutilized, with only 20% of adults with OUD receiving needed treatment each year. Cost and access are primary barriers.19 With implementation of CARA, NPs, as part of the treatment team, will be able to prescribe some of the medications used in MAT, thereby expanding access to patients.

Implications for women’s healthcare and WHNP practice

Although both men and women experience opioid misuse/abuse and related fatalities, certain gender-related differences exist. Women, when compared with men, are more likely to be prescribed OPR, to use these agents long term, and to receive prescriptions for higher doses.20 Every 3 minutes, a woman goes to the ED for a reason related to prescription OPR misuse/abuse.21 Evidence suggests that women, relative to men, may progress to dependence on OPR at a more accelerated rate.22 

Men are more likely than women to die of an opioid overdose, but the gap is closing. Prescription OPR overdoses in women cause more deaths than do overdoses of benzodiazepines, antidepressants, and heroin combined.21 In fact, for women, OPR are involved in 7 out of 10 prescription drug-related deaths. Intentional OPR overdoses are involved in 1 in 10 suicides among women.2020

The potential for adverse events related to OUD extends to women across the lifespan and beyond the direct health effects. OUD places women at risk for behaviors that further jeopardize their well-being, including prostitution, stealing, and other criminal activities that are often associated with violence. Women with OUD may engage in these risky behaviors in order to support themselves and their addiction. These behaviors place these women at risk for experiencing legal ramifications of their criminal activities, being victims of violence, and acquiring sexually transmitted infections. Women who inject opioids through intravenous or intradermal routes are at added risk for contracting HIV and hepatitis C infections.3,23

Nurse practitioners should ask female patients of all ages about the use of prescription OPR and other medications for nonmedical reasons as part of routine alcohol and substance use screening. Validated screening tools are available to use with adolescents, pregnant women, and adults.23,24 Early identification of opioid misuse/abuse allows NPs to provide evidence-based brief interventions,25 actively participate in MAT if they meet criteria for prescribing treatment medication, and/or make referrals for additional services when needed.

AdolescenceAttention to prevention, as well as early identification of opioid misuse and OUD in adolescents, is critical. In 2014, 467,000 adolescents were nonmedical users of OPR, with 168,000 having OUD.13 Most adolescents who misuse OPR get the drugs from a friend or relative rather than through their own prescription.26 Girls aged 12-17 years may be particularly vulnerable. These girls are more likely than males in this age group to use psychoactive drugs, including OPR, for nonmedical reasons, and they are more likely to become dependent.27 NPs should screen adolescents for opioid misuse and OUD. It is particularly important to follow state and federal regulations regarding confidentiality when an adolescent needs OUD treatment.28

The reproductive yearsSubstance abuse, including abuse of opioids, is most prevalent during the reproductive years. OPR are widely prescribed for women in this age group. NPs should assess pregnancy status, sexual activity, and contraceptive use before prescribing OPR to reproductive-aged women.10 For women who are pregnant or could become pregnant while using OPR, NPs should discuss potential risks versus benefits, as well as alternative treatments. Data are limited, with a few studies suggesting a small increased risk for birth defects (e.g, neural tube defects, gastroschisis, congenital heart defects) associated with maternal OPR use, particularly when drug exposure occurs in early pregnancy.29-31 As would be done with all patients, when OPR are indicated for treatment of acute pain in women who are pregnant, NPs should prescribe the lowest dose for the shortest duration of use. Care of pregnant women taking OPR for chronic pain should be multidisciplinary.

Medication-assisted treatment is important for pregnant women with OUD. Withdrawal from opioid use during pregnancy has been associated with adverse outcomes such as preterm labor and fetal demise.23 Continuous exposure to opioids in utero —whether opioid use is illicit, prescribed for maternal pain, or through MAT—may lead to neonatal opioid withdrawal syndrome (OWS). Neonates with known in utero opioid exposure should be monitored for and treated as needed for withdrawal symptoms. The range and severity of symptoms experienced by neonates are related to the type of opioid, the duration of exposure, and concomitant exposure to other substances while in utero.32,33

Many pregnant women with OUD are late in seeking prenatal care and are erratic in attending appointments.23 But early, regular prenatal care is essential for women with OUD so that they can receive support and early treatment referrals to reduce their risks of harm and adverse pregnancy outcomes. Laws that require reporting of substance abuse during pregnancy may deter women with OUD from seeking prenatal care.34,35 NPWH opposes policies that require reporting or criminalization of substance abuse during pregnancy and supports repeal of existing laws with such mandates. WHNPs and other NPs who provide healthcare for pregnant women are on the forefront to identify, support, and provide appropriate referrals and collaborative care for pregnant women with OUD.

Mothers receiving MATwith the exception of those who are HIV positive or continuing to use illicit substances—should be encouraged to breastfeed.23,28,36 Breastfeeding supports mother–infant bonding and may reduce the severity and duration of neonatal OWS.37,38 Minimal levels of methadone or buprenorphine are found in breast milk, regardless of the maternal dosage.22,39 Both medications are considered safe during breastfeeding.23,36,39 It is important to maintain open lines of communication for early identification of relapse. If relapse does occur, mothers should be provided with assistance to transition to bottle feeding with formula or donor milk.36

Older ageAlthough women older than 65 years are generally at low risk for opioid abuse, specific concerns regarding their use of OPR still exist. WHNPs and other NPs who provide healthcare for older women should be cognizant of potential increased risks with OPR use related to reduced renal function and drug clearance, co-morbidities, polypharmacy, and impaired cognition, as well as an increased risk for falls and fractures.1 Even women older than 65 can experience OUD.

Recommendations

Women’s health NPs and other NPs who provide healthcare for women should:

Use evidence-based guidelines for management of acute and chronic pain.

Use risk-mitigation strategies when prescribing OPR for acute or chronic pain.

Assess pregnancy status, sexual activity, and contraceptive use, as well as discuss potential risks and benefits, before prescribing OPR to women who are pregnant or could become pregnant.

Use a nonjudgmental, respectful approach when broaching the topic of substance use/abuse.

Screen all women at least annually—at well-woman visits, initial prenatal visits, and other visits when indicated—for substance use/abuse with a validated screening tool. Include questions concerning use of prescription drugs for nonmedical purposes.

Provide an evidence-based brief intervention when substance abuse is identified and make referrals for additional services as needed. Know which services are available in the community.

Use evidence-based guidelines if prescribing OUD treatment medication in collaboration with an MAT team.

Collaborate in specialty care for pregnant women with OUD.

Be aware of state reporting laws for substance abuse during pregnancy and advocate for retraction of legislation that exposes pregnant women with substance use disorders to criminal or civil penalities.

References

1. Dowell D, Haegerich TM, Chou R. CDC. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49.

2. Washington State Agency Medical Directors’ Group. Interagency Guideline on Prescribing Opioids for Pain. 2015.

3. U.S. Department of Health and Human Services, Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee. Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. 2013.

4. SAMHSA. Medication and Counseling Treatment. 2015.

5. Addiction Treatment Forum. MAT with Methadone or Buprenorphine: Assessing the Evidence for Effectiveness. 2014.

6. Fullerton CA, Kim M, Thomas CP, et al. Medication- assisted treatment with methadone: assessing the evidence. Psychiatr Serv. 2014;65(2):146-157.

7. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv. 2014;65(2):158-170.

8. U.S. Congress. S.524 – Comprehensive Addiction and Recovery Act of 2016.

9. Tsang A, Von Korff M, Lee S, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9(10): 883-891.

10. CDC. Wide-Ranging Online Data for Epidemiologic Research (Wonder). Atlanta, GA: CDC, National Center for Health Statistics; 2016.

11. Frenk SM, Porter KS, Paulozzi LJ. Prescription Opioid Analgesic Use Among Adults: United States, 1999–2012. NCHS Data Brief, No. 189. Hyattsville, MD: National Center for Health Statistics; February 2015.

12. SAMHSA. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. The DAWN Report. Rockville, MD: SAMHSA; 2013.

13. SAMHSA. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. 2015.

14. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010;105(10):1776-1782.

15. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of pastyear nonmedical use: United States 2008-2011. JAMA Intern Med. 2014;174(5):802-803.

16. CDC. Vital Signs: Demographics and Substance Use Trends Among Heroin Users – United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719-725

17. Agency for Healthcare Research and Quality. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. 2014.

18. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.

19. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004-2013. JAMA. 2015; 314(14):1515-1517.

20. CDC. Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013; 62(26):537-542.

21. CDC. Vital Signs: Prescription Painkiller Overdoses: A Growing Epidemic Among Women. July 2013.

22. SAMHSA. Substance Abuse Treatment. Addressing the Specific Needs of Women: A Treatment Improvement Protocol. Tip 51. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 2009. store.

23. American College of Obstetricians and Gynecologists. Committee on Health Care for Underserved Women and the American Society of Addiction Medicine. Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. May 2012. Reaffirmed 2014.

24. National Institute on Drug Abuse. Chart of Evidence-Based Screening Tools for Adults and Adolescents. Revised September 2015.

25. SAMHSA. Quick Guide for Clinicians Based on TIP 34: Brief Interventions and Brief Therapy For Substance Abuse. Rockville, MD: SAMHSA; 2015.

26. National Institute on Drug Abuse. Drug Facts: Prescription and Over-the-Counter Medications. Bethesda, MD: NIDA; 2015.

27. National Institute on Drug Abuse. Research Reports: Misuse of Prescription Drugs. Last updated August 2016.

28. American Society of Addiction Medicine. National Practice Guidelines for the Use of Medication in the Treatment of Addiction Involving Opioid Use. 2015.

29. Broussard CS, Rasmussen SA, Reefhuis J, et al; National Birth Defects Prevention Study. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204(4):314.e1-11.

30. Whiteman VE, Salemi JL, Mogos MF, et al. Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. J Pregnancy. 2014:1-8.

31. Yazdy MM, Mitchell AA, Tinker SC, et al. Periconceptional use of opioids and the risk of neural tube defects. Obstet Gynecol. 2013;122(4):838-844.

32. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012; 129(2):540-560.

33. SAMHSA. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. Rockville, MD: SAMHSA; 2016.

34. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. Committee Opinion No. 473: substance abuse reporting and pregnancy: the role of the obstetrician-gynecologistObstet Gynecol. 2011;117(1):200-201. Reaffirmed 2014.

35. Guttmacher Institute. Substance Abuse During Pregnancy. Washington, DC: Author; 2014.

36. Reece-Stremtan S, Marinelli KA. ABM clinical protocol # 21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015;10(3):135-141.

37. McQueen KA, Murphy-Oikonen J, Gerlach K, Montelpare W. The impact of infant feeding method on neonatal abstinence scores of methadone-exposed infants. Adv Neonat Care. 2011;11(4):282-290.

38. Pritham UA. Breastfeeding promotion for management of neonatal abstinence syndrome. J Obstet Gynecol Neonat Nurs. 2013;42(5):517-526.

39. Wong S, Ordean A, Kahan M; Society of Obstetricians and Gynecologists of Canada. SOGC clinical practice guideline: substance use in pregnancy: no. 256, April 2011. Int J Gynaecol Obstet. 2011;114(2):190-202.

Approved by the NPWH Board of Directors: December 2016

The elusive vulva

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.

Using simulation to practice vulvar procedure skills

Vulvar biopsy and application of trichloroacetic acid (TCA) to treat vulvar condylomata acuminata (genital warts) are two minimally invasive office procedures routinely performed by women’s health nurse practitioners (WHNPs). To ensure patient safety and good outcomes, WHNPs must receive formal education and training prior to performing these procedures. The busy women’s health or primary care clinic is not always an ideal environment for novice WHNPs or WHNP students to practice these types of skills.1

Simulation training offers an opportunity for learners to acquire knowledge, hone skills, and gain confidence. The National League of Nursing promotes simulation training as an effective teaching methodology to prepare nurses for practice.2 The current literature supports simulation-based training with practice as an effective means to achieve patient safety.Simulation provides novice WHNPs and WHNP students with an opportunity to practice office gynecology skills in a safe environment conducive to increasing competency and efficiency.4 This article provides these learners, as well as WHNP faculty and preceptors of WHNP students, with simulation modules that can be used to review, practice, and master the steps needed to perform two specific vulvar procedures.

Vulvar biopsy

Case study presentation

A G2 P2002, 69-year-old postmenopausal woman presents to the clinic with this complaint: “I’ve had persistent itching on the left side of my vulva for 3 months.” She denies having vulvar or vaginal bleeding, discharge, or odor. She has been applying over-thecounter (OTC) cream for yeast vaginitis, 1% hydrocortisone cream, and warm compresses to the affected area, with little relief. The WHNP performs a visual examination of the vulva and observes an irregularly shaped, pigmented lesion approximately 3 cm wide on the left side of the vulva. Given the patient’s presenting complaint and the physical exam findings, the WHNP thinks that a pathology report will confirm the presence of vulvar intraepithelial neoplasia (VIN). Until the pathology report is received, vulvar pruritus is documented as the diagnosis in the patient’s health record.

Indication for procedure

The American College of Obstetricians and Gynecologists recommends performing a biopsy for any pigmented lesion on the vulva or for a case involving vulvar symptoms that persist despite topical therapy.5 The purpose of the biopsy is to determine the cause of the symptoms and to rule out malignancy. Biopsy-proven VIN is a risk factor for vulvar cancer.5

Contraindications

No absolute contraindications for vulvar punch biopsy exist; relative contraindications include coagulation disorder, current infection at the biopsy site, allergy to local anesthetic, and inability to comply with wound care.6 If melanoma is suspected, the WHNP should refer the patient to a dermatologist or gynecologist-oncologist to perform the biopsy.

Diagnosis

The diagnosis in this case is vulvar pruritus; the ICD-10 code is L29.2. The CPT code for a vulvar biopsy is 56605.

Procedure directions

Initial steps include reviewing risks and benefits of the procedure with the patient, obtaining a signature on the consent form, and ruling out any allergies associated with antiseptic solutions used for cleansing the vulva. The patient is draped appropriately, assisted into the reclined position on the exam table with both feet in the stirrups, and asked if she is comfortable. Before performing the procedure, the WHNP ensures that a good light source is available.

After washing the hands and applying clean gloves, the WHNP observes the vulvar lesion to identify where to collect the biopsy; the area with the greatest observed changes in texture and

color is chosen. The WHNP cleans the area with povidone iodine or another appropriate antiseptic solution. Using a 22-gauge needle and a tuberculin syringe, the WHNP injects 1-2 mL of 2% lidocaine with epinephrine at the biopsy site. About 2-3 minutes later, the WHNP confirms with the patient that the site is numb by using a sterile cotton swab to lightly touch the area. Using a 3-mm Keyes biopsy punch, the WHNP applies gentle pressure while slowly and steadily twisting the instrument clockwise and counterclockwise until the punch is fully inserted into the pigmented lesion (Photograph 1). The punch is removed and the location of the tissue sample is identified. Using sterile forceps, the WHNP picks up the tissue sample and removes it using sterile scissors (Photograph 2). The WHNP places the specimen into a pathology container with liquid formalin. If bleeding is observed at the site, the WHNP applies pressure using sterile cotton gauze or a cotton swab. Next, the WHNP applies a small amount of antibacterial ointment to the biopsy site and covers it with a bandage.

The WHNP confirms that the patient’s identification information is documented on the outside of 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 includes the patient’s name, a second patient identifier, date and time of the biopsy collection, specimen source, diagnosis, ICD-10 code, and practitioner’s name.

Post-procedure patient education

The WHNP reassures the patient that slight bleeding at the biopsy  site is normal and that minor discomfort may be experienced. The patient is asked to notify the WHNP if she experiences pain unrelieved by use of an OTC nonsteroidal anti-inflammatory drug (NSAID), malodorous or bloody drainage from the biopsy site, or a temperature of 100.5º F or higher.6

Description of the simulation

Supplies (Table 1 ) may be purchased from a medical supplier, a craft store, or a grocery store. Most of the supplies are disposable, but some can be reused. Simulation training is a safe and cost-effective way to practice procedures. This vulvar biopsy simulation can be performed at a cost of about $5.

Step-by-step simulation assembly and video link

The first step is to cut a small piece (3 cm x 3 cm) of raw calf’s liver with the shiny sheath visible on top. A lesion can be drawn on the liver with a red marker if desired. The liver is dried with the disposable underpad before the lesion is drawn. Readers can access a video link for the vulvar biopsy simulation.*

Trichloroacetic acid treatment for vulvar condylomata acuminata

Case study presentation

A G0 20-year-old woman visits the clinic for the first time. She presents with the complaint, “I have vulvar warts—again,” and asks the WHNP for treatment. She denies having vaginal discharge, itching, or odor. She is single and sexually active with one partner. She uses depot medroxyprogesterone acetate for contraception. She denies ever smoking cigarettes. She also denies receiving the HPV vaccination. The WHNP inspects the patient’s vulva and visualizes a small cluster of condylomata acuminata 2 cm in diameter and two individual warts about 1 cm in diameter each on the right side of the vulva at the 4 o’clock position. No discharge or odor is present. Given the patient’s history of condylomata acuminata, the WHNP discusses treatment options with her and recommends topical treatment with TCA. In addition, the patient is advised to receive the first of three doses of the 9-valent HPV vaccine. The first application of TCA and the first dose of the HPV vaccine are administered at this visit. The WHNP asks the patient to return for a follow-up visit in 1 week and educates her about the importance of undergoing cervical cancer screening when she reaches age 21, along with the importance of routine condom use for sexually transmitted infection prevention.

Indication for procedure

Ninety percent of genital warts are caused by HPV type 6 or 11.7 Genital warts can occur as simple lesions or in clusters. Patients describe them as unattractive, irritating, and itchy. Left untreated, genital warts can disappear within 12-24 months, remain unchanged, or multiply.7  Various treatments can relieve the aesthetic concerns and bothersome symptoms, but no therapy can eradicate the HPV infection from the body.7 Treatment of existing genital warts does not prevent future ones from occurring.

Contraindications

The only absolute contraindication for using TCA is the presence of a hypersensitivity or an allergy to it. TCA should not be used to treat genital warts of the urethra, vagina, cervix, or rectum.

Diagnosis

The diagnosis in this case is anogenital warts. The ICD-10 code is A63.0. Application of TCA is considered simple destruction of vulvar lesions and is billed as a CPT code of 56501.

Treatment procedure directions

Prior to the TCA application, the WHNP discusses risks and benefits of the procedure with the patient and obtains her signature on the consent form. The patient is asked if she has any allergies, especially those related to povidone iodine or TCA. The patient is draped appropriately, assisted into the dorsal lithotomy position on the exam table with both feet placed in the stirrups, and asked if she is comfortable.

After washing the hands and applying clean gloves, the WHNP inspects the external genitalia to locate the vulvar warts. The area is cleaned with povidone iodine or another appropriate antiseptic solution. Using a small cotton-tip swab, the WHNP applies petroleum jelly to a thin circular area around each wart to prevent the TCA from spreading when it is applied (Photograph 3). In addition,the WHNP can numb the area surrounding the warts with 2% topical lidocaine gel if this product is available in the clinic. The TCA is then applied to the warts using a small cotton-tip swab (Photograph 4 ). The WHNP touches the swab directly to the wart and holds it there until the area blanches. The TCA is allowed to dry completely. The patient’s discomfort level is assessed. If she is experiencing discomfort, then the WHNP applies baking soda to the treated area to help neutralize the acid.These steps are repeated until the warts have a frost-like appearance (Photograph 5).

Post-procedure patient education

The WHNP informs the patient about the pain and burning sensation commonly experienced after application of TCA. The patient is advised to use sitz baths, topical lidocaine, cool compresses, and/or oral NSAIDs to help relieve the discomfort. She is advised to wear a small peri-pad for the remainder of the day to protect the surrounding tissue. Sitz baths are used to cleanse the area. The patient is asked to notify the practitioner if she experiences increased vulvar swelling, malodorous drainage, erythema, bleeding from the procedure site, pain not resolved with NSAIDs, or a temperature of 100.5° F or higher. A follow-up appointment is scheduled for the patient 1 week after the initial TCA application. Depending on their size and shape, many warts fall off after a few applications of TCA.

Description of the simulation

All of the supplies (Table 2) are easily obtained from a convenience store, grocery store, or online store. Supplies for this simulation are disposable and can be purchased at a cost of $2-$3. Liver is preferred; other meat sources will not blanch when TCA is applied. TCA is sold online and by medical supply companies.

Step-by-step simulation assembly and video link

Wearing disposable gloves, the WHNP cuts a small piece (4 cm x 4 cm) of chilled, raw calf’s liver with the shiny sheath visible on top and places it on a disposable underpad. The shiny sheath of the liver will blanch with TCA application. The WHNP cuts a small piece of tissue paper into a ó inch x ó inch square and then molds it into a small ball with the thumb and index finger and secures it on the piece of liver with a straight pin to give the appearance of warts on the vulva (Photograph 6). Readers can access a video link for the TCA application simulation.*

Conclusion

Women’s health NPs need to know how to safely and accurately perform vulvar procedures, including a vulvar biopsy and condylomata acuminata treatment with TCA. The busy clinic setting does not provide novice WHNPs or WHNP students with an environment conducive to master newly learned procedures. Simulation learning can provide educational and clinical benefits to enhance practice.3  In a controlled, simulated envi ronment, learners can focus on achieving accuracy, confidence, and competence when performing vulvar procedures.3, 8

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.

Acknowledgment

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. National League of Nursing Board of Governors. A Vision for Teaching with Simulation. April 20, 2015.

3. McGaghie WC, Issenberg SB, Cohen MR, et al. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86(6):706-711.

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

5. Committee on Gynecologic Practice of American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 509: Management of vulvar intraepithelial neoplasia. Obstet Gynecol. 2011;118(5):1192 1194.

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

7. CDC. Sexually transmitted diseases treatment guidelines. MMWR. Morbid Mortal Wkly Rep. 2015;64(3):84-90.

8. 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.

*These videos are 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.