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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

Bone densitometry: Performance, interpretation, and clinical application

The authors discuss how to determine who is a candidate for bone densitometry, interpret the results, ascertain when treatment is indicated, and choose among various treatment options.

CASE PRESENTATIONS

You see a 70-year-old mother and her 50-year-old daughter in your practice. You order bone density scans for each of them. Although the scans show that each woman has a T-score of –2.3 at the femoral neck, you will be treating only the older woman with medication.

The daughter underwent a total abdominal hysterectomy 6 months previously and was started on estrogen therapy. She has no history of fracture and reports no use of corticosteroids, no smoking, and minimal intake of alcohol. Pertinent physical examination and laboratory findings are:

• Height, 62 inches; weight, 110 lb;

• Hyperextensible joints;

• Small bone structure;

• Tandem gait excellent; and

• Complete blood count (CBC), complete metabolic panel (CMP), vitamin D, parathyroid hormone (PTH), and 24-hour urinary calcium values all within normal limits.

Based on her FRAX® results (more about this tool later), her 10-year fracture risk is 7.3% for a fragility fracture and 0.5% for a hip fracture. You make sure that she has adequate calcium and vitamin D intake through diet and supplements, and you recommend that she engage in activities that maintain her good balance, engage in weight-bearing exercise, and work out with light weights.

The mother fractured her hip 2 years previously after tripping on a dog toy. She reached menopause at age 45 but chose to forgo hormone therapy. She does not take steroids, smoke, or drink alcohol. Her own mother sustained a hip fracture at age 85. Pertinent physical exam and lab findings are:

• Height, 62 inches; weight, 120 lb;

• Flexibility normal;

• Small bone structure;

• Slight limp from hip fracture;

• Tandem gait done with some difficulty; and

• CBC, CMP, vitamin D, PTH, and 24-hour urinary calcium values all within normal limits.

Based on her FRAX results, her 10-year fracture risk is 35% for a fragility fracture and 14% for a hip fracture. History of a hip fracture alone merits osteoporosis treatment. You recommend adequate calcium and vitamin D intake through diet and supplements, balance training and weight-bearing exercises, and pharmacotherapy with an oral bisphosphonate.

Why did both women undergo bone density scans? And, given the fact that mother and daughter got the same T-score, why is the mother, but not the daughter, a candidate for pharmacotherapy? Some background information is needed to answer these questions.

Osteoporosis is a skeletal disease characterized by low bone mass and microarchitectural deterioration of the bone tissue, with a consequent increase in bone fragility that increases the risk for fracture.1 Approximately 10 million persons in the United States have osteoporosis and another 44 million have osteopenia (low bone mass that is less severe than osteoporosis), placing them at increased risk for fracture.2 Fifty percent of women experience an osteoporosis-related fracture in their lifetime, an incidence greater than that of myocardial infarction, stroke, and breast cancer combined.2 Of note, especially for healthcare providers (HCPs) who see young female patients, osteoporosis is not just a disease of bone loss, which commonly occurs as people age. Osteoporosis can also develop in people who do not reach peak bone mass during childhood and adolescence—without the accelerated bone loss that can accompany aging.1

Instead of testing bone strength, which is inappropriate in humans, HCPs can check their patients’ bone mineral density (BMD), which accounts for about 70% of bone strength and serves as a proxy measure for it.1 BMD is ascertained most commonly by dual-energy x-ray absorptiometry  (DXA) of the hip and spine—or in rare cases, the forearm. DXA is used to establish or confirm a diagnosis of osteoporosis, to help predict future fracture risk, and to monitor patients over time, particularly those undergoing osteoporosis treatment.3, 4

Areal BMD can be expressed in absolute terms of grams of mineral per square centimeter scanned (g/cm2) and as a relationship to two norms: the BMD of a young-adult reference population (T-score) and the BMD of an age-, sex-, and race- or ethnicity-matched reference population (Z-score). T-scores and Z-scores are calculated by determining the difference between a patient’s BMD and the mean BMD of the reference population, divided by the standard deviation (SD) of the reference population. Spine and hip BMD measurements in postmenopausal white women are interpreted using the World Health Organization’s T-score definitions of osteoporosis and osteopenia (Table 1).5

Osteoporosis is defined clinically as a fragility fracture of the hip or spine in the absence of other metabolic bone disease, a BMD of –2.5 or lower at any location, or a FRAX score indicating a 10-year risk of a major fragility fracture equal to or greater than 20% or a 10-year risk of hip fracture equal to or greater than 3%.The Fracture Risk Assessment Tool,or FRAX, is a computer-based algorithm that calculates fracture probability from clinical risk factors—age, sex, body mass index, smoking, alcohol use, prior fracture, parental history of hip fracture, corticosteroid use, rheumatoid arthritis (RA), and secondary osteoporosis—and BMD at the femoral neck.8

Fracture

Bone mineral density and fracture risk are inversely related. Each 1 SD decrease in BMD is associated with a 1.6- to 2.6-fold increase in risk of fracture, depending on the skeletal site.Along with low BMD, non-skeletal factors—especially the tendency to fall—contribute to fragility fracture risk. About 90% of fragility fractures occur after falls.10 The pathogenesis of falls in older adults is complex and is related to factors such as age-related deficits in visual, proprioception, and vestibular systems; frailty and de-conditioning; health conditions such as neuropathy, or prior stroke; use of certain medications (e.g., hypnotics, antihypertensives) and polypharmacy; and environmental factors (e.g., poor lighting, loose rugs).11, 12

More than 2 million fragility fractures occur each year in the U.S., accounting for $17 billion in healthcare costs.13 Seventy percent of fragility fractures occur in women. Despite these numbers, fewer than 25% of women aged 67 or older with an osteoporosis-related fracture undergo BMD measurement or begin osteoporosis treatment.12

Vertebral fracture, the most common osteoporotic fracture, may occur in the absence of trauma or after minimal trauma (e.g., bending, lifting).14 Although most vertebral fractures are clinically silent at first, they can eventually cause pain, disability, deformity, and mortality.15 Hip fracture, the most serious consequence of osteoporosis,12 is associated with chronic pain and disability, loss of independence, decreased quality of life, and increased mortality—8% to 36%—within a year.4 More than half of hip fracture survivors cannot live independently; many require longterm nursing home care.16

Although for many years there was awareness of the morbidity and mortality associated with fragility fractures, real progress came only with the ability to diagnose osteoporosis before fractures occur and the development of effective treatments.Measurement of BMD with DXA, which entered routine clinical practice in the late 1980s, has played a vital role in both of these developments. Although BMD correlates with fracture risk, HCPs should keep in mind that most fractures occur in patients with osteopenia. Therefore, patients with osteoporosis or with osteopenia may need treatment.

Osteoporosis workup

According to guidelines published by the American Association of Clinical Endocrinologists and the American College of Endocrinology (AACE/ACE) in 2016, all postmenopausal women aged 50 years or older should undergo clinical assessment for osteoporosis and fracture risk, starting with a detailed history and physical examination.12 HCPs should check for prior non-traumatic fractures, low body weight (<127 lb), height loss or kyphosis, a family history of osteoporosis and/or fractures, smoking, early-onset menopause, and excessive alcohol intake (3 drinks/day). HCPs should also assess each woman’s risk factors for falling.

The AACE/ACE recommends lateral spine imaging with standard radiography or vertebral fracture assessment (VFA).12 VFA is a method for imaging the thoracic and lumbar spine by DXA for the purpose of detecting vertebral fracture deformities in patients with unexplained height loss, self-reported but undocumented prior spine fractures, or steroid therapy equivalent to 5 mg/day prednisone for 3 months or longer.

The AACE/ACE recommends BMD measurement in women at increased risk for osteoporosis and fractures who are willing to consider pharmacologic treatment if osteopenia or osteoporosis is documented.12 Candidates for BMD measurement include all women aged 65 years or older, as well as younger postmenopausal women who (1) have a history of fracture without major trauma, (2) are on long-term systemic steroids, (3) have radiographic osteopenia, or (4) have clinical risk factors for osteoporosis.12 Three major health organizations—the U.S. Preventive Services Task Force, the National Osteoporosis Foundation (NOF), and the American Congress of Obstetricians and Gynecologists—offer similar screening recommendations.17-19

The AACE/ACE advises that treatment decisions for osteoporosis or osteopenia include consideration of fracture probability.12 Therefore, BMD results should be combined with other clinical risk factors for accurate fracture risk assessment. The FRAX tool can be used to calculate patients’ probability of fracture over 10 years.

In terms of the first question posed at the beginning of this article—Why did both women undergo bone density scans?—the answer is that both the mother and the daughter met criteria for BMD testing: The mother is 70 years old, and the daughter is a 50-year-old postmenopausal woman with low body weight and a mother who sustained a hip fracture.

Management

If postmenopausal osteoporosis is documented based on clinical and imaging fi ndings, HCPs should first ascertain whether it might be secondary to another cause. Certain health conditions that cause or exacerbate bone loss may be asymptomatic and require laboratory testing for detection. Lab tests include a CBC, a CMP, 25-hydroxyvitamin D, PTH, bone-specifi c alkaline phosphatase, and a 24-hour urine collection for calcium and creatinine.12 When indicated, HCPs should address causes of secondary osteoporosis and correct any calcium and/or vitamin D deficiencies. The general approach to management of osteoporosis and osteopenia is as follows:

Nutritional and nonpharmacologic interventions

All women, not just those with low bone mass—should aim for an adequate intake of vitamin D and calcium, participation in weight-bearing and muscle-strengthening exercises, smoking cessation as applicable, minimization of alcohol intake as applicable, and treatment of risk factors for falling. Many scientific organizations recommend an intake of 1,000 IU/day of vitamin D for adults aged 50 or older.12 Serum 25-hydroxyvitamin D levels should be measured in those at risk for vitamin D defi ciency, and vitamin D supplements should be prescribed as needed.4 Adults aged 50 or older are advised to consume 1,200 mg/ day of calcium through diet and a supplement, if needed.20

Measures to reduce falls include individual risk assessment; Tai Chi, yoga for seniors, and other exercise programs; home safety assessment, especially when done by an occupational therapist, and modification as needed; withdrawal of psychotropic medications if possible; and appropriate correction of visual impairment.Measures to be taken inside the home include anchoring rugs, minimizing clutter, removing loose wires, using nonskid mats, installing handrails where needed, adding lighting to stairwells and hallways, wearing sturdy shoes, and avoiding potentially dangerous activities.12

Pharmacotherapy

The AACE and NOF strongly recommend pharmacotherapy for persons with:

• Osteopenia and a history of a fragility fracture of the spine or hip;

• A T-score of –2.5 or lower in the spine, femoral neck, total hip, or distal one-third radius; or

• A T-score between –1.0 and –2.5 in the spine, femoral neck, total hip, or distal one-third radius and a 10-year risk of hip fracture equal to or greater than 3% or a 10-year risk of a major osteoporosis-related fracture equal to or greater than 20%.4,12

In terms of the second question posed at the beginning of this article—Why is the mother, but not the daughter, a candidate for pharmacotherapy?—the answer is that the 50-year-old daughter does not meet criteria for pharmacologic intervention; her BMD is in the osteopenia range, but she has no history of fracture and her FRAX scores do not show a high enough 10-year fracture risk to merit treatment. By contrast, the 70-year-old mother has osteopenia, a personal history of fracture, a maternal history of fracture, and FRAX scores that are high enough to warrant treatment.

Healthcare providers can choose among a variety of medications (Table 2), depending on patients’ health status and fracture risk.4,12 Four agents—alendronate, risedronate, zoledronic acid, and denosumab—have evidence for “broad spectrum” anti-fracture efficacy and are considered initial options in most cases.

Patients with moderate fracture risk, but no fragility fractures, can be started on an oral agent—that is, alendronate or risedronate. Patients with the highest fracture risk are usually started on an injectable such as teriparatide, denosumab, or zoledronic acid. The injectables are also appropriate for patients with upper gastrointestinal (GI) problems who might not tolerate oral medications, those with lower GI problems who might not absorb oral medications, and those with difficulty remembering to take oral medications on a regular basis or coordinating an oral bisphosphonate (BP) with other oral medications or their daily routine.

Bisphosphonates

Three of the aforementioned firstline agents, alendronate, risedronate, and zoledronic acid, are BPs; another member of this class is ibandronate. These agents, which are approved for both prevention and treatment of osteoporosis, have proven anti-fracture efficacy as well; on average, they reduce the incidence of vertebral and hip fractures by 50% over 3 years and they may increase BMD. The major downside is that nearly all oral BP products must be taken on an empty stomach and swallowed with a full glass of water, with at least a half hour intervening before anything other than water is ingested. Many BP users report painful swallowing, nausea, heartburn, or esophageal irritation. Other side effects include hypocalemia; bone, joint, or muscle pain; rash/allergy; and renal dysfunction. Presence of hypocalcemia is a contraindication to BP use. BPs should be used with caution, if at all, in patients with reduced renal function.

Two serious, but rare, adverse effects of long-term BP treatment are osteonecrosis of the jaw (ONJ) and atypical fracture of the femur (AFF). Pain in the thigh or groin area, which can be bilateral, often precedes an AFF. To put the risks of ONJ and AFF in perspective, out of 100,000 postmenopausal women, 50,000 will experience an osteoporosis-related fracture. By contrast, out of 100,000 persons on osteoporosis medication for 5 years, 1 may develop ONJ and 16, AFF.21

Calcitonin

Salmon calcitonin is approved for the treatment of osteoporosis in women who are at least 5 years postmenopausal when alternative treatments are not suitable. Calcitonin reduces vertebral fracture occurrence by about 30% in persons with prior vertebral fractures, but it has not been shown to reduce the risk of nonvertebral fractures and it has only a weak effect on BMD. The most common side effects of nasally administered calcitonin are nasal discomfort, rhinitis, and epistaxis.

Raloxifene

Raloxifene, an estrogen agonist/antagonist, is approved for prevention and treatment of postmenopausal osteoporosis, as well as for the reduction of breast cancer risk. Raloxifene is contraindicated in women of childbearing potential and in those with a history of venous thromboembolism (VTE). Raloxifene has been shown to reduce the risk of vertebral fracture (by 30%-55%), but not nonvertebral fracture or hip fracture. Adverse effects of  this agent include VTE (a 3-fold increased risk, but the absolute risk is low), menopausal symptoms, and leg cramps.

Of note, estrogen therapy is FDA approved only for osteoporosis prevention, not treatment. Likewise, a medication that combines conjugated estrogens with the estrogen agonist/antagonist bazedoxifene is approved to prevent, not treat, osteoporosis after menopause, as well as to treat moderate to severe vasomotor symptoms.

Denosumab

Denosumab, a fully human monoclonal antibody, is approved for treatment of osteoporosis in postmenopausal women at high risk of fracture. This agent decreases bone resorption, increases BMD, and reduces fracture risk by 20%-70% over 3 years, depending on the site. Given subcutaneously (SC) every 6 months, denosumab must be administered by an HCP. Denosumab may be considered for use in certain patients with renal insuffi ciency; impaired renal function does not signifi cantly alter the metabolism or excretion of the drug.22 Denosumab may cause hypocalcemia, which must be corrected before treatment is started. Potential side eff ects include back pain, musculoskeletal pain, cystitis, and hypercholesterolemia. Denosumab has been associated with cellulitis and skin rash, as well as ONJ and AFF in rare cases.

Teriparatide

Recombinant human PTH, or teriparatide, builds bone—as opposed to reducing bone resorption. It is approved for initial treatment of women with postmenopausal osteoporosis who are at high risk of fracture or have failed or been intolerant of previous osteoporosis therapy. Administered SC by patients themselves, teriparatide reduces fracture risk by 50%-65%, depending on the site, after 18 months of therapy. Use of this agent is limited to 2 years. It is contraindicated in patients with pre-existing hypercalcemia, severe renal impairment, or a history of bone metastases or skeletal malignancies, and in those who are at an increased baseline risk for osteosarcoma.23 Potential side effects include orthostatic hypotension, dizziness, myalgias, arthalgias, leg cramps, transient hypercalcemia, increased serum uric acid, hypercalciuria, headache, and nausea.

Monitoring treatment response

After initiating treatment, patients are seen 1-3 months later to check their adherence to the medication regimen and for lab testing. Patients are seen at least yearly to assess their response. Stable or increasing BMD at the spine and hip, as well as no fractures, indicates a satisfactory response.12 Therefore, serial central DXA, performed 1-2 years after initiating therapy and every 2 years thereafter, is a vital component of osteoporosis management. The decision to test BMD every 2 years is based on the time it takes for treatment-related improvement in BMD to occur and on Medicare and health insurance company reimbursement.

Yearly height measurement is also a crucial determinant of osteoporosis treatment efficacy. Patients who lose 2 cm (0.8 in) of height either acutely or cumulatively should undergo repeat vertebral imaging to determine whether new or additional vertebral fractures have occurred since the previous test.4

Duration of pharmacologic treatment

In 2016, the American Society for Bone and Mineral Research issued guidelines for long-term BP treatment.24 The society recommends that, after 5 years of oral therapy or 3 years of IV therapy, HCPs reassess patients’ fracture risk. For women at high risk, HCPs should consider continuing treatment for up to 10 years (oral) or 6 years (IV), with periodic evaluation. Although the risk of AFF, but not ONJ, increases with BP treatment duration, it is outweighed by the benefit of vertebral fracture risk reduction. For women not at high fracture risk, a drug holiday of 2-3 years can be considered after 3-5 years of treatment. By contrast, a drug holiday is not recommended for denosumab users because BMD benefits are rapidly lost with drug discontinuation. Treatment with teriparatide, which is taken for no longer than 2 years, is followed by treatment with an antiresorptive agent to prevent BMD decline and loss of fracture efficacy.

All non-BP osteoporosis medications produce temporary beneficial effects that wane upon discontinuation. By contrast, BPs may allow residual protection against fracture even after treatment cessation. Therapy should be resumed if a fracture occurs, if BMD declines beyond the least significant change (a value computed by each testing facility for relevant measurement sites to determine the magnitude of diff erence that represents a real change), or patients meet initial treatment criteria.

Conclusion

Healthcare providers can decrease postmenopausal patients’ risk of developing osteoporosis and/or experiencing a fragility fracture by clinically assessing them for these risks, ordering radiographic imaging and BMD measurement via DXA as indicated, and prescribing nondrug interventions and pharmacotherapy as needed. Patients who adhere to and tolerate their drug regimens can reduce their fracture risk, depending on the medication and the site, by about half. Patients on osteoporosis medication should be monitored at least once yearly to assess response to treatment, which is gauged by height measurement (every year), BMD via DXA (every 1-2 years), and absence of new fractures.

References

1. National Institutes of Health. Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Statement; March 27-29, 2000.

2. National Osteoporosis Foundation. Osteoporosis Fast Facts. 2015.

3. Blake GM, Fogelman I. The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgrad Med J. 2007;83(982):509-517.

4. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2014;25(10):2359-2381.

5. World Health Organization. Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis: Technical Report Series 843. Geneva, Switzerland: WHO; 1994.

6. Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. J Bone Joint Surg Am. 2010;92(3):743-753.

7. FRAX® Fracture Risk Assessment Tool. n.d.

8. Kanis JA, Hans D, Cooper C, et al; Task Force of the FRAX Initiative. Interpretation and use of FRAX in clinical practice. Osteoporos Int. 2011;22(9):2395-2411.

9. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312(7041):1254-1259.

10. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003;348(1):42-49.

11. Berry SD, Kiel DP. Falls as risk factors for fracture. In: Marcus R, Feldman D, Nelson DA, Rosen CJ, eds. Osteoporosis. 3rd ed. San Diego, CA: Academic Press; 2008.

12. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis – 2016. Endocr Pract. 2016;22(suppl 4):1-42.

13. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475.

14. International Osteoporosis Foundation. Vertebral Fracture Initiative. Part I: Overview of Osteoporosis: Epidemiology and Clinical Management.

15. Lewiecki EM, Laster AJ. Clinical review: Clinical applications of vertebral fracture assessment by dual-energy x-ray absorptiometry. J Clin Endocrinol Metab. 2006;91(11):4215 4222.

16. Orwig DL, Chan J, Magaziner J. Hip fracture and its consequences: differences between men and women. Orthop Clin North Am. 2006;37(4):611-622.

17. U.S. Preventive Services Task Force. Final Recommendation Statement: Osteoporosis: Screening. April 2016.

18. National Osteoporosis Foundation. Bone Density Exam/Testing. 2016.

19. American College of Obstetricians and Gynecologists. Osteoporosis Guidelines Issued. August 21, 2012.

20. Institute of Medicine Committee to review dietary reference intakes for vitamin D and calcium. In: Ross AC, Taylor CL, Yaktine AL et al, eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011.

21. Kaiser Permanente. Southern California. Fracture Liaison Service. 2013.

22. Block GA, Bone HG, Fang L, et al. A single-dose study of denosumab in patients with various degrees of renal impairment. J Bone Miner Res. 2012;27(7):1471-1479.

23. Quattrocchi E, Kourlas H. Teriparatide: a review. Clin Ther. 2004;26(6):841-854.

24. Adler RA, El-Hajj Fuleihan G, Bauer DC, et al. Managing Osteoporosis in Patients on Long Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016;31(1):16-35.

Influence of education strategies on young women’s knowledge and attitudes about the HPV vaccine

The incidence of cervical cancer, a preventable disease, in the United States was 6.7 per 100,000 women in 2011, with a mortality rate of 2.3 per 100,000.1 Nearly all cervical cancers (99.7%) are caused by the human papillomavirus (HPV).Vaccination against HPV can prevent 90% of cervical cancers, but only 20% of U.S. women aged 19-26 years have received at least one dose of the vaccine.3 The author conducted a study to assess the usefulness of two educational interventions in increasing women’s knowledge about HPV and the Pap test, with the ultimate hope that this greater knowledge would translate into increased HPV vaccine uptake.

A systematic search of the health science databases Academic Search Premier, Women’s Health International, CINAHL, Medline, and PubMed was performed using the key words HPV, knowledge, beliefs, behaviors, education, prevention, and intervention to identify current research on educational intervention studies to promote HPV vaccination. Almost 5,000 articles were found. The search was then narrowed to English-language, scholarly, peer-reviewed studies with interventions aimed at females aged 13-64 years and published since 1999. After the limits were applied, 74 studies met inclusion criteria and were synthesized to draw conclusions about HPV knowledge and beliefs, women’s educational needs, and the types of educational interventions found effective at increasing HPV vaccine uptake among women.

A review of educational intervention studies suggested that lack of knowledge about HPV is a common barrier to HPV vaccine uptake.4-7 HPV knowledge tended to increase post-intervention. However, the studies all used only one educational approach to increase HPV knowledge. Most used written information alone; a few used oral presentations or videos. Some authors suggested that written material alone might not be as effective as verbal or video messages.8,9 To ascertain the usefulness of adding video messaging, the author compared the effectiveness of video plus written information with written information alone at increasing women’s HPV knowledge, Pap test knowledge, and vaccine intentions. Implications are drawn for future patient education strategies and healthcare provider (HCP) practice.

Method

Following acquisition of Internal Review Board approval, a quasi-experimental pre-test/post-test design was used. Participants were recruited from rural women’s healthcare clinics and via university email and Facebook. The prospective sample included 194 women aged 18-26 years who had not yet had the HPV vaccine. Women were excluded if they did not meet age criteria, were non-English speaking, were pregnant, or had received any HPV vaccinations. Participants were assigned to one of two educational interventions: (1) a written HPV factsheet created by the CDC (Group 1) or (2) a video containing HPV information and a cervical cancer survivor story plus the written HPV factsheet (Group 2).*

All participants gave written informed consent prior to completing the pre-test. Post-tests were administered 2 months after enrollment. A 2-month follow-up was chosen to allow time for participants to access the HPV vaccine series post-intervention, and to assess long-term HPV knowledge retention as a result of the educational intervention. Vaccine status was verified for all but 12 participants (6%) using a 3-step approach: chart audit, 42%; state immunization database, 39%; and self-report, 13%. Four participants in Group 1 and four in Group 2 received the HPV vaccine during the study period. Therefore, vaccine intention, rather than vaccine uptake, was evaluated as the study outcome variable. Intention to accept the HPV vaccine was determined based on a yes/no response to the question, “If cost were not an issue, would you accept the HPV vaccine for yourself?”

The instrument chosen for this study was used with permission from its designer, who confirmed its validity and reliability.10 The instrument is based on health belief model (HBM) constructs. Modifications of specific HBM constructs were made for this study; additional psychometrics are displayed in Table 1 and Table 2. Items assessing health beliefs were scored on a 4-point Likert scale, wherein 1 = strongly disagree and 4 = strongly agree. Other items on the instrument included history and demographic information to assess each participant’s sexual history, race, age, relationship status, and education level. In addition, 5 items assessed vaccine acceptability (e.g., Would you get a vaccine to prevent HPV infection?), 12 items assessed HPV knowledge, and 6 items assessed Pap test knowledge.

Results

Mean age of the 194 participants was 22 years. Most were white (n = 174); the remainder were black (n = 5), Hispanic/Latina (n = 4), Asian (n = 6), Native American (n = 1), or mixed (n = 4). Ninety-one participants were single, 84 were married and/or living with a partner, and 19 were in a relationship but not living with a partner. Ninety-one participants had attended some college, 45 had a high school diploma or GED, 36 had a bachelor’s degree, and 12 reported a graduate or professional degree.

Risk factors for HPV

Most participants had several risk factors for contracting HPV infection, including early age of sexual debut (mean age, 17 years), having >1 lifetime sexual partner (mean number of partners, 5), and not using condoms with their last act of sexual intercourse (proportion, 57%). In addition, 29 women older than 21 years reported never having had a Pap test. Among women who had undergone a Pap test, 38 had an abnormal result, with 19 knowing that the abnormality was a result of an HPV diagnosis, placing them at risk for developing cervical cancer.

HPV vaccine attitudes and perceived barriers

Reported barriers to getting the vaccine included cost, perceived risk, lack of availability, and lack of need for it. Figure 1 shows the percentage of participants who perceived these barriers before and after the educational intervention. The groups did not differ significantly in this regard, so the findings are reported as the total sample.

HPV vaccine intentions

Before and after receiving the HPV educational intervention, participants were asked about their willingness to accept the HPV vaccine for themselves and, if they became parents, for their adolescent children. This willingness increased significantly in both Group 1 and Group 2, with no difference between groups in terms of their willingness to accept the vaccine for themselves or their adolescent daughters. However, after the educational intervention, participants in Group 2 were significantly more likely than those in Group 1 to say they would accept the vaccine for their adolescent sons (Figure 2).

Knowledge scores

Participants were assessed on HPV and Pap test knowledge at baseline and at study completion. The groups did not differ on knowledge scores at pre-test or posttest, and both showed significant knowledge gains as a result of receiving education. This latter finding suggests that the two educational approaches (i.e., the factsheet alone vs. the video plus factsheet) did not differ in their effectiveness (Table 3 and Table 4).

Discussion

Impact on knowledge

The author hypothesized that the combination of a factsheet and a video-based first-person account story of a woman diagnosed with cervical cancer, with clear messages about prevention and treatment, would be a more powerful educational tool for increasing participants’ HPV and Pap test knowledge than a written factsheet alone. It turned out that knowledge increased significantly in both groups, and that the difference in knowledge gains between groups was not significant. This finding was similar to that of Krawczyk et al,11 who compared the efficacy of two HPV educational interventions, a pamphlet versus a video, in increasing HPV knowledge and vaccination intentions in college students. The investigators found that both educational interventions were similarly effective in this regard.11 The current study used a video that incorporated music, images, and cultural brokerage through a first-person account of a cervical cancer survivor. Although the difference between groups was not significant, Group 2 did have slightly higher knowledge scores than Group 1. It is unclear whether this slight edge was a result of the video messaging itself or the receipt of two educational strategies that reinforced each other.

At enrollment, participants’ HPV and Pap test knowledge levels were low, even among those who had regular contact with HCPs for Pap testing. This finding is consistent with the literature.12-16 Persistence of knowledge deficits despite increasing access to HCPs through the Affordable Care Act (ACA) speaks to unmet educational needs. Reasons for any woman’s knowledge deficits with regard to HPV and Pap testing, despite regular contact with an HCP, are unclear but may reflect a lack of time in the office for face-to-face education or an HCP’s lack of skill in imparting such information to a patient.17 In this study, 29 participants aged 21 or older reported never having had a Pap test. Lack of knowledge has been cited as a barrier to disease prevention-seeking behaviors such as getting a Pap test.18,19 Studies have shown that many women do not understand the purpose of a Pap test.20-22

Impact on HPV vaccination intentions

In this study, after the intervention,  both groups were similarly and significantly more willing to accept the HPV vaccine for themselves and their adolescent children; Group 2 was significantly more willing than Group 1 to accept the vaccine for their adolescent sons. Evaluation of content in the two educational tools showed that the video may have been more gender neutral than the factsheet with regard to eligibility criteria for HPV vaccination. The video simply mentioned the ages for which the vaccine has FDA approval—“All males and females 9-26 years of age can receive the HPV vaccine”—whereas the factsheet was more specific about different age and risk groups who should be vaccinated.23 

Although vaccination intentions increased, vaccine uptake during the study was not significantly affected; only 8 participants, 4 in each group, became vaccinated. Several barriers to vaccination might have influenced this finding. A major barrier was cost. Even though 84% of the participants reported having insurance coverage, nearly 41% of respondents on the pre-test and 34% of respondents on the post-test cited cost as a barrier to getting vaccinated. Although more young people are being insured through the ACA, there may be gaps in insurance coverage or lack of knowledge regarding vaccine coverage among the newly insured. Another barrier was access; many private HCP offices did not stock the vaccine. A third barrier may have been respondents’ lack of perceived need for the HPV vaccine. Some felt monogamy with a male partner or having a lesbian orientation eliminated the need. Others were at the end of the age bracket for HPV vaccination and did not seek to begin the vaccine series. A few reported prior diagnosis with HPV as a reason for not getting vaccinated. Finally, some participants had an inherent fear of all vaccines.

Limitations

Most study participants were white—the sample had little ethnic or racial diversity—and resided in rural Appalachia. Inferences about women from other ethnicities, races, or geographic locations cannot be made. Self-selection may indicate some bias by participants toward the topic, which would make their responses less representative of the population as a whole. Strict inclusion criteria for non-vaccinated participants prevented some age-eligible women from participating. Less stringent inclusion criteria might have provided interesting comparisons between vaccine-naïve and experienced participants. Finally, few participants became vaccinated during the study; therefore, conclusions can be drawn only regarding the impact HPV education had on intentions toward HPV vaccination.

Clinical implications

Nurse practitioners (NPs) are many patients’ first point of contact for healthcare information. NPs need to recognize that knowledge deficits regarding HPV and Pap testing exist, even among patients who visit regularly for Pap testing. NPs can aim to fill these gaps during every patient encounter. A simple factsheet can help fill the gap, but if NPs can provide educational videos to supplement the factsheet, patients may be even more motivated to get the HPV vaccine. NPs also need to remember that even if a given patient is older than 26, if she learns about the ability of the HPV vaccine to prevent cervical cancer, she will likely know that she should get her own children—including sons as well as daughters—vaccinated when they reach their preteen years. HPV vaccination is recommended by the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American Academy of Pediatrics, the CDC, and the Immunization Action Coalition.24 In addition to using educational tools to increase women’s knowledge about HPV and Pap testing, NPs can aim to overcome barriers to patients receiving the HPV vaccine by:

• helping insured patients understand that vaccines are covered by most insurance plans;

• helping uninsured patients by locating low- or no-cost vaccine options through state Vaccines for Children programs and pharmaceutical discount programs;

and

• dispelling fears and vaccine myths by distributing factsheets in their offices or clinics.

NPs can also try to disseminate information in places commonly viewed by the general public. This approach is important for women who do not undergo regular checkups. NPs need to try to reach these women where they live, work, shop, or travel to provide health information on the necessity of Pap testing and HPV vaccination.

More research on theoretically grounded educational interventions among differing populations at risk for HPV is needed. In particular, more research is needed to determine why women who have regular contact with HCPs lack knowledge about HPV and the HPV vaccine. In addition, more research is needed regarding gender bias in HPV vaccine recommendations. This study indicates a significant increase in women’s willingness to vaccinate adolescent sons following the video-based educational program. It is unclear whether the more gender-neutral video messaging was the cause of the discrepancy. Replication of this study among parents of adolescent children would help enhance NPs’ knowledge about adaptations that might be needed with regard to future HPV educational literature.

Crystal G. Sheaves is a Senior Lecturer at West Virginia University School of Nursing in Charleston. Financial support for this article was provided by West Virginia Immunization Network, a program of The Center for Rural Health Development, Inc.; and Sigma Theta Tau, Alpha Rho Chapter. The author states that she became a speaker for Merck & Co. after the study was conducted, and that Merck played no role in the funding of this study.

Acknowledgments

The author thanks Shalanda Bynum, PhD; Ilana Chertok, PhD; Stacey Culp, PhD; Marilyn Smith, PhD; Barbara Nunely, PhD; and Janie Leary, PhD, for their scientific guidance on the study.

References

1. Cervical Cancer Screening and Prevention. Practice Bulletin No. 157. Obstet Gynecol. 2016;127(1):e1-e20.

2. Ault KA. Epidemiology and natural history of human papillomavirus infections in the female genital tract. Infect Dis Obstet Gynecol. 2006;2006 suppl:40470.

3. CDC. Adult vaccination coverage – United States, 2010. MMWR Morbid Mortal Wkly Rep. 2012;61(4):66-72.

4. Mills LA, Vanderpool RC, Crosby RA. Sexually related behaviors as predictors of HPV vaccination among young rural women. J Womens Health (Larchmt). 2011;20(12):1909-1915.

5. Juraskova I, Bari RA, Obrien MT, McCaffery KJ. HPV vaccine promotion: does referring to both cervical cancer and genital warts affect intended and actual vaccination behavior? Womens Health Issues2011;21(1):71-79.

6. Mock J, McPhee SJ, Nguyen T, et al. Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women. Am J Public Health. 2007;97(9):1693-1700.

7. Patel DA, Zochowski M, Peterman S, et al. Human papillomavirus vaccine intent and uptake among female college students. J Am Coll Health. 2012;60(2):151-161.

8. Rosen NO, Knäuper B, Dio P, et al. The impact of intolerance of uncertainty on anxiety after receiving an informational intervention about HPV: a randomized controlled study. Psychol Health. 2010;25(6):651-668.

9. Waller J, Marlow LA, Wardle J. The association between knowledge of HPV and feelings of stigma, shame, and anxiety. Sex Transm Infect. 2007;83(2):155-159.

10. Bynum SA, Brandt HM, Friedman DB, et al. Knowledge, beliefs, and behaviors: examining human papilloma-virus-related gender differences among African American college students. Am Coll Health. 2011;59(4):296-302.

11. Krawczyk A, Lau E, Perez S, et al. How to inform: comparing written and video education interventions to increase humanpapilloma virus knowledge and vaccination intentions in young adults. J Am Coll Health. 2012;60(4):316-322.

12. Cermak M, Cottrell R, Murnan J. Women’s knowledge of HPV and their perceptions of physician educational efforts regarding HPV and cervical cancer. Community Health. 2010; 35(3):229-234.

13. Fry AM, Ferries-Rowe EA, Learman LA, Haas DM. Pap smear versus speculum examination: can we teach providers to educate patients? J Womens Health (Larchmt). 2010;19(9): 1715-1719.

14. Kahn JA, Slap GB, Bern stein DI, et al. Psychological, behavioral, and interpersonal impact of human papillomavirus and Pap test results. J Womens Health (Larchmt). 2005;14(7):650- 659.

15. Waller J, Marlow LA, Wardle J. Anticipated shame and worry following an abnormal Pap test result: the impact of information about HPV. Prev Med. 2009;43(5): 415-419.

16. Warren K. HPV knowledge among female college students and the short-term effectiveness of HPV education. Internet J Acad Phys Assist. 2010;7(2).

17. Bayer AM, Nussbaum L, Cabrera L, Paz-Soldan VA. Missed opportunities for health education on Pap smears in Peru. Health Educ Behav. 2011;38(2): 198-209.

18. Bynum S, Brandt HM, Friedman DB, et al. Knowledge, beliefs, and behaviors: Examining human papillomavirus-related gender differences among African American college students. J Am Coll Health. 2011; 59(4):296-302.

19. Juraskova I, O’brien M, Mullan B, et al. HPV vaccination and the effect of information framing on intentions and behavior: an application of the theory of planned behavior and moral norms. Int J Behav Med2012;19(4):518-525.

20. Hawkins NA, Cooper CP, Saraiya M, et al. Why the Pap test? Awareness and use of the Pap test among wom en in the United States. J Womens Health (Larchmt)2011;20(4):511-515.

21. Panagopoulou E, Giata O, Montgomery A, et al. Human papillomavirus and cervical screening misconceptions undermine adherence. Am J Health Promot. 2011;26(1):6-9.

22. Vasconcelos CT, Pinheiro AK, Castelo AR, et al. Knowledge, attitudes, and practice related to the Pap smear test among users of a primary health unit. Rev Lat Am Enfermagem. 2011; 19(1):97-105.

23. CDC. Genital HPV Infection – Fact Sheet. Last updated May 19, 2016.

24. Give a strong recommendation for HPV vaccine to increase uptake!

*Note: This video was prepared, and the study was conducted, before the HPV 9-valent vaccine became available.

Four APN students’ narratives on abortion training in Mexico City

Throughout the world, 40% of all pregnancies are unintended.1 In the United States, nearly half of pregnancies are unplanned; 40% of these pregnancies are terminated legally by abortion.2 The percentage of women seeking to terminate an unintended pregnancy in countries where abortion is illegal is similar to that in the U.S.; what varies is the rate of complications from illegal and unsanctioned abortions.3 In 2008, the incidence of unsafe abortion was 1/1,000 women aged 15-44 years in developed countries versus 16/1,000 women of the same age in developing countries.Women die as a result of illegal abortions; the number of abortion-related deaths due to unsafe abortion in 2008 was 90 in developed regions versus 47,000 in developing regions.4 Although abortion is a legal option in the U.S., access varies from state to state and region to region. Eighty-nine percent of all counties in this country have no abortion provider, and the number of abortion clinics declined from 851 to 839 from 2008 to 2011.2

Early aspiration abortion is an in-clinic procedure that involves dilating the cervix, inserting a sterile cannula into the uterus, and applying gentle suction to remove pregnancy tissue. Medication abortion can be done through various regimens; in the U.S., it involves sequential administration of two drugs, mifepristone and misoprostol, to halt embryonic development and induce uterine contractions so the patient may pass the pregnancy at home. Numerous recent studies have shown that advanced practice nurses (APNs) can provide both aspiration and medication abortion procedures with the same safety and quality outcomes as their physician colleagues.5 Despite the evidence, only a dozen states permit APNs to provide medication abortion and fewer than half of these states allow APNs to perform aspiration abortion.5,6

Although evidence shows that APNs can safely provide aspiration and medication abortions, obtaining training to perform these procedures presents a challenge. Foster et alinvestigated the status of abortion education in accredited nurse practitioner (NP), certified nurse midwife (CNM), and physician assistant programs, and found educational opportunities to be deficient. These authors concluded that didactic and clinical training in abortion care should be included in routine curricula. Unfortunately, not much has changed since the publication of their report 10 years ago.

In this commentary, we present narratives from three NPs and one CNM who sought abortion training as APN students. All four of them completed the same program in Mexico City and learned the essential skills to perform an aspiration abortion: bimanual examination for gestational age assessment, basic ultrasonographic evaluation, paracervical block administration, cervical dilation, uterine aspiration, and identification of the products of conception. Their experience differs from those of medical residents who have in-country access to training in abortion procedures through their academic institutions.8 APN students lack access to such training in this country. The objective of this commentary is to describe why four APN students sought training to become abortion providers, how they achieved their goal, and how they are using their abortion training experience to best serve patients in their current clinical practice.

Narrative One

My post-college plan was to become a midwife. I moved to Texas to train as an apprentice and interned in Mexico with traditional midwives. I learned about pregnancy care and experienced the joy of birth. What left a lasting impression, though, was when a woman presented with an unintended pregnancy and was sent away to a whispered location. I decided to become a nurse practitioner and enrolled in a program that I hoped would prepare me to offer full-scope reproductive care within the context of primary care. As an NP student, I sought abortion training in the U.S., but the opportunity fell through.

I reached out to a midwife I met in Mexico to discuss my dilemma. She told me about an organization that trained physicians and midwives in manual vacuum aspiration (MVA). After some persistence, I was invited to participate in their 6-week Integrated Medical Model of Aspiration Procedures for Unintended Pregnancies training. The program entailed long days and many hours of studying. I learned more hands-on skills in 6 weeks than in a year of clinical rotations at school. I performed 30 MVA procedures, including 16 solo procedures, and several post-procedure intrauterine device (IUD) insertions, all while expanding my Spanish-speaking and gynecologic skills.

Today, I work at a community clinic in the South Bronx—a marginalized area with a long list of health challenges, including unplanned pregnancy. Although I do not perform abortions here, my training experience in Mexico shaped me as a provider. The patient-centered care model and the hands-on skills I acquired there prepared me for performing procedures such as endometrial biopsy and IUD insertion. The experience equipped me with counseling tools that I use to discuss all pregnancy options with patients who present with an unintended pregnancy. I hope that abortion training will be offered to all interested APN students here in the U.S. so that safe abortion will be easily accessible to anyone who needs it.

Narrative Two

When I began my NP program, I knew I wanted to focus on sexual and reproductive healthcare; I liked the idea of caring for patients’ most sensitive needs and helping them understand their bodies in a nonjudgmental space. I had always supported a person’s right to choose, but I hadn’t felt strongly about becoming an abortion provider myself. When I started my graduate studies, I wasn’t even aware that NPs could provide abortions. That all changed when I attended my first National Abortion Federation (NAF) conference.

Prior to the conference, I had learned nothing about abortion in my NP program. At NAF, I learned that NPs could legally provide abortions in some states. I attended a lecture by another APN student who had trained in Mexico City. She spoke about the complexities of working in a country where abortion is legal only up to 12 weeks’ gestation and only in the capital city. She discussed how these restrictions forced women to carry undesired pregnancies to term, undergo unsafe abortions, or travel long distances to receive care. She addressed the fact that when abortion access is restricted or denied—as is increasingly the case in the U.S.—patients suffer. These realizations made the proverbial light bulb go off in my head: I needed to become an abortion provider in order to fully meet the needs of my patients by providing all reproductive care options.

There was nowhere in the U.S. for me to train. In the summer before my final year of APN school, I traveled to Mexico City to become an abortion provider. Over an intensive 6 weeks, I studied, trained, and completed 28 MVA abortion procedures.

In my current clinical work in California, I provide comprehensive reproductive healthcare, including medication abortion. I will soon offer MVA because I live in a state where APNs can legally provide aspiration procedures. My training in Mexico City laid the groundwork for me to become a full-scope abortion provider.

Narrative Three

Abortion care has always been a passion of mine, so I decided to pursue a career in midwifery and women’s healthcare. A classmate once commented that I care about contraception and abortion in “the same way other midwives feel about birth.” Prior to nursing school, I worked as a family planning and abortion counselor. I became aware that the experience of ending a pregnancy can be as transformative as giving birth, and that supporting a woman through this experience is a privilege. To me, abortion care is a natural extension of midwifery care; if the meaning of the word midwife is “with woman,” then midwives should provide the same holistic care for women undergoing abortion they do for those undergoing pregnancy and childbirth.

Having exhausted all options for training in the U.S., I attended the program in Mexico City as a nurse midwife student. I am so grateful for the unique learning opportunity it afforded me. The doctors in the clinic were excellent teachers. After 5 weeks of training, I felt confident in my MVA skills and in my ability to manage abortion complications. I improved in my physical assessment techniques and I felt more selfassured with IUD insertions. I finished the program better able to counsel patients in either English or Spanish regarding all pregnancy options.

I now work as a CNM in Massachusetts. NPs and CNMs are restricted from providing aspiration abortion in this state, but I am involved with advocacy groups to advance efforts to include all aspects of abortion care as part of our scope of practice. My patients know they can come to me for patient-centered midwifery, including abortion care.

Narrative Four

When I began nursing school, I had a strong desire to make meaningful change in the world. In pursuit of this goal, I planned to become an NP and provide individualized care. After meeting abortion providers during clinical rotations, I learned how common abortion is and saw first-hand the value of a provider who offers whole-hearted support while discussing all the options that a pregnant patient has. I learned that abortion is simple and safe. It became important to me that abortion care be a part of my future practice as a clinician. The experience of providing abortion care is summed up well in Virginia Henderson’s definition of nursing: “It is a service, which, at its best, is emotionally and intellectually rewarding to those who give it, and highly-prized by those who receive it.”9

After unsuccessful attempts to find training in the U.S., I heard about the program in Mexico City. I was mentored and strategically trained in aspiration abortion by doctors to whom I am forever grateful. As a clinician, I support my patients to become their most complete and healthy selves. If becoming a parent, carrying a pregnancy to term, or choosing adoption does not make sense for a given patient, I am honored to support her in her decision to have an abortion. Working in outpatient healthcare settings does not often allow a provider to see patients “cured” in one visit. Seeing a woman enter the clinic with an unwanted pregnancy and leave feeling cared for and respected is extremely satisfying for both patient and clinician.

Today, I work in California, a state that recognizes my ability to provide effective and safe aspiration and medication abortions. At my place of employment, I am receiving continued aspiration abortion training by a physician and performing the procedure independently.

Conclusion

In her treatise on the concept of nursing, Virginia Henderson stated, “The most successful preparation of nurses will always include whatever gives them the broadest possible understanding of humanity and the world in which they live.”Henderson proposed that all nursing students have an opportunity to participate in learning in a variety of healthcare settings in order to gain broad knowledge of the world, humanity, and the multifaceted needs of the patients they serve.

These narratives demonstrate how abortion training helped prepare four APNs for clinical practice. They also reveal the lack of access to abortion training for APN students in this country. With motivation and resourcefulness, these students were able to receive the education they desired. These narratives validate the favorable impact that abortion training has on the development of both clinical skills and confidence as an APN.

Advanced practice nursing students should not need to leave the U.S. to acquire clinical skills that they are legally permitted to apply in several states. Expansion of training opportunities in full-scope reproductive care, including abortion care, via both didactic and clinical experience, should be included in nursing curricula in this country. This training will be essential in preparing the next generation of APNs to meet the needs of all our patients by providing fullscope, patient-centered reproductive care.

Annelle Taylor is a women’s health and adult primary care NP at a family-centered community health clinic in the South Bronx, New York. Alison Hathaway is a women’s health and adult NP at Planned Parenthood Mar Monte in San Jose, California. Michelle Luneau is a women’s health and adult NP in clinical practice at Planned Parenthood of the Pacific Southwest in San Diego, California. Fedelma McKenna is a CNM working in full-spectrum women’s health in a community hospital and birth center in Cambridge, Massachusetts. Joyce D. Cappiello is Assistant Professor of Nursing at the University of New Hampshire in Durham. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann. 2014;54(3):301-314.

2. Guttmacher Institute. Induced Abortion in the United States. May 2016.

3. Guttmacher Institute. Induced Abortion Worldwide. Global Incidence and Trends. May 2016.

4. World Health Organization. Unsafe Abortion Incidence and Mortality. Global and Regional Levels in 2008 and Trends During 1990-2008.

5. Guttmacher Institute. State Laws and Policies: Medication Abortion. August 2016.

6. Weitz TA, Taylor D, Desai S, et al. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health. 2013;103(3):454-461.

7. Foster AM, Polis C, Allee MK, et al. Abortion education in nurse practitioner, physician assistant and certified nurse-midwifery programs: a national survey. Contraception. 2006;73(4):408-414.

8. Singer J, Fiascone S, Huber WJ 3rd, et al. Four residents’ narratives on abortion training: a residency climate of reflection, support, and mutual respect. Obstet Gynecol. 2015;126(1):56-60.

9. Henderson V. The concept of nursing. J Adv Nurs. 2006;53(1):21-31.

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.

Seeing our invisible patients: The importance of providing inclusive sexual and reproductive healthcare to LGBTQ populations

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Statement of the problem

Women who identify as lesbian or bisexual (also known as sexual minority women, or SMW), as well as those who were assigned female gender at birth but identify as transgender, gender-queer, or gender non-conforming (TQ), represent subsets of the LGBTQ population. These groups have historically experienced discrimination and stigma in healthcare. As a result, they may be less likely than heterosexual women or cis-gender women (those whose gender identity matches the female sex they were assigned at birth) to seek sexual and reproductive healthcare. Even if they seek this type of care, they may not be properly assessed, managed, or educated if their healthcare providers (HCPs) lack the knowledge and communication skills they need to provide inclusive sexual and reproductive care to SMW and TQ patients. In a video from the National LGBT Education Center, LGBT individuals share some of the experiences, both bad and good, that they have had with HCPs.

Dearth of research

Perpetuating this healthcare disparity is a dearth of research on LGBTQ-specific healthcare needs (with the exception of HIV/AIDS and mental health problems in gay men). Only in the past 5 years have the many health disparities experienced by LGBTQ individuals and the need for LGBTQ-specific research become a topic of conversation on a national level. From 1989 until 2011, 0.5% of studies funded by the National Institutes of Health (NIH), the largest funder of medical research in the world, pertained to LGBTQ health, and of that 0.5%, only 13.5% was allocated to SMW and 0.2% to transgender men.1 In 2011, the CDC identified health disparities related to sexual orientation as one of the main gaps in current health disparities research.2 In the same year, the Institute of Medicine reported the inadequacy of LGBTQ health research, identified challenges in conducting research on these populations, and established recommendations for the NIH, including implementation of a research agenda designed to advance knowledge and understanding of LGBTQ health.3

Dearth of educational programs

The curricula in most clinical education programs do not include adequate LGBTQ-related content. One study that specifically assessed inclusion of LGBTQ-related content in medical school curricula in the United States and Cana da found, on average, 5 hours of instruction in this area.Although corresponding studies assessing nursing school curricula have not been reported, they would likely reveal similarly discouraging findings. Educating future HCPs, through both classroom instruction and clinical experiences, to care for LGBTQ patients will help increase the number of HCPs who are competent and comfortable in this area.

Ways to provide competent and inclusive healthcare for LGBTQ populations

As a basic foundation in this regard, HCPs must understand the differences among the terms sex assigned at birth, sexual orientation, and gender identity. Sex assigned at birth, also referred to as biological sex, is based objectively on genital appearance, hormones, and chromosomes. Sexual orientation refers to the object of a person’s physical and/or emotional attraction. Gender identity represents how one perceives oneself—as female, as male, or somewhere in between.

Both U.S. society and the healthcare community within it are hetero-normative and cis-normativeinadvertently creating an environment that is a source of implicit discrimination toward LGBTQ populations.In a heteronormative society, heterosexuality is the expected and “normal” sexual orientation. Similarly, in a cis-normative society, being cis-gender—having a gender identity that matches one’s sex assignment at birth—is expected and “normal.” By these definitions, anyone who lives/behaves as anything other than heterosexual or who identifies as anything other than cisgender is considered “abnormal.”

Recognize and aim to overcome health disparities

Although the literature has been sparse, newly emerging studies provide information about the sexual and reproductive health behaviors of young SMW populations. In general, researchers have found that SMW (and/or sexual minority teens), compared with their heterosexual counterparts:

• display a greater number and range of sexually risky behaviors (e.g., younger age at sexual debut, greater number of sex partners, greater use of alcohol or drugs during sexual encounters, greater likelihood of having unprotected sex)6-11;

• with the exception of lesbians11 have higher rates of sexually transmitted infections (STIs)7,8,10;

• have similar rates of unwanted pregnancy and higher rates of abortion6,8,10;

• have lower rates of contraceptive and gynecologic care seeking, including a lesser likelihood of getting Pap tests and the HPV vaccine series12-15;

• have a greater likelihood of being subjected to intimate partner violence (IPV)6-8; and

• may have an elevated risk for breast cancer because of their increased rate of nulliparity, older age at first live birth, and greater rates of obesity and alcohol consumption.16

Fewer studies have addressed the sexual and reproductive health disparities that affect TQ populations, which also include gender non-binary individuals, who reject the assumption that gender is strictly an either/or option of male/female that matches the sex they were assigned at birth.17 Instead, these individuals view gender identity as a spectrum of possibilities. No epidemiologic studies on transgenderism in the U.S. have been published, and demographic studies based on national surveys have been limited because of a lack of questions about gender identity.18

About 0.3% of adults in the U.S. (~1 million persons) are thought to identify as transgender.18 Most of the available literature concerns transgender females (i.e., persons who are assigned the male sex at birth but who identify as female). In studies conducted in countries outside the U.S., the prevalence of transgender males (i.e., persons who are assigned the female sex at birth but who identify as male) has been reported as 1:30,400 to 1:200,000.19

Many transgender individuals have experienced discrimination in healthcare, particularly after disclosing their gender identity to their HCP. Experiences of hostility and/or insensitivity from their own HCP can cause mistrust of HCPs in general.20 This cycle can lead to a lack of utilization of healthcare services, particularly when care is not critical for survival.

Despite the lack of research, transgender males do express concerns related to their sexual and reproductive healthcare, particularly with respect to discrimination, lack of validation of their gender identity, physical discomfort during examinations, fertility preservation, and pregnancy. Another fact to keep in mind: Although a person born with a uterus and ovaries may not identify as female, this person may wish to have biological children. In a cross-sectional Web-based survey of transgender males who had been pregnant and delivered a baby, two-thirds of the pregnancies were planned, and pregnancy, delivery, and birth outcomes did not differ according to whether or not the patient had used testosterone prior to pregnancy.21

Avoid faulty assumptions

Not all patients are heterosexual and cis-gender. If a reproductive-aged patient states that she is sexually active, an HCP should not necessarily follow up with the question “What type of birth control are you using?” First, the HCP needs to determine the patient’s sexual orientation; she may not need to practice birth control. Instead of giving patients two gender options—“male” and “female”—on intake forms, the HCP can provide a box labeled “other” that can be filled in with the patient’s stated identity.

These concepts also apply to the way that visit types are labeled in the office. Visits related to contraception care are often termed family planning visits, and those that occur yearly are often termed well-woman exams. The terminology for these visit types can be off-putting to persons, including staff members, who may not use contraceptives for birth control and for those who may not identify as women even though they have female genitalia and reproductive organs. HCPs should aim to create an inclusive office atmosphere so that SMW and TQ patients can build trust in their provider and receive healthcare that meets their needs.

Create an inclusive environment

Providers should not assume that a patient coming into the office for contraceptive care or for a yearly checkup is heterosexual and cis-gender. One of the first things any patient does in an office visit is complete intake and health history forms. Forms are more inclusive when the term partner or spouse is used instead of husband or wife and when transgender and other identitywith a write-in area, are added to the cis-gender options of male and female. HCPs need to ask patients who identify as transgender, gender-queer, or gender non-conforming about their preferred names and which gender pronouns they use (e.g., he, she, they). Preferred names may differ from the legal documentation on their driver’s licenses and insurance cards; HCPs must avoid using a name that the patient no longer uses or that may cause distress. Questions about preferred names and gender pronouns are appropriate and polite, and demonstrate from the outset of the professional relationship that the HCP and the staff acknowledge and validate all their patients’ sexual orientations and gender identities.

Non-discrimination policies need to be posted in check-in areas and/or waiting rooms where they are easily visible. Information about and examples of patient non-discrimination policies are available through the Human Rights Campaign Healthcare Equality Index website. Staff members need to know these policies and adhere to them. After all, the first person with whom a patient has contact in a healthcare setting is usually not the HCP but, rather, the office reception staff. The National LGBT Health Education Center, a program of The Fenway Institute, offers online webinars and video training sessions that can be used to help educate clinical and administrative office staff members.

Follow health screening and preventive health recommendations

Recommendations are implemented for SMW and TQ patients within the same parameters as for heterosexual and cis-gender female patients. Screening for STIs and HIV is based on behaviors and risk factors, not on sexual orientation or gender identity. HCPs need to ask patients about the types of sexual behaviors in which they engage so that the types of STI screenings and the sites of sampling can be determined. HCPs also need to advise patients to catch up on their HPV vaccinations if they have not completed them.

Providers need to ask patients whether they have a partner with whom it would be possible to get pregnant, and whether they are having penetrative vaginal sex with this partner. If so, and if the patient does not desire a pregnancy, HCPs need to discuss and offer all available and appropriate contraceptive options. HCPs need to inform SMW and TQ patients that, even if they are not engaging in what is typically considered heterosexual or cis-normative sex, they could still be at risk for cervical dysplasia or cancer and should undergo cervical cancer screening according to current guideline recommendations. Screening for a history of or current IPV needs to be included.

Clinical breast exams need to be performed and screening mammography recommendations followed, even in patients who have had “top surgery” or a bilateral mastectomy because these individuals may have residual breast tissue. Because this topic may be a sensitive one, HCPs must allow adequate time to communicate openly and compassionately about it.

Enhance competence and understanding

Conferences and webinars on providing healthcare to LGBTQ patients, many with continuing education credit, are available from organizations such as the World Professional Association for Transgender Health, UCSF Center of Excellence for Transgender Health, The Fenway Institute, and Health Professionals Advancing LGBT Equality (formerly the Gay and Lesbian Medical Association). These organizations and others have developed vetted lists of articles, publications, and online training sessions that can be used as resources (Table). For HCPs seeking more intensive education in LGBTQ health, graduate certificate programs are available through institutions such as Drexel University in Philadelphia, The George Washington University in Washington, DC, and New York University in New York City.

Conclusion

Healthcare providers who manage the sexual and reproductive health concerns of heterosexual and cisgender women are used to providing sensitive and compassionate care during vulnerable stages throughout the lifespan. They need to expand their knowledge and understanding, and acknowledge their implicit assumptions and biases, if they exist, in order to provide the same quality of care to SMW and TQ patients. These populations are often overlooked or “invisible” in healthcare settings, or they experience discrimination, stigma, and hostility, precluding their full access to and utilization of routine and preventive care.

Nationally representative research is needed to fully reveal the health disparities and risk factors that burden these populations. Curricula must be expanded to prepare future HCPs to adequately address these concerns and provide competent and inclusive sexual and reproductive healthcare. HCPs need to use available evidence, create inclusive office environments, and commit to continuing education that expands knowledge about LGBTQ healthcare needs for themselves and their staff to help make a meaningful difference and have a beneficial effect in caring for these populations.

References

1. Coulter RWS, Kenst KS, Bowen DJ, Scout. Research funded by the National Institutes of Health on the health of lesbian, gay, bisexual, and transgender populations. Am J Public Health. 2014;104(2):e105-e112.

2. CDC. CDC Health Disparities and Inequalities Report – United States, 2011. MMWR Suppl. 2011;60(1):1-2.

3. The National Academies Press. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. March 31, 2011.

4. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977.

5. Morrison S, Dinkel S. Heterosexism and health care: a concept analysis. Nurs Forum. 2012;47(2):123-230.

6. Tornello SL, Riskind RG, Patterson CJ. Sexual orientation and sexual reproductive health among adolescent women in the United States. J Adolesc Health. 2014;54(2):160-168.

7. Oshri A, Handley ED, Sutton TE, et al. Developmental trajectories of substance use among sexual minority girls: associations with sexual victimization and sexual health risk. J Adolesc Health. 2014;55:100-106.

8. McCauley HL, Silverman JG, Decker MR, et al. Sexual and reproductive health indicators and intimate partner violence victimization among female family planning clinic patients who have sex with women and men. J Womens Health (Larchmt). 2015; 24(8):621-628.

9. Matthews AK, Cho YI, Hughes T, et al. The relationships of sexual identity, hazardous drinking, and drinking expectancies with risky sexual behaviors in a community sample of lesbian and bisexual women. J Am Psychiatr Nurses Assoc. 2013;19(5):259-270.

10. Herrick A, Kuhns L, Kinsky S, et al. Demographic, psychosocial, and contextual factors associated with sexual risk behaviors among young sexual minority women. J Am Psychiatr Nurses Assoc. 2013;19(6):345-355.

11. Estrich CG, Gratzer B, Hotton AL. Differences in sexual health, risk behaviors, and substance use among women by sexual identity: Chicago, 2009-2011. Sex Transm Dis. 2014; 41(3):194-199.

12. Lindley LL, Barnett, CL, Brandt HM, et al. STDs among sexually active female college students: does sexual orientation make a difference? Perspect Sex Reprod Health. 2008; 40(4):212-217.

13. Waterman L, Voss J. HPV, cervical cancer risks, and barriers to care for lesbian women. Nurse Pract. 2015; 40(1):46-53.

14. Charlton BM, Corliss HL, Missmer SA, et al. Influence of hormonal contraceptive use and health beliefs on sexual orientation disparities in Papanicolaou test use. Am J Public Health. 2014;104(2):319-325.

15. McRee A-L, Katz ML, Paskett ED, Reiter PL. HPV vaccination among lesbian and bisexual women: findings from a national survey of young adults. Vaccine. 2014;32(37):4736-4742.

16. Clavelle K, King D, Bazzi AR, et al. Breast cancer risk in sexual minority women during routine screening at an urban LGBT health center. Womens Health Issues. 2015;25(4):341-348.

17. Green ER, Maurer, L. Teaching Transgender Toolkit: A Facilitator’s Guide to Increasing Knowledge, Decreasing Prejudice and Building Skills. Ithaca, NY: Planned Parenthood of the Southern Finger Lakes; 2015.

18. Stroumsa D. The state of transgender health care: policy, law, and medical frameworks. Am J Public Health. 2014;104(3):e31-e38.

19. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7.

20. Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender- related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013; 103(10):1820-1829.

21. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127.

Web resources (Table)

E. lgbt.ucsf.edu/lgbt-education-and-training

F. http://transhealth.ucsf.edu/

G. glma.org/index.cfm?fuseaction=Page.viewPage&pageId=534

H. fenwayhealth.org/the-fenway-institute/

I. mazzonicenter.org/training-and-resources

J. straightforequality.org/Healthcare

K. wpath.org/site_page.cfm?pk_association_webpage_menu=2577&pk_association_webpage=6633

L. hrc.org/hei/the-national-lgbt-health-education-center#.VttJLVKzWu4

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.

Hypothyroidism in pregnancy

Thyroid disorders are fairly common in pregnancy, with the most common being hypothyroidism. Undiagnosed or inadequately treated hypothyroidism during pregnancy can have devastating consequences on the developing fetus. By contrast, early recognition and effective management of thyroid disorders in pregnancy can minimize risk for both maternal and neonatal complications.

Approximately 4% of women seeking prenatal care have previously been diagnosed with hypothyroidism.In iodine-sufficient areas such as the United States, the major cause of hypothyroidism in women of childbearing age is chronic autoimmune thyroiditis (Hashimoto’s disease).However, worldwide, iodine deficiency remains the most important cause of thyroid insufficiency.2,3 In addition, prior thyroidectomy; radioiodine therapy; use of medications such as amiodarone, anti-thyroid drugs, or lithium; and pituitary or hypothalamic disease can result in hypo-thyroidism.2

The prevalence of hypothyroidism diagnosed during pregnancy is 0.3%-0.5% for overt hypothyroidism and 2%-3% for subclinical hypothyroidism.Unrecognized or inadequately treated hypothyroidism during pregnancy has been associated with spontaneous abortion, preeclampsia, intrauterine fetal demise, preterm birth, low birth weight, postpartum hemorrhage, and irreversible detrimental effects on fetal neurodevelopment.2,4 The degree of neurocognitive deficit is related to the severity, duration, and gestational age at which hypothyroidism occurs.2,4,5

To reduce pregnancy complications and enhance optimal pregnancy outcomes, nurse practitioners (NPs) need to understand normal thyroid physiology, changes in thyroid physiology and laboratory values during pregnancy, fetal thyroid development and functioning, and strategies for effective pharmacologic management and thyroid monitoring for women with hypothyroidism during pregnancy. The purpose of this article is to increase this understanding.

Synthesis and regulation of thyroid hormones

The follicular cells are the functional cells of the thyroid gland. The follicular cells, in combination with iodine and the amino acid tyrosine, synthesize and secrete thyroid hormone (TH). TH synthesis is also controlled by serum iodide levels. The first step in TH synthesis is the concentration of iodide within the thyroid. Iodide is the inorganic form of iodine and the form in which iodine enters the thyroid. Iodide is oxidized to iodine by the enzyme thyroidal peroxidase (TPO) in the follicular cells.6

Thyroglobulin, a large glycoprotein synthesized by the follicular cells, is the precursor of TH. Thyroglobulin contains the amino acid tyrosine and is joined with one or two iodine molecules within the follicular cells. This joining, facilitated by TPO, results in the formation of iodotyrosine complexes.6 Two of these iodotyrosine complexes form the active THs: tri-iodothyronine (T3), which has three iodine molecules, and thyroxine (T4 ), which has four iodine molecules.

Thyroid hormone is stored in the thyroid as a colloid compound until needed. Of the TH that is synthesized, 90% is T4 , although T3 is physiologically more potent. Only a small amount of T3 is synthesized in the thyroid, with about 80% formed in the liver, kidneys, and muscles from de-iodination of T4 . T3 and T4 are transported in the circulation for the most part bound to thyroxine-binding globulin (TBG) and other plasma proteins such as albumin.6 Proteinbound TH acts as a reservoir, with free TH released as needed. Only free TH can enter target receptor cells, where it then influences a variety of metabolic processes in the body.

Thyroid hormone is regulated through a negative feedback loop involving the hypothalamus-pituitary- thyroid (HPT) axis. Thyrotropin-releasing hormone (TRH), synthesized in the hypothalamus, circulates via the hypothalamic-pituitary portal system to the anterior pituitary, where it stimulates release of thyroid-stimulating hormone (TSH).6 TRH is released in response to cold, stress, and decreased levels of free T4 (FT4 ). TSH, in turn, binds with receptors on the plasma membrane of the thyroid follicular cells and causes an immediate release and increase in synthesis of TH (Figure).6 

Thyroid changes during pregnancy

In response to increased metabolic needs during pregnancy, thyroid activity and hormone production increase. The thyroid typically enlarges moderately due to hyperplasia of glandular tissue and increased vascularity. Human chorionic gonadotropin (hCG) secreted by the placenta, similar in structure to TSH, directly stimulates the maternal thyroid to produce TH. TBG levels increase beginning at about 20 weeks’ gestation as a result of increased estrogen levels. These two changes—that is, hCG stimulation of TH synthesis and increased TBG levels—lead to a decrease in TSH levels in the first trimester, with a return to baseline in the second trimester, and an increase in total TH levels* throughout pregnancy. Table 1 shows the physiologic changes in thyroid function during pregnancy.4,8,9

*Total TH includes both free and protein-bound forms; the increase in total TH is due mainly to the increased protein-bound forms of the hormone. The free circulating form of TH remains relatively unchanged throughout pregnancy.7,8

Nurse practitioners should note that non-pregnancy laboratory reference ranges do not apply to pregnant women. In fact, reference ranges change throughout pregnancy to reflect the physiologic changes occurring in thyroid function. Therefore, NPs should use trimester-specific, assay-specific normal ranges. If these ranges are unavailable, then these ranges for TSH should be used:3,4

• First trimester: 0.1-2.5 mIU/L

• Second trimester: 0.2-3.0 mIU/L

• Third trimester: 0.3-3.0 mIU/L

In addition, the elevated TBG seen in pregnancy interferes with immunoassays for FT4 levels. TSH is the most sensitive indicator of thyroid status in pregnant women.7

Fetal thyroid development and function

Fetal thyroid development and function can be divided into three overlapping phases: embryogenesis (phase I), functional development (phase II), and maturation (phase III) (Table 2).5,9,10 The thyroid is the first fetal endocrine gland to develop. It starts as a thickening at the base of the tongue and migrates down the neck to reach its final position in front of the trachea by 7 weeks’ gestation.9,10 Follicle cells form and begin thyroglobulin production by 8 weeks’ gestation. Although the fetal thyroid is able to start concentrating iodine and synthesizing iodothyronines by about 10 weeks’ gestation, little TH synthesis occurs until about 18 weeks’ gestation.During fetal development, T4 is the major TH being produced; T3 is not detected until the third trimester.9,10

The fetal hypothalamus is visible by 7 weeks’ gestation, with levels of TRH detectable by 9 weeks.10 The fetal pituitary is visible by 4 weeks, with TSH starting to become detectable at 10-12 weeks.10 The fetal HPT axis begins to function mid-gestation (18-20 weeks), with the fetus beginning to implement feedback mechanisms for TH production.9,10 During this time, fetal receptors for TRH and TSH become responsive. Further maturation of the HPT axis continues throughout the remainder of pregnancy.10

Maternal hypothyroidism is particularly harmful to the fetal brain  in the first half of pregnancy, when fetal T4 production is low. TH is critical for neuron development and neural pathway organization.5,9 It is the transplacental transfer of T4 and iodine in the first trimester that promotes fetal brain development until the fetal thyroid becomes functional.5 Even during the second and third trimesters, when the fetal thyroid is producing T4 , much of the Tneeded for development is still of maternal origin.5,9

Overt hypothyroidism

Overt hypothyroidism (OH) in pregnancy, evidenced by elevated TSH and low serum FT4, is linked to adverse fetal/obstetric outcomes. Stillbirth, preterm delivery, postpartum hemorrhage, and infants with neuropsychological and cognitive impairment have been reported in women with inadequately treated OH.2,4,5 OH should be treated with levothyroxine (LT4), with the goal of normalizing trimester-specific TSH values.Women who have been euthyroid on their LT4 dosages pre-pregnancy will need dosage changes throughout pregnancy in order to maintain the euthyroid state.

Subclinical hypothyroidism

Subclinical hypothyroidism (SH) is by far the most frequent thyroid dysfunction occurring during pregnancy.11 SH is associated with elevated TSH and normal FT4. SH represents early, mild thyroid dysfunction. Sixty percent to 80% of these cases demonstrate the presence of antithyroid peroxidase antibodies, a marker of chronic thyroiditis (Hashimoto’s disease).12 Because of limited and conflicting data, controversy exists regarding the effects of SH on fetal/obstetric outcomes, including the need to screen or treat women with SH. Several obstetric complications have been associated with SH, with pregnancy loss being one of the most frequent.11,12 Other reported complications include gestational hypertension, preeclampsia, low birth weight, placental abruption, and postpartum hemorrhage, albeit at lower frequencies than those recorded in pregnant women with untreated OH.11,12

Early studies reported impaired cognitive development in infants born to mothers whose SH was inadequately treated, but not in infants born to women with adequately treated SH.12,13 However, in 2012, a large randomized controlled trial, the Controlled Antenatal Thyroid Screening Study, revealed no difference in the neurocognitive development of infants born to women who were screened and treated for SH versus those whose SH status was not revealed until after delivery.14 As a result, the American Congress of Obstetricians and Gynecologists (ACOG), the Endocrine Society, and the American Thyroid Association (ATA) do not recommend universal screening for thyroid disease in pregnancy.4,7 Instead, screening is recommended only in women who are at increased risk for OH, those with symptoms of thyroid disease, and those with a personal history of thyroid disease.

However, a lack of consensus exists regarding the need to treat SH in pregnant women. ACOG recommends against treatment for pregnant woman with SH because of a lack of research showing benefit.7 However, the Endocrine Society and the ATA recommend LTtherapy for all women with SH.4,7

Levothyroxine therapy

Levothyroxine, a Pregnancy Category A medication, remains the  drug of choice for the treatment of all types of hypothyroidism. In typical cases, the LT4 dosage is increased as the pregnancy advances because of the hypermetabolic state that pregnancy induces.3,4 In fact, dosage requirements may increase by as much as 30%-50% during pregnancy, and these increases may be needed as early as the fifth week of gestation.3 Replacement therapy in dosages of 1-2 mcg/kg/day, or about 100 mcg/day, is recommended.12,137 NPs should check patients’ TSH levels every 4-6 weeks during pregnancy so that dosages can be adjusted as necessary. The goal is to maintain maternal serum TSH in the trimester-specific range.3,4 Because only minimal amounts of LT4 cross the placenta after the first trimester, the fetus is not at risk for thyrotoxicosis from maternal LT4 replacement.4,8

Because of differences, albeit subtle, in bioavailability among LT4 formulations, patients should stay with one formulation when possible. NPs should educate patients to take LT4 on an empty stomach—45 minutes before consumption of food, beverages, or other medications—for optimal absorption.3,15 Prenatal vitamins, calcium, and iron can interfere with the absorption of LT4 and should be avoided within 4 hours of taking LT4.3 Likewise, medications used to treat gastroesophageal reflux, including histamine-2 blockers, proton pump inhibitors, and antacids, can decrease LT4 absorption.15 Finally, NPs need to ascertain whether pregnant women are using any herbal products that contain lemon balm, also known as bee balm, honey plant, or sweet balm.16 Lemon balm, used as a tea or oil to treat anxiety, insomnia, and indigestion, is known to have anti-TSH effects, and can prevent T4 absorption from the small intestine.15,16

After delivery, the LT4 requirement drops immediately; women who were on LT4 prior to pregnancycan revert to their pre-pregnancy dosage.3,5 Women who were started on LT4 to treat OH during their pregnancy can likely reduce their dosage to half that taken just before delivery.3,4,7 If they were receiving LT4 to treat SH, the medication can be stopped and thyroid function tests performed in 6 weeks to determine whether further treatment is required.3,4,7 LT4 is considered safe to use during lactation.3,17

Iodine requirements and pregnancy

Iodine is a critical trace element required for TH synthesis; both maternal and fetal TH production depends on an adequate dietary intake of iodine.7 Iodine deficiency may be a factor contributing to concurrent maternal and fetal hypothyroidism. In the United States, iodized salt is an important source of iodine. (About 70% of salt sold for household use is iodized.) Other common dietary sources of iodine in the U.S. are dairy products, seafood, eggs, meat, and poultry.The prevalence of iodine deficiency is lowest in the Americas (10%) and highest in Europe (59.9%).3,8

In pregnancy, because of an increase in renal excretion of iodine and transfer of iodine to the placenta and fetus, the thyroid triples its uptake of iodine.8 Dietary iodine requirements are therefore increased during pregnancy. Although most U.S. women have adequate iodine intake to meet the increased demand for both maternal and fetal TH production, it is difficult to identify those who are at risk for or who may have mild to moderate iodine deficiency.4

In cases of mild to moderate iodine deficiency, the thyroid decreases synthesis of T4 in favor of T3 , the T3 levels remain normal, and circulating TSH does not rise. Thyroid function tests may indicate euthyroidism even though the amount of T4 available to the fetus may be insufficient.3 Severe iodine deficiency in pregnancy can cause hypothyroidism, poor pregnancy outcome, irreversiblemental retardation, and cretinism. Recent studies show that even mild iodine deficiency has been associated with impaired neurologic outcomes in children.3,8,9

The World Health Organization recommends an intake of 250 mcg/day of iodine during pregnancy and breastfeeding.4,18,19 To achieve this level, the ATA recommends that women in North America who are planning pregnancy or are pregnant or breastfeeding take a daily supplement containing 150 mcg of iodine.1,4 Among the roughly 200 prenatal vitamin brands marketed in the U.S., only half contain iodine, and among the products that do contain iodine, not all contain the recommended dose.4 In addition, studies have shown about 20% of pregnant woman do not take their prenatal vitamin supplement.1,4 NPs need to educate their pregnant patients about why they need to take all the supplements that are prescribed for them.

Conclusion

The normal physiologic changes in the thyroid during pregnancy occur to compensate for increased maternal metabolic demands and to provide adequate TH and iodine for fetal brain development. Hypothyroidism in pregnant women presents unique challenges related to these changes. The physiologic changes affect both interpretation of thyroid studies and dosing of LT4 during pregnancy. The goal of treatment is to restore euthyroidism as soon as possible and to maintain TSH in the trimester-specific reference range. NPs need to consider these key practice points:

• Thyroid disease is the second most common endocrine disorder of pregnancy (following diabetes).

• Iodine requirements increase in pregnancy and lactation. Women should be advised to take a prenatal vitamin that contains 150 mcg of iodine in its formulation.

• Under ideal circumstances, women with hypothyroidism should have their LT4 dose optimized prior to pregnancy and then reviewed each trimester.

• The dosage of LT4 needed to maintain a euthyroid state increases during pregnancy.

• Women with OH should be treated to maintain serum TSH in the trimester-specific goal range.

• Controversy exists regarding whether SH in pregnant women should be treated.

• T4 drops immediately following delivery; the LT4 dosage will need to be readjusted.

Carol A. Botwinski is Director/Chair of the Department of Nursing at the University of Tampa in Tampa, Florida. 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. Haddow JE. The new American Thyroid Association Guidelines for thyroid disease during pregnancy and postpartum: a blueprint for improving prenatal care. Thyroid. 2011;21(10): 1047-1048.

2. Negro R, Mestman JH. Thyroid disease in pregnancy. Best Pract Res Clin Endocrinol Metab. 2011; 25(6):927-943.

3. Klubo-Gwiezdzinska J, Burman K, Van Nostrand D, Wartofsky L. Levothyroxine treatment in pregnancy: indications, efficacy, and therapeutic regimen. J Thyroid Res. 2011;1-12.

4. Stagnaro-Green A, Abalovich M, Alexander E, et al; American Thyroid Association Taskforce on Thyroid Disease during Pregnancy and Postpartum. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011;21(10):1081-1104.

5. Mann N. Congenital hypothyroidism – what’s new? Paediatr Child Health. 2011;21:295-300.

6. Matfin G. Disorders of endocrine control of growth and metabolism. In: Porth C, ed. Essentials of Pathophysiology4th ed. Philadelphia, PA: Wolters Kluwer; 2015:767-792.

7. American College of Obstetricians and Gynecologists. Practice bulletin No. 148: Thyroid disease in pregnancy. Obstet Gynecol. 2015; 125(4):996-1005.

8. Girling J, Sykes L. Thyroid disorders and other endocrinological disorders in pregnancy. Obstet Gynaecol Reprod Med. 2013;23:171-179.

9. Blackburn S. Maternal, Fetal, & Neonatal Physiology: A Clinical Perspective4th ed. St. Louis, MO: Saunders; 2012.

10. Rose S. Thyroid disorders. In: Martin R, Fanaroff A, Walsh M, eds. Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 9th ed. St. Louis, MO: Elsevier; 2011:1556-1584.

11. McLeod D, McIntyre H. Subclinical hypothyroidism and related biochemical entities in pregnancy: implication and management. Obstet Med. 2010;3:139-144.

12. Cooper D, Biondi B. Subclinical thyroid disease. Lancet. 2012; 379(9821):1142-1154.

13. Behrooz HG, Tohidi M, Mehrabi Y, et al. Subclinical hypothyroidism in pregnancy: intellectual development of offspring. Thyroid. 2011;21(10): 1143-1147.

14. Lazarus JH, Bestwick JP, Channon S, et al. Antenatal thyroid screening and cognitive function. N Engl J Med. 2012:366(6):493-501.

15. Eligar P, Eligar V. Levothyroxine: factors affecting its intestinal absorption and metabolism. W London Med J. 2011;3:9-14.

16. University of Maryland Medical Center. Lemon Balm. Updated May 7, 2013.

17. National Institute of Health. Toxnet. Substance Name: Levothyroxine.

18. World Health Organization. Iodine Supplementation in Pregnant and Lactating Women. 2015.

19. World Health Organization. Joint statement by the WHO and UNICEF: Reaching optimal iodine nutrition in pregnant and lactating women and young children. 2007.

Interventions to increase LARC acceptances, with a focus on IUCs

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

Long-acting reversible contraceptives, or LARC, are growing in popularity because they are highly effective, safe, and well tolerated. In addition, LARC methods require virtually no effort on the part of users besides seeing their healthcare provider (HCP) for insertion and removal. The authors describe their experience in “getting to yes”—that is, in encouraging HCPs to offer LARC methods in a patient-friendly environment and patients to consider using them—so that teens and women have access to all methods, autonomy over their method decision, and decreased risk of unintended pregnancy. Key words: long-acting reversible contraceptives, LARC, intrauterine contraceptive, IUC, IUD, LNG-IUS

Of the 6.1 million pregnancies in the United States each year, 45% are unintended—either mistimed (27%) or unwanted (18%).1,2 Ninety-five percent of unintended pregnancies occur in females who do not use contraceptives (54%) or who use them inconsistently (41%).These unintended pregnancies may end in abortion (42%) or birth (58%),both of which have socioeconomic, fiscal, and health-related consequences. Births resulting from unintended or closely spaced pregnancies can have a variety of adverse maternal and child health outcomes.1 Furthermore, females who have children before they are ready are less likely to reach their educational, career, financial, and/or family-related goals.

Unintended pregnancies can be avoided by correct and consistent use of a birth control method. Among all reversible methods, those that require the least amount of effort by the user have been demonstrated to be the most effective at pregnancy prevention.

Background information on LARC

Long-acting reversible contraceptives, or LARC, include the subdermal implant and intrauterine contraceptives (IUCs).Both implants and IUCs are highly effective in preventing pregnancy and are FDA-approved for 3-10 years of use. In addition, these methods are reversible and do not impair fertility once they are removed; users who wish to become pregnant can have them removed at any time. LARC methods are the most effective forms of reversible birth control available: During the first year, fewer than 1% of implant or IUC users will become pregnant.4 Failure rates associated with the use of other contraceptives are considerably higher.

Devices

The implant is a single, matchstick-sized, etonogestrel-containing rod that is placed in the subdermal tissue of the inside aspect of the upper non-dominant arm.5 The implant, which is marketed as Nexplanon®, contains barium, allowing localization with radiography. The implant is FDA-approved for 3 years of use.

Intrauterine contraceptives, either an intrauterine device (IUD) or an intrauterine system (IUS), are T-shaped devices containing copper or levonorgestrel (LNG).Four IUCs are available, the Copper T 380A (ParaGard®) and three LNG-IUS products: Mirena®, Skyla®, and Liletta®. The copper IUD is effective immediately following placement7 and is FDA approved for 10 years of use.Mirena is FDA approved for 5 years of use, and Skyla and Liletta for 3 years of use.6 Data collection for Liletta is ongoing; it is expected that the manufacturer will ultimately seek approval for up to 7 years of use. If an LNG-IUS product is placed during the first 7 days of the menstrual cycle or immediately following birth, a miscarriage, or a first-trimester abortion, then back-up contraception is not needed.6,8 Otherwise, a backup method is recommended for the first 7 days.

Of note, LARC methods do not protect users against sexually transmitted infections (STIs). Condoms are needed for protection against STIs.

Medical eligibility criteria

All teenagers and women should be considered candidates for LARC use until proven otherwise.9-11 Readers can access the CDC’s Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. Information from the CDC is also available as a free iPhone or iPad app at the iTunes store or as an eBook available on an eReader app.

Trends in LARC use

LARC methods are gaining in popularity for many reasons, but mainly because of their high efficacy.12 According to an analysis of National Survey for Family Growth (NSFG) data, the proportion of female U.S. contraceptors using the IUD or implant increased from 2.4% in 2002 to 3.7% in 2007 and to 8.5% in 2009.13 According to a more recent analysis of the NSFG data, the prevalence of LARC use among contraceptors rose from 8.5% in 2009 to 11.6% in 2012, a significant increase.14,15 Much of this trend was driven by IUC use, which increased from 7.7% to 10.3%; implant use remained low (1.3%) and did not change significantly between these two time periods.

The Contraceptive CHOICE Project

Although increased use of LARC methods has been encouraging, uptake is still relatively low—especially considering the high rate of unintended pregnancy in this country, the superior efficacy of these methods, and the many non-contraceptive benefits they offer. The next logical question is, What can be done to increase education about and access to LARC methods for reproductive-aged females who wish to prevent pregnancy?

Purpose and methods

The Contraceptive CHOICE Project was undertaken to remove educational, financial, and access barriers to contraception; to promote the most effective methods of birth control; and to reduce unintended pregnancy in the St. Louis, Missouri, area.16 Objectives of the project were to increase uptake of LARC; to measure/analyze method choice, satisfaction, side effects, and continuation across all reversible contraceptive methods; and to provide enough no-cost contraception to exert a population impact on unintended pregnancies particularly with respect to teen pregnancy and repeat abortion.

Enrollment began in August 2007 and ended in September 2011. Prospective enrollees ranged in age from 14-45 years, wanted to avoid pregnancy for ≥1 year, and were willing to initiate a new form of reversible contraception.17,18 Recruitment was done via word of mouth, referral from private and community healthcare providers (HCPs), and from the two abortion facilities in the St. Louis region. Participants underwent standardized evidencebased contraceptive counseling by trained non-clinicians. The counseling was structured on effectiveness tiers, and included the risk and benefits of each method. Tier 1 contraceptives—the most effective methods, which include LARC (IUCs and the implant)— were described first. Next, the counselor described tier 2 methods or refillables: depot medroxy-progesterone acetate (DMPA), and the pill/patch/ring (PPR). Tier 3 methods, including the diaphragm, the condom, the sponge, spermicide, withdrawal, and fertility awareness-based methods, were described last. Participants received their chosen contraceptive free of charge, and they could switch methods as frequently as they wanted for the duration of their study participation (2-3 years).

Results

Contraceptive choices of the entire cohort and of the teen cohort alone are shown in the FigureAmong 9,256 adult and teen participants, 75% chose a LARC method; among teens alone, 71% chose a LARC method.

Continuation rates

Among LARC users, adults and teens had high continuation rates—87% and 82%, respectively— at 12 months.19,20 Non- LARC users had much lower 12- month continuation rates: 59% for adults and 49% for teens. Among LARC users, continuation rates at 24 months were still high: 78% for adults and 67% for teens.20 Only 42% of adult non-LARC users and 37% of teen non-LARC users continued using the contraceptive method they chose at baseline for 24 months. At 3 years, continuation rates were 67.2% among LARC users and 31.0% among non-LARC users.21

Satisfaction levels

Twelve-month satisfaction levels mirrored continuation rates. A greater proportion of LARC users than non-LARC users reported being very satisfied or somewhat satisfied with their method (81.2% vs. 48.8%).19 This differential in satisfaction between LARC users and non-LARC users held true for adults (82% vs. 50%) and for teens (75% vs. 42%). Satisfaction was similarly high among users of the subdermal implant, copper IUD, or LNG-IUS (range, 72% for teen users of the copper IUD to 84% for adult users of the LNG-IUS) and similarly low among users of DMPA or PPR (range, 31% for teen users of the ring to 52% for adult users of DMPA or the ring).

Unintended pregnancy and abortion rates

Even more important, among 7,486 participants included in this analysis, 334 (4.5%) experienced unintended pregnancies.4 Failure rates among PPR users were 4.8%, 7.8%, and 9.4% in years 1, 2, and 3, respectively; corresponding rates among LARC users were 0.3%, 0.6%, and 0.9%
(P <.001). Failure rates among DMPA users were similar to those of the LARC users. LARC methods were highly effective in preventing pregnancy regardless of a user’s age, whereas teen PPR users were twice as likely as adult PPR users to become pregnant.

One of the primary outcomes of interest was the percentage of abortions that were repeat abortions.18 Using vital statistics data from Missouri’s state health department, the investigators found a significant difference in the proportion of repeat abortions between the St. Louis region and Kansas City in 2009 (respective rates, 46% vs. 49%; P = .02) and 2010 (respective rates, 44% vs. 51%; P <.01). In addition, they detected a significant decline in the proportion of repeat abortions over time in the St. Louis region (= .002). Another analysis revealed that pregnancy, birth, and abortion rates among teens in the CHOICE Project were substantially lower than national rates among sexually experienced teens.22 Respective annual rates of pregnancy, birth, and abortion were 34.0, 19.4, and 9.7 per 1,000 teen CHOICE Project participants, as compared with 158.5, 94.0, and 41.5 per 1,000 sexually experienced U.S. teens in 2008.

Summary of main findings

LARC methods, as compared with shorter-acting methods, were associated with higher continuation rates and user satisfaction levels, regardless of age. In addition, LARC methods were associated with lower rates of unintended pregnancy and, as a consequence, lower rates of birth and abortion. An informative video about the Contraceptive CHOICE Project is available at Pathway to Choice. Box 1 shows how CHOICE got to yes.

Barriers to IUC use, and how to overcome them

In order for the encouraging results of the CHOICE Project to translate to other populations throughout the country, barriers must be overcome. From this point onward, this article focuses on IUCs.

The National Committee for Quality Assurance has issued a White Paper, Women’s Health: Approaches to Improving Unintended Pregnancy Rates in the United States, that describes numerous barriers that impede our nation’s ability to reduce the rate of unintended pregnancy. To read a summary of these barriers, click here. To read the entire White Paper, click here.

Provider barriers

Many HCPs have concerns about prescribing and placing IUCs. Many of these concerns are easily addressed.

Lack of training

If an HCP’s training occurred prior to 2001, she or he may not have received instruction in IUC placement. To acquire such training, HCPs can seek out instructors provided by product manufacturers or academic institutions, or they can attend conferences where such training is provided. HCPs need not be certified by the manufacturer to place IUCs; any HCP who feels comfortable with the instructions and the procedure may place them.

Too few patients to gain competency

An HCP such as a primary care provider or a rural health provider may not see enough patients to maintain a comfortable competency in IUC placement. This barrier may or may not be surmountable; each HCP has her or his own threshold for a feeling of competency. One approach is to form a collaborative relationship with a high-volume provider who can offer ongoing support and training. In addition, if HCPs view each patient encounter with a reproductive-aged female as an opportunity to address her goals with respect to pregnancy and/or pregnancy prevention, then they will likely be providing many more contraceptive services than they think.

Fear of litigation

Some HCPs may fear litigation if complications arise; some of the items in the bulleted list in the next section can help dispel this fear. Concerns based on myths Each of these myths surrounding IUCs is debunked.

Teenagers and nulliparous women are not appropriate candidates for IUCs. Evidence shows that these females are excellent candidates for IUCs, which are highly effective regardless of age or parity.10

Young women won’t like IUCs because placement is too painfulPlacement comfort varies from patient to patient. Many young women tolerate the placement procedure very well.23

Most patients cannot afford IUCsMany women have coverage for IUCs.24 More will be able to get them as the Affordable Care Act (ACA) continues to implement the 2011 Institute of Medicine recommendations.

Women should have IUC counseling at one visit and return for IUC placement at the next visitTwo-thirds of women prefer to have the IUC placed on the same day it is prescribed.25 Adding a second visit places an extra barrier between the patient and her receiving the desired contraceptive, thereby increasing her risk for unintended pregnancy.

Patients won’t keep their IUCsIUCs had the highest continuation rates of any method offered in the CHOICE Project.26

Patients already know what they want. When CHOICE Project participants were advised of all their birth control options and allowed to choose what they wanted, 58% chose an IUC. In the real world, only 10% of U.S. females choose an IUC.14,15 Many females are unfamiliar with LARC methods or harbor misconceptions about them. They cannot know what they want unless they are fully informed about the options.

HCPs don’t have time to tell patients about every methodTrained staff members can inform patients of their options, starting with the most effective methods.27 In addition, HCPs can provide decision aids that patients can use in the waiting room before their visits.

High upfront cost

The high cost to stock IUCs, with a delay in reimbursement, may keep some HCPs from offering them. The ACA has helped in that the cost of a contraceptive and its placement should be fully covered, with no cost share to the patient. However, barriers do remain: Some health insurance plans exclude contraceptive coverage for religious reasons, small companies need not comply, and some state plans do not cover at 100% or have restrictions on use.

Concern about a prospective IUC user being pregnant 

According to the U.S. Selected Practice Recommendations for Contraceptive Use, an HCP can be reasonably certain that a patient is not pregnant if she has no signs or symptoms (S/S) of pregnancy, has a negative urine pregnancy test result, and meets any one of these criteria8:

• ≤7 days after the start of her normal menses;

• abstinence since the start of her last normal menses;

• correct and consistent use of contraception;

• ≤7 days after spontaneous or induced abortion;

• within 4 weeks postpartum; or

• fully or nearly fully breastfeeding, amenorrheic, and <6 months postpartum.

Concern about a prospective IUC user having an STI

At-risk patients can be tested for gonorrhea and chlamydia at IUC placement.10 If a positive result is noted, the device can still remain in place. The HCP can treat the infection, offer expedited partner therapy as per CDC guidelines, inform patients about the warning S/S of pelvic inflammatory disease (PID; e.g., new-onset abdominal or pelvic pain, foul-smelling vaginal discharge, pain during or shortly after sex, fever, abnormal uterine bleeding), and retest in 3 months. However, if an HCP suspects active infection at the time, the device should not be placed. Instead, the patient is tested and treated as needed. No evidence suggests that IUCs increase the risk for developing an STI.

Patient barriers

These barriers include lack of knowledge about IUCs, negative influence of friends or the media, lack of access to HCPs who can provide IUCs, and cost concerns. The CHOICE Project overcame these barriers by having non-clinicians educate participants about all birth control methods. HCPs provided same-day LARC placement as per the U.S. Selected Practice Recommendations for Contraceptive Use guidelines.The birth control methods were provided free of charge. In Open the Dialogue, CHOICE Project participants describe how they felt when education, access, and cost barriers were removed and they could choose any birth control method they wanted.

IUC risks and side effects

One of the main concerns about IUC placement is uterine perforation, which occurs in about 1 in 1,000 placements.3 Red flags indicating acute uterine perforation include the uterus sounding to a depth greater than that appreciated on bimanual examination, sudden loss of resistance, and patient pain disproportionate to that expected. Vaginal bleeding is unlikely.

Another concern is PID, which develops in fewer than 1% of IUC users, usually during the first 20 days post-placement. Appropriate precaution—screening highrisk women at the time of placement and delaying placement in those with active cervicitis—is the best way to minimize this risk. In very rare cases, pregnancy may occur with the IUC in place; if so, there is a higher chance that it will be an ectopic pregnancy. IUC users with a positive pregnancy test result need to be promptly evaluated to rule out ectopic pregnancy and undergo pregnancy options counseling.

With the copper IUD, menstrual pain and bleeding may increase at first.3 Intermenstrual bleeding may occur as well. These side effects are common in the first few months of use and tend to subside within a year. The LNG-IUS may be associated with spotting, irregular bleeding, and menstrual cramping in the first few months of use. Again, these side effects tend to diminish over time. Some users may experience LNG-related effects such as headache, nausea, depression, and breast tenderness.

Creating a LARC-friendly practice

Healthcare providers who wish to create a LARC-friendly practice know that LARC methods are the most effective reversible methods. They know that every patient is a LARC candidate until proven otherwise. They have ensured that all office staffers are knowledgeable about LARC, can follow an effectiveness tier-based counseling approach as per the CDC guidelines, and promote LARC use. After all, support staff members’ perceptions can greatly affect patients’ decisions. Other tenets of a LARC-friendly practice include the following:

• Every effort is made to help patients obtain the method of their choice.

• Same-day LARC placement is the standard.

• All HCPs have received proper LARC training.

• LARC methods are stocked if possible.

More information about setting up a LARC-friendly practice, including an introductory video, is available at the LARC First website. A message from the authors appears in Box 2.

Conclusion

Long-acting reversible contraceptives are the most effective birth control methods on the market. As shown in the CHOICE Project, IUCs and implants are superior to other methods in terms of continuation rates and satisfaction levels. As such, LARC methods should be considered first-line options for all females, including adolescents and nul liparous women. LARC method efficacy does not depend on user compliance. HCPs should provide counseling and reassurance so that patients know what to expect at the time of placement, as well as possible side effects. Same-day IUC placement should be the standard. As providers of healthcare to teenage girls and women, HCPs are privileged to be able to have a dramatic impact on patients’ lives with such a simple intervention.

References

1. Guttmacher Institute. Unintended Pregnancy in the United States. Fact Sheet. March 2016.

2. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843-852.

3. American Congress of Obstetricians and Gynecologists. Long-Acting Reversible Contraception (LARC): IUD and Implant. May 2016.

4. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998-2007.

5. Association of Reproductive Health Professionals. Choosing a Birth Control Method. Implant. Updated June 2014.

6. Association of Reproductive Health Professionals. Choosing a Birth Control Method. Intrauterine Contraception. Updated June 2014.

7. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.

8. Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. July 29, 2016.

9. ACOG Practice Bulletin. Long-Acting Reversible Contraception. #121, July 2011.

10. CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. July 29, 2016.

11. MacGregor KE, Khadr SN. Contraception for adolescents (American Academy of Pediatrics). Arch Dis Child Educ Pract Ed. 2016;101(2):61-64.

12. Branum AM, Jones J, for the Centers for Disease Control and Prevention. Trends in Long-acting Reversible Contraception Use Among U.S. Women Aged 15–44. NCHS Data Brief No. 188, February 2015.

13. Finer LB, Jerman J, Kavanaugh MLO. Changes in use of long-acting contraceptive methods in the United States, 2007-2009. Fertil Steril. 2012;98(4):893-897.

14. Kavanaugh ML, Jerman J, Finer LB. Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009-2012. Obstet Gynecol. 2015;126(5):917-927.

15. Guttmacher Institute. Use of Long-Acting Reversible Contraceptive Methods Continues to Increase in the United States. Press release. October 8, 2015.

16. Contraceptive CHOICE Project.

17. 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.

18. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120(6):1291-1297.

19. Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol. 2012;120(6):1298-1305.

20. O’Neil-Callahan M, Piepert JF, Zhao Q, et al. Twenty-four-month continuation of reversible contraception. Obstet Gynecol. 2013;122(5): 1083-1091.

21. Diedrich JT, Zhao Q, Madden T, et al. Three-year continuation of reversible contraception. Am J Obstet Gynecol2015;213(5):662.e1-8.

22. Birgisson NE, Zhao Q, Secura GM, et al. Preventing unintended pregnancy: the Contraceptive CHOICE Project in review. J Womens Health (Larchmt). 2015;24(5):349-353.

23. McNicholas CP, Madden T, Zhao Q, et al. Cervical lidocaine for IUD insertional pain: a randomized controlled trial. Am J Obstet Gynecol. 2012;207(5):384.e1-6.

24. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press; 2011.

25. Stanek AM, Bednarek PH, Nichols MD, et al. Barriers associated with the failure to return for intrauterine device insertion following firsttrimester abortion. Contraception2009;79(3):216-220.

26. Peipert JF, Madden T, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105-1113.

27. Madden T, Mullersman JL, Omvig KJ, et al. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception. 2013;88(2):243-249.

The role of anti-Müllerian hormone in diagnosing and managing PCOS

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting females of reproductive age and the leading cause of anovulatory infertility.1 Lack of correct diagnosis and management of PCOS can lead to reproductive challenges (e.g., infertility, early miscarriage, gestational diabetes), metabolic disorders (e.g., type 2 diabetes mellitus), or cardiovascular disorders (e.g., hypertension, dyslipidemia).2 Advanced practice nurses (APNs) are tasked with correctly diagnosing and managing PCOS in order to prevent these associated morbidities, which can compromise quality of life.

According to the Rotterdam criteria for diagnosing PCOS, at least two of these three elements must be met: clinical and/or biochemical hyperandrogenism, ovulatory dysfunction, and polycystic ovarian (PCO) morphology.3 PCO morphology has been defined as the presence of more than 12 follicles measuring <10 mm and/or an increased ovarian volume (>10 mL) without a cyst or dominant follicle in either ovary.3 According to Lujan et al,the inclusion of ultrasonographic(USG) evidence of polycystic ovaries as a diagnostic marker has substantially broadened the phenotypic spectrum of PCOS, yet much debate surrounds the validity of these newly identified milder variants of the syndrome.

In light of such concerns, the use of anti-Müllerian hormone (AMH) level as a more reliable marker for PCO morphology than follicle size and number on USG has been investigated in recent studies. Results of these studies indicate a consistent relationship between AMH level and USG estimates of antral follicle count (AFC) and ovarian volume.5-7 Research has shown that serum AMH levels are significantly increased in women with PCOS versus those without PCOS.1,5,6 Although further research is needed, serum AMH measurement may prove to be a useful tool for APNs in diagnosing phenotypes of PCOS that satisfy the Rotterdam criteria.

Development of polycystic ovaries

To appreciate the role of AMH in PCOS, APNs must understand the two-cell, two-gonadotropin model of estrogen synthesis, as well as how disruption of this process may lead to development of polycystic ovaries.8 This model describes the working hormonal balance between the outer theca cell layer and the inner granulosa cell layer in the ovarian follicle; the former cell layer secretes androgens and the latter, estrogens. When luteinizing hormone (LH) stimulates cholesterol in the theca cells, androgen is released. Upon exposure to follicle- stimulating hormone (FSH), androgen is converted into estrogens in the granulosa cells.

When this two-cell, two-gonadotropin process is disrupted, a hormonal imbalance ensues, such that circulating LH concentrations exceed FSH concentrations. Ovarian androgen production increases, resulting in serum androgen excess. The increased androgen stimulates the growth of smaller antral follicles yet inhibits later follicular development and maturation.9 Such arrest in follicle growth can lead to PCO morphology. These smaller antral follicles cannot be released via ovulation or subsequent luteinization.

Function of AMH

Anti-Müllerian hormone has been identified as the hormone secreted by sertoli cells in the male testes during embryonic sexual differentiation.10,11 In females, AMH is a glycoprotein produced by the granulosa cells of antral follicles. The highest level of AMH secretion is evident in antral follicles ≥4 mm in diameter and continues to be expressed until the differentiation stage (8-9 mm), in which FSH selects a dominant follicle for future ovulation.12 Evidence suggests that AMH inhibits follicular growth by inhibiting estrogen secretion in the antral follicles prior to FSH selection. As a result, estrogen and AMH have an inverse relationship; AMH exerts a regulatory function by ensuring that not all primordial follicles are released at once.13

Levels of AMH fluctuate only minimally throughout the menstrual cycle, and not to the same extent as FSH and other pituitary and ovarian hormone levels. AMH levels are noted to be lower in women during pregnancy. These levels decline steadily after age 25 and are undetectable after menopause.14 Information on whether AMH levels are affected by the use of hormonal contraception is conflicting.15,16

Current uses of AMH measurement

Because AMH is secreted by antral follicles prior to the differentiation stage, it is most often used as a clinical biomarker for ovarian reserve in infertility diagnosis and management and in detection of premature ovarian aging.17,18 AMH is an excellent predictor of ovarian responsiveness in ovulation induction and in vitro fertilization, as well as a useful tool to help predict ovarian hyper-stimulation, oocyte yield, and ovarian function pathology in an infertility setting.13,19-21 In addition, AMH may be useful in assessing the need for fertility-preservation strategies and detecting post-chemotherapy or surgical damage to the ovarian reserve.13,22

Use of AMH measurement in diagnosing PCOS

A thorough history, physical examination, and select laboratory tests are important elements in determining the presence of androgen excess and ovulatory dysfunction— two of the three Rotterdam criteria used for PCOS diagnosis.As described earlier, polycystic ovaries, the third criterion, are identified via USG by the presence of more than 12 antral follicles measuring <10 mm and/or an increased ovarian volume (>10 mL) without a cyst or dominant follicle in either ovary. However, USG has potential shortcomings, including sensitivity of the machine, less-than-perfect operator technique, and subjective interpretation of the findings. In addition, transvaginal USG imaging may be inappropriate or less accurate in certain patient populations (e.g., obese persons or those who have never been sexually active).3,4

Determination of a patient’s AMH level, an objective laboratory value, may help minimize the subjectivity of the USG findings. In several studies, a serum AMH level >18 pmol/L, when compared with USG, provided better sensitivity and specificity for PCO morphology in women who met Rotterdam criteria for PCOS.5,23,24 Other studies have been performed to determine the optimal cutoff for the AMH value:

• A meta-analysis of data extracted up until January 2013 showed that an AMH value of 33.6 pmol/L was 82.8% sensitive and 79.4% specific in diagnosing PCOS in symptomatic women.25

• In 2013, a study of 60 infertile women with PCOS showed that an AMH value of 23.8 pmol/L was 98% sensitive and 93% specific in diagnosing PCOS.26

• Another 2013 study, conducted on 59 infertile women, 37 of whom had characteristics of PCOS, showed that an AMH level of 33 pmol/L was 95% sensitive and 95% specific in diagnosing PCOS.1

• In a study conducted in 2011 on 240 patients, an AMH value of 35.7 pmol/L was 92% sensitive and 97% specific in identifying PCO morphology.5

These findings notwithstanding, a standard AMH level for diagnosing PCOS has yet to be established. Furthermore, several limitations preclude AMH from becoming widely utilized for PCOS diagnosis. First, lack of a universally accepted method and assay to measure AMH prevents it from becoming an established diagnostic tool for PCOS.27 Second, because AMH declines with advancing age, the threshold for PCOS diagnosis may need to be modified through the life span.28 Third, research involving the use of AMH level to diagnose PCOS in adolescents is limited.27, 29, 30 Finally, the 2013 Endocrine Society guidelines do not include a recommendation for using AMH measurement as a routine diagnostic tool for PCOS.3

Although AMH level and oligoanovulation are correlated, AMH has not been proven to be an acceptable indicator of ovulatory dysfunction or hyper androgenism.23 Hence, AMH level, if used, should be combined with other laboratory or clinical measures of hyperandrogenism and/or ovulatory dysfunction to maximize its diagnostic sensitivity and specificity. Furthermore, the role of AMH is unclear in diagnosing subtypes of PCOS, especially those that do not present with classic symptoms. Studies have suggested that ovulatory PCOS phenotypes, compared with anovulatory types, are associated with differing levels of serum AMH.31

Use of AMH measurement in gauging response to PCOS treatment

The goal of PCOS treatment is managing symptoms and minimizing co-morbidities. Proper management can reduce the risk for certain gynecologic cancers and infertility. Management should be both individualized and holistic and may include weight reduction through lifestyle modification and use of hormonal contraceptives, metformin, and gonadotropin/estrogen modulators. Current methods of monitoring the effectiveness of these management modalities include patient-reported symptom improvement and menstrual regulation, physical examination for reduction in signs of hyperandrogenism, measurement of insulin and glucose levels, and achievement of successful pregnancy outcome.

Many recent studies have been conducted to assess the relationship between various PCOS management modalities and patients’ AMH levels; the Table (pp 3839) lists a representative sample of such studies.15, 16, 32-37 Additional research is needed to demonstrate the utility of these AMH measurements, especially as compared with current methods (e.g., clinical signs, patient-reported symptoms, other lab test findings) in making decisions about and evaluating the effectiveness of treatment.

Discussion

Based on what is known at this time, use of the AMH level is not recommended as a replacement for any component of the Rotterdam criteria in terms of diagnosing PCOS or as an assessment tool for monitoring the success of existing management modalities. However, AMH may be a useful supplemental tool for APNs because it is an objective and more reliable marker for diagnosing PCO morphology. Indeed, AMH can help providers who are not trained in pelvic or transvaginal USG in diagnosing PCOS. Although more research is needed in this area, AMH may be another component of PCOS diagnosis and management in the future.

Conclusion

Although the Rotterdam criteria are the gold standard for diagnosing PCOS, concern regarding the subjective nature of polycystic morphology on USG has been voiced over the years. An AMH value >35 pmol/L may have the highest sensitivity and specificity in terms of indicating polycystic ovaries. However, data supporting the use of AMH levels to make treatment choices or to monitor the effectiveness of such treatments in females with PCOS are inconclusive. At the very least, findings from studies assessing changes in AMH levels related to specific treatment modalities may offer more insight into the pathophysiology of this complex endocrine disorder.

Tiffany A. Tseng is a women’s health nurse practitioner at HRC Fertility in Pasadena, California. 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. Casadei L, Madrigale A, Puca F, et al. The role of serum anti-Müllerian hormone (AMH) in the hormonal diagnosis of polycystic ovary syndrome. Gynecol Endocrinol. 2013;29(6):545-550.

2. Jayasena CN, Franks S. The management of patients with polycystic ovary syndrome. Nat Rev Endocrinol. 2014;10(10):624-636.

3. Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013;98(12):4565-4592.

4. Lujan ME, Chizen DR, Pierson RA. Diagnostic criteria for polycystic ovary syndrome: pitfalls and controversies. J Obstet Gynaecol Can2008;30(8):671-679.

5. Dewailly D, Gronier H, Poncelet E, et al. Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. Hum Reprod. 2011;26(11):3123-3129.

6. Pigny P, Merlen E, Robert Y, et al. Elevated serum level of anti-mullerian hormone in patients with polycystic ovary syndrome: relationship to the ovarian follicle excess and to the follicular arrest. J Clin Endocrinol Metab. 2003;88(12):5957-5962.

7. Piltonen T, Morin-Papunen L, Koivunen R, et al. Serum anti-Müllerian hormone levels remain high until late reproductive age and decrease during metformin therapy in women with polycystic ovary syndrome. Hum Reprod. 2005;20(7):1820-1826.

8. Hillier SG, Whitelaw PF, Smyth CD. Follicular oestrogen synthesis: the ‘two-cell, two-gonadotrophin’ model revisited. Mol Cell Endocrinol. 1994; 100(1-2):51-54.

9. Vendola KA, Zhou J, Adesanya OO, et al. Androgens stimulate early stages of follicular growth in the primate ovary. J Clin Invest. 1998; 101(12):2622-2629.

10. La Marca A, Stabile G, Artenisio AC, Volpe A. Serum anti-Mullerian hormone throughout the human menstrual cycle. Hum Reprod. 2006; 21(12):3103-3107.

11. Vigier B, Picard JY, Tran D, et al. Production of anti-Müllerian hormone: another homology between Sertoli and granulosa cells. Endocrinology. 1984;114(4):1315-1320.

12. Weenen C, Laven JS, Von Bergh AR, et al. Anti-Müllerian hormone expression pattern in the human ovary: potential implications for initial and cyclic follicle recruitment. Mol Hum Reprod. 2004;10(2):77-83.

13. Dewailly D, Andersen CY, Balen A, et al. The physiology and clinical utility of anti-Müllerian hormone in women. Hum Reprod Update. 2014;20(3):370-385.

14. Leader B, Baker V. Maximizing the clinical utility of antimullerian hormone testing in women’s health. Curr Opin Obstet Gynecol. 2014;26(4):226-236.

15. Somunkiran A, Tavuz T, Yucel O, Ozdemir I. Anti-Müllerian hormone levels during hormonal contraception in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2007;134(2):196-201.

16. Panidis D, Georgopoulos NA, Piouka A, et al. The impact of oral contraceptives and metformin on anti-Müllerian hormone serum levels in women with polycystic ovary syndrome and biochemical hyperandrogenemia. Gynecol Endocrinol. 2011; 27(8):587-592.

17. van Rooij IA, Broekmans FJ, Scheffer GJ, et al. Serum antimullerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: a longitudinal study. Fertil Steril. 2005;83(4):979-987.

18. Lie Fong S, Schipper I, Valkenburg O, et al. The role of anti-Müllerian hormone in the classification of anovulatory infertility. Eur J Obstet Gynecol Reprod Biol. 2015;186:75-79.

19. van Rooij IA, Broekmans FJ, te Velde ER, et al. Serum anti-Müllerian hormone levels: a novel measure of ovarian reserve. Hum Reprod. 2002;17(12):3065-3071.

20. Amer SA, Mahran A, Abdelmaged A, et al. The influence of circulating anti-Müllerian hormone on ovarian responsiveness to ovulation induction with gonadotrophins in women with polycystic ovarian syndrome: a pilot study. Reprod Biol Endocrinol. 2013;11:115.

21. Dąbkowska-Huć A, Lemm M, Sikora J, et al. Anti-Müllerian hormone dynamics during ovulation induction treatment with recombinant follicle-stimulating hormone in women with polycystic ovary syndrome. Endokrynol Pol. 2013; 64(3):203-207.

22. Dunlop CE, Anderson RA. Uses of anti-Müllerian hormone (AMH) measurement before and after cancer treatment in women. Maturitas. 2015;80(3):245-250.

23. Sahmay S, Aydin Y, Oncul M, Senturk LM. Diagnosis of polycystic ovary syndrome: AMH in combination with clinical symptoms. J Assist Reprod Genet. 2014;31(2):213-220.

24. Lauritsen MP, Bentzen JG, Pinborg A, et al. The prevalence of polycystic ovary syndrome in a normal population according to the Rotterdam criteria versus revised criteria including anti-Mullerian hormone. Hum Reprod. 2014;29(4):791-801.

25. Iliodromiti S, Kelsey TW, Anderson RA, Nelson SM. Can anti-Mullerian hormone predict the diagnosis of polycystic ovary syndrome? A systematic review and meta-analysis of extracted data. J Clin Endocrinol Metab. 2013;98(8):3332-3340.

26. Saikumar P, Selvi VK, Prabhu K, et al. Anti mullerian hormone: a potential marker for recruited non growing follicle of ovarian pool in women with polycystic ovarian syndrome. Clin Diagn Res. 2013;7(9):1866-1869.

27. Dewailly D, Lujan ME, Carmina E, et al. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update. 2014;20(3):334-352.

28. Zec I, Tislaric-Medenjak D, Megla ZB, Kucak I. Anti-Müllerian hormone: a unique biochemical marker of gonadal development and fertility in humans. Biochem Med (Zagreb). 2011;21(3):219-230.

29. Cengiz H, Ekin M, Dagdeviren H, et al. Comparison of serum anti-Müllerian hormone levels in normal weight and overweight-obese adolescent patients with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2014;180:46-50.

30. Pinola P, Morin-Papunen LC, Bloigu A, et al. Anti-Müllerian hormone: correlation with testosterone and oligo- or amenorrhoea in female adolescence in a population-based cohort study. Hum Reprod. 2014; 29(10):2317-2325.

31. Alebić MS, Stojanović N, Duhamel A, Dewailly D. The phenotypic diversity in per-follicle anti-Müllerian hormone production in polycystic ovary syndrome. Hum Reprod. 2015;30(8):1927-1933.

32. Neagu M, Cristescu C. Anti-Müllerian hormone—a prognostic marker for metformin therapy efficiency in the treatment of women with infertility and polycystic ovary syndrome. Med Life. 2012;5(4):462-464.

33. Tomova A, Deepinder F, Robeva R, et al. Anti-Müllerian hormone in women with polycystic ovary syndrome before and after therapy with metformin. Horm Metab Res. 2011;43(10):723-727.

34. Kriseman M, Mills C, Kovanci E, et al. Antimullerian hormone levels are inversely associated with body mass index (BMI) in women with polycystic ovary syndrome. J Assist Reprod Genet. 2015;32(9):1313-1316.

35. Piouka A, Farmakiotis D, Katsikis I, et al. Anti-Mullerian hormone levels reflect severity of PCOS but are negatively influenced by obesity: relationship with increased luteinizing hormone levels. Am J Physiol Endocrinol Metab. 2009;296(2):E238-E243.

36. Thomson RL, Buckley JD, Moran LJ, et al. The effect of weight loss on anti-Müllerian hormone levels in overweight and obese women with polycystic ovary syndrome and reproductive impairment. Hum Reprod. 2009;24(8):1976-1981.

37. Mahran A, Abdelmaged A, El-Adawy AR, et al. The predictive value of circulating anti-Müllerian hormone in women with polycystic ovarian syndrome receiving clomiphene citrate: a prospective observational study. J Clin Endocrinol Metab.

Updated contraception resources from the CDC

The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 (MEC)1 and the U.S. Selected Practice Recommendations for Contraceptive Use, 2016 (SPR)2 were both released to the public on July 29, 2016. The MEC provides guidance to healthcare providers (HCPs) regarding safe use of contraceptive methods by individuals with certain personal characteristics (e.g., age, smoking status, postpartum status) or medical conditions (e.g., hypertension, diabetes, headaches). The SPR, a companion document to the MEC, provides guidance for common contraceptive management topics such as how to be reasonably certain that a woman is not pregnant, when to start contraception, which exams and tests are medically indicated prior to starting a contraceptive method, what type of follow-up is needed, and how problems should be managed.

The first edition of the MEC was published in 20103 and the first edition of the SPR, in 2013.4 The 2016 updates were made after a thorough review of the scientific evidence and consultation with national experts. A summary of the MEC changes since 2010 is provided in Appendix A of the 2016 edition and a summary of the SPR changes since 2013 appears on page 2 of the 2016 SPR.1, 2

MEC updates

The 2016 MEC provides more than 1,800 recommendations for more than 60 personal characteristics and medical conditions.1 As in the 2010 edition, the 2016 MEC continues to use four categories of medical eligibility to help HCPs assess the safety of a particular contraceptive method for persons with specific personal characteristics or medical conditions (Box). HCPs are reminded that although the MEC recommendations provide guidance, individual circumstances should always be considered in contraceptive method counseling and decisions. Take-home messages in the 2016 MEC remain the same as those in the 2010 edition:

Most women can safely use most contraceptives.

Women with medical conditions associated with an increased risk for adverse health events as a result of pregnancy need highly effective contraception for reproductive life planning.

Women, men, and couples should be informed of  the full range of methods to decide what will be best for them.

Use of the MEC can help HCPs decrease barriers to choosing safe and effective contraceptive methods.

New recommendations

New to the 2016 MEC are recommendations for women with multiple sclerosis (MS) or cystic fibrosis (CF) and for women taking selective serotonin reuptake inhibitors (SSRIs) or St. John’s wort. Ulipristal acetate (UPA) has been added to the recommendations on emergency contraception (EC).

Multiple sclerosis

HCPs should check the MS subsection of the Neurologic Conditions section of each appendix. In Appendix C, Classifications for Progestin-Only Contraceptives (POCs), depot medroxyprogesterone acetate (DMPA) is listed in category 2 for women with MS, with the comment that these women’s bone health may be compromised due to disease- related immobility and use of corticosteroids. Use of DMPA, which has been associated with small changes in BMD, might be of concern in this patient population. The other POCs, the subdermal implant and progestin-only pills (POPs), are listed in category 1 for women with MS. In Appendix D, Classifications for Combined Hormonal Contraceptives (CHCs), CHCs are listed in category 3 for women with MS who have prolonged immobility and in category 1 for women with MS who do not have prolonged immobility. Of note, although no data suggest an increased risk for venous thromboembolism (VTE) in women with MS using CHCs, these women are at overall higher risk than unaffected women for VTE.

Cystic fibrosis

HCPs should check the CF subsection of the Respiratory Conditions section of each appendix. CF is described as a condition associated with an increased risk for adverse health events as a result of pregnancy. Certain drugs used to treat CF (e.g., lumacaftor) might reduce the effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives. In Appendix C, Classifications for POCs, DMPA is listed in category 2 for women with CF, with the comment that these women have a higher prevalence of osteopenia, osteoporosis, and fragility fractures than the general population. Use of DMPA, which has been associated with small changes in BMD, might be of concern in this patient population. The other POCs in women with CF are listed in category 1.

Selective serotonin reuptake inhibitors 

HCPs should check the Drug Interactions section in each appendix for specific information about this drugclass. In Appendix A, SSRIs are listed in category 1 for all contraceptives. Available data, albeit limited, show no decrease in the effectiveness of hormonal contraceptives in SSRI users. Likewise, available data show no difference in the effectiveness or in the adverse effects of SSRIs in women using hormonal contraceptives versus those not using them. The comments sections of Appendix C and Appendix D note that drugs that are inhibitors of CYP3A4 or CYP2C9 have the potential, at least in theory, to raise levels of contraceptive steroids, which might increase adverse events. The SSRI fluvoxamine is known to be a moderate inhibitor of both CYP3A4 and CYP2C9; however, no clinical or pharmacokinetic studies were identified to explore these potential drug–drug interactions.

St. John’s wort

HCPs should check the Drug Interactions section in each appendix for information about this herbal product. In Appendix A, St. John’s wort is listed in category 1 for intrauterine devices (IUDs) and DMPA, and in category 2 for the implant, POPs, and CHCs. With regard to the implant, POPs, and CHCs, as noted in Appendix C and Appendix D, limited available data raise concern that St. John’s wort might decrease the effectiveness of hormonal contraceptives by increasing the metabolism of estrogen and progestins. Interactions may be dependent on the dose of St. John’s wort. Also, the concentration of active ingredients in St. John’s wort products may vary. Any potential impact of this herbal product on the contraceptive effectiveness of DMPA is less likely than with the other POCs because of the higher dose of progestin.

Ulipristal acetate

HCPs should check Appendix J, Classifications for  Emergency Contraception, for more information about UPA, which has been added to the EC appendix. Like levonorgestrel (LNG) and combined oral contraceptives (COCs) used for EC, UPA is listed in category 2 for women with a history of severe cardiovascular disease, severe liver disease, or obesity, and in those who use a CYP3A4 inducer (e.g., bosentan, carbamazepine, felbamate, griseofulvin, oxcarbazepine, phenytoin, rifampin, St. John’s wort, topiramate, efavirenz, lumacaftor). Of note, for women who are obese or who use strong CYP3A4 inducers, UPA, LNG, and COCs used for EC are listed in category 2 because of possibly reduced effectiveness. There are no personal characteristics or medical conditions that place UPA, LNG, or COCs used for EC in category 3 or 4.

Women who are breastfeeding and have taken UPA are advised to express and discard breast milk for 24 hours after taking the medication. This recommendation has been made because UPA is excreted in breast milk, with highest concentrations in the first 24 hours.

Other MEC revisions

Revisions to recommendations have been made for postpartum and breastfeeding women, as well as for several medical conditions. The revisions to recommendations for postpartum and breastfeeding women include those presented in the 2011 CDC revised recommendations for these populations related to use of the IUD, POCs, and CHCs.5 Appendix B, Classifications for IUDs, includes changes for women with gestational trophoblastic disease, HIV infection, and certain factors related to sexually transmitted infections. Appendix D, Classifications for CHCs, includes changes for women with migraines, superficial venous disease, or known dyslipidemias, and for women on antiretroviral therapy.

SPR updates

As in the 2013 edition, the 2016 SPR provides information organized by contraceptive method.2 Charts and algorithms are included in appendices that summarize guidance across all methods for when to start, examinations and tests that are needed, routine followup, and management of bleeding irregularities. SPR updates are consistent with changes in the 2016 MEC. Take-home messages in the 2016 SPR remain the same as in the 2013 edition:

Most women can start most methods anytime.

Few, if any, exams or tests are needed.

Routine follow-up is generally not required.

Regular contraception should be started after emergency contraception.

Anticipatory counseling for potential contraceptive-related bleeding changes and proper management are important.

Use of the SPR can help HCPs decrease medical barriers to accessing and using contraception.

New recommendation: use of medications to ease IUD insertion

Misoprostol is not recommended for routine use before IUD insertion but might be helpful in some circumstances—for example, in a woman with a recent failed insertion. A paracervical block with lidocaine might reduce pain during IUD insertion.

Updated recommendation: when to start regular contraception after taking UPA

Under ideal circumstances, women should start or resume a hormonal contraceptive method no sooner than 5 days after taking UPA because of a risk that hormonal contraceptives might decrease the effectiveness of UPA. However, if the chosen hormonal method would require an additional visit to an HCP (e.g., DMPA, implant, IUD), the risk of reduced effectiveness needs to be weighed against the risk that a regular contraceptive method might not be started. Women who have taken UPA should abstain from sexual intercourse or use a barrier method for 7 days after starting or resuming regular contraception or until the next menses, whichever comes first. Any nonhormonal contraceptive method can be started immediately after taking UPA.

Useful tools for HCPs

The CDC provides a variety of useful tools and aids to facilitate use of the MEC and SPR in clinical practice. The summary MEC chart has been updated, as has the MEC and SPR Smartphone app. Printable PDF versions of When to Start Contraceptive Methods and Routine Follow-up and What to Do If Late, Missed, or Delayed CHC are available. 

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 Publication Coordinator for NPWH. 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. Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. July 29, 2016.

2. CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. July 29, 2016.

3. CDC. U.S. medical eligibility criteria for contraceptive use, 2010. June 18, 2010.

4. CDC. U.S. selected practice recommendations for contraceptive use, 2013. MMWR. 2013;62(RR-5):1-46.

5. CDC. Update to CDC’s U.S. medical eligibility criteria for the use of contraceptive methods, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. MMWR. 2011;60(26):878-883.

Editor-in-chief’s message

Dear Colleagues,

August is National Breastfeeding Awareness Month. As providers of women’s healthcare, we all know the benefits of breastfeeding for babies and mothers. The American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that infants receive nothing but breast milk for the first 6 months of life and that mothers continue breastfeeding until the end of a baby’s first year.

Breastfeeding rates. In 2011, 76% of new mothers began breastfeeding and 47% continued doing so at 6 months, but only 26% were breastfeeding at 12 months.1 Only 18.8% of infants were breastfed exclusively through the first 6 months. Healthy People has set target goals for 2020 that include increasing the proportions of infants who are breastfed at 6 months to 60.6%, are breastfed at 12 months to 34.1%, and are breastfed exclusively through the first 6 months to 25.5%.1

Breastfeeding and the workplace. One obstacle to continuing breastfeeding is the desire and/or need for mothers to return to work. Although the Family and Medical Leave Act provides for unpaid maternity leave of up to 12 weeks after giving birth, only 20% of working mothers meet the eligibility criteria.2 Even among working mothers eligible for this benefit, many choose not to participate because they cannot afford to take unpaid leave. One-third of working mothers return to work within 3 months of the birth of their child and two-thirds return within 6 months.2 Women employed full time are less likely to initiate breastfeeding or to continue breastfeeding once they return to work. How can we support working women who want to breastfeed their babies?

Evidence shows that a supportive work environment, where women have access to a quality breast pump and a private place to express milk, helps women feel better about continuing to breastfeed after returning to work.

Access to electric breast pumps.Women should be able to obtain breast pumps prior to giving birth and should have an expedited process to acquire a breast pump quickly when they need it. Current federal guidance that allows plans to cover only manual pumps should be changed. When women return to work, they may find using an electric pump more compatible with the need to express milk quickly and efficiently.2

Access to a private place to express milk. Twenty-seven states plus the District of Columbia have legislation specifying the rights and responsibilities of employers in supporting breastfeeding employees.3 The National Conference of State Legislatures provides a summary of breastfeeding state laws.3 Most of these laws require that employers provide reasonable time and private accommodations (other than a bathroom) for employees to express milk at the workplace. In 2009, 25% of employers provided onsite lactation rooms. As of 2014, 28% of employers did so.2 Healthy People has set a 2020 target goal to increase this rate to 38%.1 The Center for Prevention and Health Service of the National Business Group on Health has published Investing in Workplace Breastfeeding Programs and Policies: An Employer’s Toolkit,2 which includes information on workplace breastfeeding options; tools for employers to use to start, maintain, and evaluate outcomes of their workplace breastfeeding support programs; and information for breastfeeding employees.

Insurance coverage. The Affordable Care Act requires insurance plans to cover breastfeeding supplies, support, and counseling without co-payments, deductibles, or co-insurance. Although this coverage represents a huge step forward in providing women with the support and equipment to successfully breastfeed as long as they want, obstacles remain. The National Women’s Law Center’s State of Breastfeeding Coverage describes some of the violations of the provision that have impeded women’s access to these mandated services.4 Insurance plans that do not have trained providers for lactation counseling support within their own network must provide timely access to out-of-network providers at no cost-sharing. This access must extend throughout the duration of breastfeeding.

NP role. As advocates for healthy women and babies, we should help women navigate the sometimes burdensome insurance coverage process. We should report violations by insurers. We can also promote workplace programs that support employees who desire to breastfeed after returning to work.

Beth Kelsey, EdD, APRN, WHNP-BC

References

1. Healthy People 2020. Maternal, Infant, and Child Health. 2014.

2. National Business Group on Health. Center for Prevention and Health Services. 2009. Investing in Workplace Breastfeeding Programs and Policies: An Employer’s Toolkit.

3. National Conference of State Legislatures. Breastfeeding State Laws. 2015.

4. National Women’s Law Center. State of Breastfeeding Coverage: Health Plan Violations of the Affordable Care Act. 2015.

When the warrior is a woman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and

• Pharmacy services by mail-order and online.1 

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

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

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

How is the VA addressing gender differences?

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

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

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

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

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

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

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

What type of maternity care does the VA offer?

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

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

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

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

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

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

• ensures gender parity in performance measures.

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

Diagnosis and management of pelvic organ prolapse: The basics

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

Risk factors

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

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

Clinical picture

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

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

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

Physical examination

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

Grading system

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

• Grade 0: no prolapse;

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

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

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

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

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

Inspection of external genitalia

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

Speculum examination

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

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

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

Bimanual examination

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

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

Examination while patient is standing

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

Differential diagnoses

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

Treatment

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

Pelvic floor muscle strengthening

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

Pessary

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

Surgery

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

Patient counseling

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

Referral

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Boosting HPV vaccination rates: A call to action

Faculty

Nancy R. Berman, MSN, ANP-BC, NCMP, FAANP, is a nurse practitioner at Michigan Healthcare Professionals in Farmington Hills and a Clinical Instructor in the Department of Obstetrics and Gynecology at Wayne State University School of Medicine in Detroit, both in Michigan.

Intended audience

This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners, certified nurse-midwives, and other advanced practice clinicians who care for women.

CE approval period

Now through May 31, 2017

Estimated time to complete this activity

1 hour

CE approval hours

1.0 contact hour of CE credit, including 1.0 contact hour of pharmacology content

Needs assessment

Most cervical cancers are preventable. The incidence of cancer related to HPV infection has declined significantly since the inauguration of screening programs in the U.S. more than 50 years ago. However, too many women are still developing cervical cancer, and 4,400 are dying of it each year. More cases of cervical cancer could be prevented with increased uptake of HPV vaccination, increased addition of HPV testing in screening, and improved access to cervical cancer screening in under-screened and unscreened populations.

Goal statement

Nurse practitioners and other advanced practice clinicians who care for women will make a strong recommendation that children aged 11 or 12 get fully immunized against HPV so as to prevent HPV-related diseases in the future.

Educational objectives

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

1. Understand the efficacy, safety, and immunogenicity of the HPV vaccine, including the new 9-valent vaccine.

2. Be familiar with all of the ACIP guidelines for the HPV vaccine.

3. Boost HPV vaccine uptake in their patient population.

Accreditation statement

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

Faculty disclosures

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

Nancy R. Berman, MSN, ANP-BC, NCMP, FAANP, has disclosed that she has financial relationships with Hologic and Shionogi.

Disclosure of unlabeled use

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

Disclaimer

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

Successful completion of this activity

Successful completion of this activity, J-16-02, requires participants to:

1. “Sign In” at the top right-hand corner of the website if you have an NPWH account. You must be signed in to receive credit for this course. If you do not remember your username or password, please follow the “Forgot Password” link and instructions on the sign-in page. If you do not have an account, please click on “Create an Account.”

2.Read the learning objectives, disclosures, and disclaimers on the next page.

3.Check “Agree to Terms” on the next page and then click the “Continue” button.

4. Study the material in the learning activity during the approval period (now through May 31, 2017).

5.Complete the posttest and evaluation. You must earn a score of 70% or better on the posttest to receive CE credit.

6.Print out the CE certificate if successfully completed.

Commercial support

This activity is supported by educational grants from Merck & Co., Inc.

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

Cervical cancer, caused in nearly all cases by human papillomavirus (HPV), is considered a vaccinepreventable disease. Anogenital warts and other forms of cancer can also be caused by HPV, and can be reduced in frequency with HPV vaccination. Despite the proven efficacy and safety of the three available HPV vaccines—one of which targets up to nine different HPV genotypes—only about one-third of girls in the United States have received the three recommended doses. The author reviews information about the HPV vaccines and the guidelines for their use, and offers strategies for healthcare providers to implement in order to improve HPV vaccine uptake in their age-appropriate patients.

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States.Almost all sexually active adults are or will be infected by HPV at some point in their lives, even if they have had sex with only one other person. Although the vast majority of HPV infections are asymptomatic and resolve spontaneously, a few persist and can lead to cancer.2 Persistent infections with oncogenic HPV types can cause cancers of the cervix, vulva, vagina, anus, and penis, as well as the oropharynx. Infection with non-oncogenic HPV types can cause anogenital warts.

About 79 million persons in the U.S. are already infected with HPV, and 14 million persons acquire HPV infection each year.3 An estimated 17,600 women and 9,300 men receive a diagnosis of an HPVrelated cancer each year. For U.S. women, cervical cancer is the most common HPV-related cancer; approximately 11,000 women are diagnosed with it annually and 4,400 women die of it. For U.S. men, oropharyngeal cancer is the most common HPV-related cancer; about 7,200 U.S. men are diagnosed with it each year.

In an Annual Report to the Nation on the Status of Cancer, Jemal et alreported that many types of HPV-related cancers were on the rise, some disproportionately affecting certain racial and ethnic minorities. For example, from 2000 to 2009, oral cancer rates increased 4.9% for Native American men, 3.9% for white men, 1.7% for white women, and 1% for Asian men. Anal cancer rates doubled from 1975 to 2009. Vulvar cancer rates rose for white women and African-American women and penile cancer rates increased among Asian men.

Most cervical cancers are preventable. The incidence of this disease has declined significantly since the inauguration of screening programs in the U.S more than 50 years ago.5 However, too many women are still developing cervical cancer, and 4,400 are dying of it each year. More cases of cervical cancer could be prevented with increased uptake of HPV vaccination, increased addition of HPV testing in screening, and improved access to cervical cancer screening in under-screened and unscreened populations.

HPV vaccines

For decades, the best that healthcare providers (HCPs) could offer patients in terms of lowering their risk for developing HPV-related cancers were screenings for cervical cancer precursors and for anal pre-cancers and cancers (in highrisk populations) and inspection for vulvar pre-cancers and cancers. But in June 2006, the FDA approved the first vaccine to prevent disease caused by any of four HPV genotypes: 6 and 11, which cause anogenital warts; and 16 and 18, which are the most common causes of cervical cancer.6

Three HPV vaccines are on the market in the U.S. (Table).The bivalent HPV (2vHPV), quadrivalent HPV (4vHPV) and 9-valent HPV (9vHPV) vaccines each target HPV 16 and 18, the types that cause about 70% of cervical cancers and most other HPV-linked cancers in women and men.3,7 The 9vHPV vaccine targets five additional cancer-causing types (HPV 31, 33, 45, 52, 58), which account for about 15% of cervical cancers. The 4vHPV and 9vHPV vaccines also protect against HPV 6 and 11, the types that cause 90% of anogenital warts.

Efficacy

Clinical trials have suggested that HPV vaccines, if used optimally, could likely prevent most cervical cancers.2 Of 10,000 young women vaccinated as part of clinical trials before they could have been exposed to oncogenic forms of HPV, none developed HPV 16- or 18-associated cervical lesions, which are precursors to invasive cancer.8,9 HPV vaccines have been shown to prevent other HPV 16- or 18-associated anogenital pre-cancers and HPV 6- or 11-associated genital warts with similar efficacy.9,10 Women who received the 2vHPV vaccine as part of a clinical trial had a much lower prevalence of oral HPV infection than did participants who had not received the HPV vaccine.11

In a study reported in March 2016, Markowitz et al12 analyzed 4vHPV type prevalence (i.e., types 6, 11, 16, and 18) in cervicovaginal specimens from females aged 14- 34 years in NHANES (National Health and Nutrition Education Survey) in the pre-vaccine era (2003-2006) and during 4 years of the vaccine era (2009-2012). Within 6 years of HPV vaccine introduction, there was a 64% decrease in 4vHPV type prevalence among females aged 14-19 and a 34% decrease in 4vHPV type prevalence among those aged 20-24 years. There was no decrease in 4vHPV type prevalence in older age groups.

Because the HPV vaccine has been available for only 10 years, it will take a while to assess its efficacy in preventing invasive cancers that take years or decades to develop following persistent infection.

Safety

Three population-based safety studies of the HPV vaccine have been conducted in the U.S.13-15 These studies have identified no serious safety concerns, although one study showed an increased risk of syncope on the day of vaccination and skin infections in the 2 weeks following vaccination.15 Gee et al12 evaluated the risk for venous thromboembolism (VTE) in persons aged 9-26 years, and found no increased risk of VTE following vaccination with the 4vHPV vaccine. Chao et al14 found no association between 4vHPV vaccine use and 16 autoimmune conditions.

According to ongoing safety monitoring by the CDC, most reports of adverse reactions to the vaccine are non-serious.16 Among the 7.6% of reports classified as serious, the most common side effects are headache, nausea, vomiting, and fever. Syncope is a common non-serious problem in both female and male adolescents who receive the HPV vaccine. Of note, syncope is not specific to the HPV vaccine. It is recommended that after receiving the injection, patients remain seated for 15 minutes before leaving the clinical setting.

Impact

Drolet et al17 conducted a systematic review and meta-analysis of 20 studies in 9 high-income countries to assess population-level consequences and herd effects after female HPV vaccination programs  and to verify whether the high efficacy reported in randomized controlled trials was materializing in real-world situations. The investigators found that in countries with female vaccination coverage >50%, HPV type 16/18 infections decreased significantly, by 68%, and anogenital warts decreased significantly, by 61%, between pre- and post-vaccination periods in girls aged 13-19 years. In addition, significant reductions were recorded in HPV types 31, 33, and 45 in this age group of girls, suggesting cross-protection. Furthermore, the incidence of anogenital warts declined significantly in boys younger than 20 years and in women aged 20-39 years, suggesting herd effects. In countries with female vaccination coverage <50%, significant reductions in HPV types 16/18 infection and in anogenital warts occurred in girls younger than 20, with no indication of cross-protection or herd effects.

Duration of immunity

According to a 2011 review, the HPV vaccine was found to provide protection against persistent cervical HPV 16/18 infections for up to 8 years—the maximum time of research follow-up at that point.18 More will be known about the total duration of protection as research continues. To date, no evidence suggests waning immunity such as that seen with the menin go coccal conjugate vaccine, which now requires a second dose. Multiple cohort studies are in progress to monitor the duration of immunity.

More about the 9-valent vaccine

To gain the recent endorsement of the CDC’s Advisory Committee on Immunization Practices (ACIP), the 9vHPV vaccine had to demonstrate efficacy, immunogenicity, and safety.19 In particular, the newest vaccine had to show efficacy in terms of preventing infection and disease related to HPV 31, 33, 45, 52, and 58 in a susceptible population and of generating an antibody response to HPV 6, 11, 16, and 18 that was non-inferior to that generated by the 4vHPV vaccine. Studies conducted by Joura et al20 and Luxembourg et al21 showed precisely that.

In 7 pre-licensure studies, the 9vHPV vaccine was evaluated in more than 15,000 females and males.22 In some studies, the 9vHPV vaccine was compared with the 4vHPV vaccine. The 9vHPV vaccine caused slightly more reactions— primarily swelling and redness—at the injection site. As with the 4vHPV vaccine, side effects associated with the 9vHPV vaccine were generally mild. A video summarizing information about the 9vHPV vaccine is available here.

ACIP guidelines

Routine immunizations for 11- and 12-year-olds include HPV vaccination. HCPs should recommend the HPV vaccine on the same day and in the same way as the other vaccines for preteens.

Age, gender, and vaccine type

ACIP recommends that routine HPV vaccination be initiated at age 11 or 12, although the vaccination series can be started as early as age 9.19 Vaccination is also recommended for females aged 13-26 and for males aged 13-21 who have not been vaccinated previously or who have not completed the 3-dose series. HPV vaccination is recommended through age 26 years for men who have sex with men and for immunocompromised persons (including those with HIV infection) who have not been vaccinated previously or have not completed the 3-dose series. Females should receive the 2vHPV, 4vHPV, or 9vHPV vaccine and males should receive the 4vHPV or 9vHPV vaccine. The dosing schedule for each vaccine type is shown in the Table. If the vaccine schedule is interrupted, the vaccination series need not be restarted.

Interchangeability

ACIP recommends that, whenever possible, the HPV vaccination series for females be completed with the same HPV vaccine product.16 If vaccination providers do not know or do not have available the HPV vaccine product previously administered to a given patient, or are in settings transitioning to the 9vHPV vaccine, any available HPV vaccine product may be used to continue or complete the series for females for protection against HPV 16/18, and the 4vHPV or 9vHPV vaccine may be used to continue or complete the series for males.19 There are no data on the efficacy of fewer than 3 doses of 9vHPV.

Concomitant administration with other vaccines

HPV vaccine can be administered at the same visit as other ageappropriate vaccines, such as the tetanus/diphtheria/acellular pertussis (Tdap) and quadrivalent meningococcal conjugate vaccines.16 Giving all indicated vaccines togethe at a single visit increases the likelihood that adolescents will receive each vaccine on schedule. Each vaccine should be administered using a separate syringe at a different anatomic site.

History of sexual abuse or assault

The newest vaccination schedule issued by ACIP recommends that the HPV vaccine be given as early as age 9 or 10 if a child has a history of sexual abuse.23 Studies estimate that 1 in 4 girls and 1 in 20 boys will experience sexual abuse before age 18.

HPV vaccine coverage rates

The HPV vaccine has been available for almost 10 years. Despite its proven efficacy and safety, HPV vaccine coverage rates have been low. In 2012, only 53.8% of 13- to 17- year-old girls had received the first HPV vaccine dose and only 33.4% had completed all 3 recommended doses.24 These rates were substantially lower than HPV vaccine coverage rates in other high-income countries such as Australia and the United Kingdom (71.2% and 60.4%, respectively; Figure).2 More recent reports have indicated some improvement in HPV vaccine coverage rates. For example, in 2014, among girls aged 13-17, 60.0% received at least one dose and 39.7% received the 3 recommended doses.25 The improvement was laudable but insufficient: 6 of every 10 girls in this country are not fully vaccinated against HPV.

Strategies to boost vaccination rates

And, thus, a call to action: Concerted efforts are needed to increase HPV vaccine uptake and achieve its potential to prevent cancers.2 These efforts should promote both initiation of the first dose and completion of all 3 doses for age-eligible adolescents, as well as eligible young adults. What can HCPs do to improve vaccination rates?

1. Keep up to date on what you can do to prevent HPV-related cancers

The CDC launched a new website, HPV: You are the key to cancer prevention, for HCPs so that everything about HPV vaccination is found in one place. The website is easy to navigate; it has only 1 page and 3 tabs: Know the Facts, Commit to the Cause, and Lead the Conversation.26 The recommendations described in items 2, 3, 4, and 6 were also derived from this new CDC website.26

2. Make a strong recommendation

The high coverage rates for the Tdap and meningococcal conjugate vaccines suggest that most preteens and teens are not only going to see their HCP, but they are also getting at least one of the recommended adolescent vaccines.25 However, according to the 2013 National Immunization Survey-Teen, one-third of the parents of girls and more than half of the parents of boys said their child’s HCP had not recommended HPV vaccination—the No. 1 reason for failure to vaccinate their children.27,28 Had the HPV vaccine been administered during visits when another vaccine was given, vaccination coverage for ≥1 dose could have reached 91% by age 13 for adolescent girls born in 2000.25 Evidence shows that an HCP recommendation to get vaccinated is the single most influential factor in determining whether parents gets an immunization for their child!24 HCPs should provide clear and strong recommendations that the HPV vaccine series be given to preteens.

3. Seize the day

Timing is everything.26 Making a strong pitch for preteens to be vaccinated is necessary, but not sufficient. HCPs should take advantage of appropriate opportunities to vaccinate their preteen patients against HPV—for example, during school or camp physical exams—when these patients are still coming in for regular office visits. Once these patients go to college or to work, they are less likely to see their HCP for yearly checkups. To make a timely recommendation, HCPs should do it the same way and the same day that they recommend the Tdap and meningococcal vaccines.

4. Use a reminder system

Reminder systems shown to increase HPV vaccination rates include a reminder letter and direct messaging via automated text, prerecorded voice, and/or postcard.29,30

5. Educate mothers during their routine visits

Another useful strategy is to educate mothers when they are being screened for cervical cancer about the role of HPV infection in cervical cancer. HCPs should explain to mothers that they are undergoing an HPV test to determine whether the virus is present on their cervix, and that their preteen daughters or sons can be vaccinated to be protected from being infected by the HPV types in the vaccine. HCPs can simply say: “HPV is the cause of cervical cancer. We are screening you with the HPV test and the Pap test to detect any existing HPV infection or cervical pre-cancers, which we can then treat to keep them from progressing to cancer. But we can vaccinate your daughters and sons to prevent HPV infection and therefore prevent cervical pre-cancer and cervical cancer.”

6. Address parents’ specific concerns

If a parent’s main concern is side effects, HCPs can say: “Vaccines, like any medication, can have side effects. With the HPV vaccine, the most common side effect is pain and redness at the site of the injection. These symptoms should go away quickly. In addition, the HPV vaccine has not been linked to any serious or long-term side effects.”26 If a parent’s main concern is effect on fertility, HCPs can say, “No scientific data suggest that getting the HPV vaccine has any effect on future fertility. In fact, not getting the HPV vaccine can put a woman’s fertility in jeopardy. Persistent HPV infection can cause cervical cancer, and the treatment of cervical cancer can leave a woman unable to have children. Even treatment for cervical pre-cancer can put a woman at risk for problems with her cervix during pregnancy, causing preterm delivery or other problems.”

7. Hand out written materials

Written materials are helpful in supporting patient education. Patients can refer to them later, after they have spoken to you. Many written materials are available in languages other than English. Spanish-language materials are particularly easy to find. Patient factsheets regarding the HPV vaccine are available on the CDC website.

Conclusion

Considering how effective the HPV vaccine will be in preventing cervical cancer, as well as other HPV-related cancers in both females and males, virtually all preteen girls and boys and all eligible young women and men should be immunized. Vaccination uptake rates, although increasing slowly, are still much too low. These rates will rise dramatically only when HCPs across the country heed the call to action and educate parents about the efficacy and safety of this vaccine and take advantage of opportunities to initiate and complete administration of the 3-dose series.

References

1. Centers for Disease Control and Prevention (CDC). Genital HPV Infection – Fact Sheet. Last updated February 3, 2016.

2. President’s Cancer Panel Annual Report 2012-2013. Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer.

3. CDC. Clinician Factsheets. HPV Vaccination Information for Clinicians. Page last updated December 29, 2015.

4. Jemal A, Simard EP, Dorell C, et al. Annual Report to the Nation on the Status of Cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst. 2013; 105(3):175-201.

5. National Cancer Institute. A Snapshot of Cervical Cancer: Incidence and Mortality. November 5, 2014.

6. FDA. June 8, 2006 Approval Letter — Human Papillomavirus Quadrivalent (Types 6, 11, 16, 18) Vaccine, Recombinant.

7. CDC. Clinician Factsheets. Supplemental Information and Guidance for Vaccination Providers Regarding Use of 9- Valent HPV Vaccine. Page last updated December 29, 2015.

8. Lehtinen M, Paavonen J, Wheeler CM, et al. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4-year end-ofstudy analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012;13(1):89-99.

9. Muñoz N, Kjaer SK, Sigurdsson K, et al. Impact of human papillomavirus (HPV)-6/11/16/18 vaccine on all HPVassociated genital diseases in young women. J Natl Cancer Inst. 2010;102(5):325-339.

10. Palefsky JM, Giuliano AR, Goldstone S, et al. HPV vaccine against anal HPV infection and anal intraepithelial neoplasia. N Engl J Med. 2011; 365(17):1576-1585.

11. Herrero R, Quint W, Hildesheim A, et al. Reduced prevalence of oral human papillomavirus (HPV) 4 years after bivalent HPV vaccination in a randomized clinical trial in Costa Rica. PLoS One. 2013;8(7):e68329.

12. Markowitz LE, Liu G, Hariri S, et al. Prevalence of HPV after introduction of the vaccination program in the United States. Pediatrics. 2016;137(3):1-9.

13. Gee J, Naleway A, Shui I, et al. Monitoring the safety of quadrivalent human papillomavirus vaccine: findings from the Vaccine Safety Datalink. Vaccine. 2011;29(46):8279-8284.

14. Chao C, Klein NP, Velicer CM, et al. Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine. J Intern Med. 2012;271(2):193-203.

15. Klein NP, Hansen J, Chao C, et al. Safety of quadrivalent human papillomavirus vaccine administered routinely to females. Arch Pediatr Adolesc Med. 2012;166(12):1140-1148.

16. Markowitz LE, Dunne EF, Saraiya M, et al; CDC. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP)MMWR. 2014;63(RR-05):1-30.

17. Drolet M, Bénard É, Boily MC, et al. Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and metaanalysis. Lancet Infect Dis. 2015;15(5):565-580.

18. Romanowski B. Long term protection against cervical infection with the human papillomavirus: review of currently available vaccines. Hum Vaccine. 2011;7(2):161-169.

19. Petrosky E, Bocchini JA Jr, Hariri S, et al; CDC. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR. 2015;64(11):300-304.

20. Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372(8):711-723.

21. Luxembourg A, Bautista O, Moell er E, et al. Design of a large outcome trial for a multivalent human papillomavirus L1 virus-like particle vaccine. Contemp Clin Trials. 2015;42:18-25.

22. Markowitz L. CDC Expert Commentary. Common Questions About 9-Valent HPV Vaccine. Medscape Pharmacists. June 22, 2015.

23. Advisory Committee on Immunization Practices (ACIP). Recommended Immunization Schedules for Persons Aged 0 Through 18 Years. United States. 2016.

24. CDC. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013—United States. MMWR. 2013; 62(29):591-595.

25. CDC. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2014. MMWR. 2015;64(29):784- 792.26. CDC.

26. Human Papillomavirus (HPV). For Clinicians. HPV: You Are the Key to Cancer Prevention. Page last updated September 30, 2015.

27. CDC. Human Papillomavirus Vaccination Coverage Among Adolescents, 2007–2013, and Postlicensure Vaccine Safety Monitoring, 2006–2014 — United States. MMWR. 2014;63(29):620-624.

28. Newitt VN. HPV vaccination: Are you doing enough to make sure that your patients are protected? Nurse Pract Perspect. 2015;2(4):32-36.

29. Chao C, Preciado M, Slezak J, Xu L. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. J Adolesc Health. 2015;56(1):85-90.

30. Bar-Shain DS, Stager MM, Runkie AP, et al. Direct messaging to parents/guardians to improve adolescent immunizations. J Adolesc Health. 2015;56(5 suppl):S21-S26.

Early pregnancy loss management for nurse practitioners and midwives

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

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

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

Causes of early pregnancy loss

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

Management of early pregnancy loss

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

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

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

Expectant management

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

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

Medication management

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

Aspiration management

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

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

Resources

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

Get your child vaccinated against HPV!

Why does my child need the HPV vaccine?

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

When should my child be vaccinated?

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

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

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

Who else should get the HPV vaccine?

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

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

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

How well does the HPV vaccine work?

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

How long will the HPV vaccine provide protection?

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

Will the vaccine require a booster?

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

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

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

What are some possible side effects of HPV vaccination?

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

Will the vaccine cause cancer?

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

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

Resources

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

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

Doctoral degrees: Looking at the options

Nurse practitioners (NPs) may choose to return to graduate school for a variety of reasons. This choice may be fueled by a desire to teach, conduct research, improve the quality of healthcare and/or healthcare systems, or expand one’s knowledge base. In recent years, anticipation that, at some point in the future, a doctorate of nursing practice (DNP) would be the required degree for entry into advanced practice nursing has spurred many master’sprepared NPs to consider a doctoral degree. The decision to pursue any doctoral degree should be a thoughtful one based on specific career goals, knowledge about available options, and ability to commit the time, energy, and financial resources required.

A doctorate in nursing or education is a terminal degree, representing the highest level of formal education. Nurses with doctoral degrees are vital to the advancement of nursing science, nursing education, and patient and population health. In addition, doctorally prepared nurses are needed to meet future demands in education, policy development, and interdisciplinary collaboration with others in the healthcare community.1 In its 2011 landmark publication The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine recommended that efforts be made to double the number of nurses with doctorates by 2020 to meet these demands.2 Doctoral options for NPs include a doctorate of philosophy (PhD) in nursing, the aforementioned DNP, and the doctorate of education (EdD). Each option has a different type of educational and outcomes focus.

PhD

The curriculum for the PhD in nursing focuses primarily on nursing theory, research, and the development of nursing knowledge and nursing science. An informal online review of PhD programs in each region of the United States revealed 36-47 as the typical range of credit hours needed to complete doctoral coursework. A dissertation is completed after doctoral coursework, with an additional 12-20 credits awarded for conducting and documenting a research study.

Most academic institutions offer part- and full-time study options. A PhD program takes 3-6 years to finish, with 7 years usually being the maximum time allowed for completion. Clinical hours are not a component of a PhD curriculum, but some mentored teaching experience may be included. The PhD curriculum typically includes courses focused on advanced qualitative and quantitative research methods, theory and knowledge development, and advanced healthcare statistics. Some PhD programs may require students to submit a scholarly portfolio that includes a résumé or curriculum vitae, accomplishments such as published works, continuing education hours earned, professional goals, and evaluation of those goals.

Many individuals with a PhD in nursing choose to teach in undergraduate- and/or graduate-level nursing programs. According to the American Association of Colleges of Nursing (AACN), a PhD program should instillteaching, leadership, and mentorship skills, as well as interdisciplinary communication skills.3 One benefit of having a PhD in nursing is the opportunity to develop and participate in research specifically pertinent to nursing science. Although having a PhD degree is not essential in terms of obtaining funding for research from various sources or partnering with expert peers on scientific projects, it is certainly helpful.4 This research can directly affect nursing practice, health policy, and the formation of subsequent evidence-based theories.5 Nurses with PhD degrees who are employed in academic settings can enjoy professional growth, satisfaction, increased independence, and co-worker support.6, 7

Academic salaries for nurses with PhD degrees may not be competitive with those of faculty in other professionsor with those of nurses in clinical and administrative roles.7 This deficit may be somewhat balanced by an academic calendar and work schedule that allow time for thoughtful development and design of scholarly works. In addition, because of increased demand, PhD-prepared nurses may be able to negotiate their contract conditions and salaries upon hire. A global nursing faculty shortage exists because of an aging faculty, a reduced hiring pool of younger faculty, and increased dependence on adjunct faculty.NPs who choose to advance their education with a PhD will likely have a wide selection of positions to choose from and/or migrate to in the future. Some NPs with a PhD degree may find roles pertaining to a research specialty and becoming a nurse scientist appealing, whereas others may choose to remain in the academic setting. The ultimate goal of earning a PhD in nursing is to conduct research leading to the development or testing of theoretical frameworks and to contribute to nursing knowledge in areas such as health promotion, disease prevention, end-of-life care, and symptom and pain management in both acute and chronic illnesses.7

DNP

The DNP is the nursing doctorate degree that has gained a great deal of attention in recent years. The DNP curriculum prepares graduates to be clinical scholars and leaders in healthcare system change.5,9 Courses found in a typical DNP curriculum focus on epidemiology, health policy, evidence-based practice, societal health trends, quality improvement (QI), and patient safety. DNP program requirements include 1,000 post-baccalaureate clinical hours. Clinical hours completed in a master’s-degree program count toward this total. Students typically complete a comprehensive clinical- or community-based project. DNP programs can be completed on a part- or full-time basis depending on the options offered by each institution and individual student needs. Based on an unofficial online survey of DNP programs in each region of the U.S., the number of post-MSN credit hours ranges from 35 to 45 to obtain a DNP degree.

DNP graduates are prepared to provide the leadership to integrate evidence-based practice in providing care for patients, families, and populations for improved health outcomes.9  This degree prepares advanced practice nurses to continue working with patients in the clinical or community setting at the highest level of nursing practice. NPs with a DNP degree may be actively involved in strengthening healthcare through quality initiatives—that is, specific areas in which better nursing practice can make a difference in improving care. For example, quality initiatives in women’s health may involve maternal mortality, infant mortality, or preterm births. Quality initiatives encourage nurse leaders to get involved, partner with other disciplines, and further their understanding of the  healthcare system.10 DNP degrees may help facilitate parity of NPs with other healthcare professionals who need to earn doctoral degrees, improve the image of nursing, and attract more individuals to nursing, as well as increase the supply of faculty for clinical instruction in selected academic environments.10

Major concerns still need to be addressed regarding DNP education. DNP programs lack consistency with regard to what constitutes clinical hours to meet the 1,000- hour clinical requirement. The same concern exists for the scholarly projects required in most DNP programs.11 Project criteria vary widely, with some resembling research similar to a dissertation, others focusing on evidence-based QI endeavors, and still others consisting of an extensive literature review of a healthcare topic.

To address these concerns, AACN’s board created a task force in early 2014 to develop a white paper. In August 2015, AACN published The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations: Report from the Task Force on the Implementation of the DNP.12 The white paper describes characteristics of the DNP project, practice experiences, and practice hours. It is anticipated that DNP programs will incorporate the task force’s recommendations into their curricula.

DNP-prepared NPs can prosper in primary care settings because of their patient-centered focus, and they can help alleviate the nursing faculty shortage, especially in the role of clinical instructor. DNP graduates can contribute to the academic setting, although some research-intensive institutions do not allow faculty with DNPs to enter tenure-track positions. A challenge for DNP-prepared NPs working in the healthcare setting may be the lack of knowledge that many current or potential employers have about the benefits that these providers can bring to the organization.13, 14 DNP educators and graduates need to educate healthcare organization employers in this regard. Studies that demonstrate improved healthcare and healthcare outcomes are important.

EdD

Nurse practitioners who want to develop skills in teaching, curriculum design, and evaluation might choose to obtain the EdD. This doctoral degree focuses on preparing graduates as education researchers and scholars to add to the body of knowledge and improve educational practices and outcomes. Some EdD programs have a nursing focus, but many of them are more generalized to include individuals from a variety of professions. A typical EdD curriculum ranges from 50 to 60 credit hours and includes courses addressing teaching and learning theories, educational trends, leadership, and research with a dissertation component. NPs who wish to work with students and influence the future of the nursing profession may choose this degree.14 The EdD degree can be completed in 3-4 years, but part- and full-time status requirements vary by school. NPs with an EdD degree can thrive in the academic setting because of their background in educational theory and applied teaching methods. EdD-prepared NPs may also hold educational leadership positions in healthcare systems and health-related business, not-for-profit, and governmental organizations.

Other considerations

Prospective doctoral students should consider several other factors when contemplating a terminal degree. Although time and cost may be primary considerations, NPs should evaluate circumstances surrounding their personal lives and individual goals. For instance, a spouse, children, and job demands can influence the decision to start a doctoral program. However, with self-evaluation and an understanding and encouraging support system, NPs pursuing doctoral education can thrive and adequately balance all aspects of their lives.

Another consideration is an individual’s learning needs and preferences. A doctoral program with classes offered solely at a university campus may benefit certain students, whereas others may be more successful with an exclusively online program. A program with live classes allows for in-person communication with professors and classmates, and can facilitate communication on an interdisciplinary level as well. NPs considering an online format will want to explore how professor and peer interaction is fostered through distance modalities. A major plus of an online program is that it can provide more flexibility with regard to a student’s work and family obligations. Hybrid programs with both live and online components are also widely available, and often provide some balance between the advantages and disadvantages of each.

Prospective doctoral students should examine a variety of schools for program format, curriculum requirements, and faculty expertise. Open houses and conferences offer multiple opportunities to learn more about various programs and ask questions to help determine the best path for each student. Once a student decides on pursuing a doctorate degree to become a researcher, clinician, or educator, finding a mentor already in the selected role can provide valuable guidance throughout the instruction and training process. In addition, NPs should explore part- and full-time option availability and accreditation status before choosing a program. AACN lists the main differences between the PhD and DNP degrees. In addition, AACN has compiled a list of Commission on Collegiate Nursing Education (CCNE)-accredited DNP programs with links to various schools’ websites (organized by state). Furthermore, AACN provides a comprehensive list of PhD and EdD programs with more detailed school and contact information. With regard to DNP programs, they should be both regionally and nationally accredited in order for students to obtain recognition for title and job purposes after graduation. The quality of a doctoral program can enhance the student experience and influence potential employers at the completion of the degree.

Conclusion

Nurse practitioners with doctoral degrees are needed in academic and patient education, research, health policy, and QI efforts. Many factors should be considered when choosing among options for doctoral degrees. NPs with a variety of doctoral degrees can complement each other and work together to further nursing education, implement changes, and favorably affect patient care outcomes.

Cathy R. Kessenich is Professor of Nursing and Department of Nursing Director at the University of Tampa in Tampa, Florida. Sasha T. Persaud works in pediatrics and is an MSN student and former graduate assistant in the nursing department at the University of Tampa. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Fortier ME. So you want to get a doctorate. Am Nurse Today. 2013;8(5):41-44.

2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2010.

3. American Association of Colleges of Nursing. The Research-Focused Doctoral Program in Nursing: Pathways to Excellence. 2010.

4. Nardi DA, Gyurko CC. The global nursing faculty shortage: status and solutions for change. J Nurs Scholar. 2013;45(3):317-326.

5. Melnyk BM. Distinguishing the preparation and roles of doctor of philosophy and doctor of nursing practice graduates: national implications for academic curricula and health care systems. J Nurs Educ. 2013;52(8):442-448.

6. Dreher HM, Glasgow MES, Cornelius FH, Bhattacharya A. A report on a national study of doctoral nursing faculty. Nurs Clin North Am. 2012;47(4):435-453.

7. McDermid F, Peters K, Jackson D, Daly J. Factors contributing to the shortage of nurse faculty: a review of the literature. Nurs Educ Today. 2012;32(5):565-569.

8. Duke University School of Nursing PhD Program.

9. Moore K. How DNP and PhD nurses can collaborate to maximize patient care. Am Nurse Today. 2014;9(1):48-49.

10. Dunbar-Jacob J, Nativio DG, Khalil H. Impact of doctor of nursing practice education in shaping health care systems for the future. J Nurs Educ. 2013;52(8):423-427.

11. Grey M. The doctor of nursing practice: defining the next steps. J Nurs Educ. 2013;52(8):462-465.

12. American Association of Colleges of Nursing. The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations: Report from the Task Force on the Implementation of the DNP. August 2015.

13. Stoeckel P, Kruschke C. Practicing DNPs’ perceptions of the DNP. Clin Schol Rev. 2013;6(2):91-97.

14. Evans JD. Factors influencing recruitment and retention of nurse educators reported by current nurse faculty. J Prof Nurs. 2013;29(1):11-20.

Using simulation to practice and perfect gynecologic procedure skills

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

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

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

Endocervical polypectomy

Case study presentation

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

Indications for procedure

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

Diagnosis

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

Procedure directions

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

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

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

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

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

Post-procedure patient education

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

Description of the simulation 

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

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

Step-by-step simulation assembly and video link

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

Endometrial biopsy

Case study presentation

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

Indications for procedure

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

Diagnosis

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

Procedure directions

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

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

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

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

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

Post-procedure patient education

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

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

Description of the simulation 

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

Routine postpartum care

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

Scope of the problem

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

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

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

Demographic trends

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

First-time mothers are older.

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

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

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

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

Family composition has diversified.

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

Generational characteristics

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

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

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

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

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

Clinical implications

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

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

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

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

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

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

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Effectiveness of portal notification in completion of cervical cancer screening in 50- to 65-year-old female family medicine patients

Purpose

Cervical cancer screening (CCS) guidelines changed in 2012.Women aged 50-65 years who have undergone CCS annually for decades may be unaware of these changes. Even if they are aware of the changes, they may be confused about the new time frames or forget to schedule their CCS as recommended. During routine office visits, nurse practitioners can provide education regarding the new guidelines. In addition, use of a patient web portal to remind women about scheduling their CCS may aid in eliminating the problem— that is, patients’ lack of awareness of and confusion about CCS.2

A large Northeast Florida Family Medicine Department was the setting for a quality improvement (QI) project to implement and evaluate a strategy to improve CCS screening rates in women aged 50-65 years. An existing but underutilized patient web portal was used to send invitations to patients to schedule overdue CCS. The QI project’s main purpose was to determine whether utilizing a computer-based patient portal for notification of overdue CCS would facilitate scheduling the appointment and completing the screening.

Methods

An electronic query of 598 charts of patients aged 50-65 years was completed. Inclusion criteria were being in the designated age group and being at least 6 months overdue for CCS. Patients with histories of hysterectomy, cervical disorders, off-campus gynecologic care, treatment for a current cervical disorder, or no portal enrollment were excluded.

A letter of invitation for CCS was developed. Individual invitations were sent privately through the clinic web portal communication system. Patients were asked to reply through the web portal and schedule an appointment within 2 months of receiving the notice. After 2 weeks, a second letter was sent to non-responders and to account for non-delivery of the first letter. Subsequent responses were collected for 2 more weeks. Project endpoints included response time from the first and second invitations and completion of CCS appointments. Confidence intervals (CIs) were calculated for each endpoint.

Results

Among the 598 patients whose charts were reviewed, 88 (14.7%) met criteria for the project and received an invitation letter via the web portal. Of the 88 patients, 25 responded to the invitation, scheduled an appointment, and completed the CCS within a 2-month time frame (28%; 95% CI, 19%-39%). Of the 25 patients, 22 responded to the first invitation (mean response time, 5.7 days) and 3 to the second invitation (mean response time, 1 day), which met the endpoint criterion of making a response within 14 days. The remaining 63 patients (72%) did not meet the endpoint criteria of opening and/or responding to the invitation within 14 days and/or making and completing a CCS appointment within 2 months of receiving the invitation via the patient portal (95% CI, 61%-81%).

Limitations

This family medicine department lacked a standardized method of follow-up of patients who were overdue for CCS. As a consequence, there was no way to perform a cohort study for comparison of the web portal notification method with another CCS reminder method.

Implications for women’s health

Cervical cancer may be preventable if recommended screenings are completed according to evidence-based guidelines. Technological advances provide various effective

modes of notifying and scheduling patient screenings. A patient web portal may be successful if utilized routinely and efficiently by provider and patient. 

Karen E. Lane is a graduate of the Doctorate of Nursing Practice program at Jacksonville University and a certified family nurse practitioner at Mayo Clinic Family Medicine Clinic, and Hilary Morgan is Assistant Professor of Nursing at Jacksonville University, all in Jacksonville, Florida.

References

1. U.S. Preventive Services Task Force. Final Recommendation Statement. Cervical Cancer: Screening, March 2012.

2. Krist A, Woolf S, Rothemich S, et al. Interactive preventive health record to enhance delivery of recommended care: a randomized trial. Ann Fam Med. 2012; 10(4):312-319.

Our Capstone corner department is now our DNP projects: Spotlight on practice department. We invite DNP students or recent graduates to submit reports on their DNP projects for publication consideration. Please see our Guidelines for Authors for more information.

The cervical cancer screening dilemma: Choosing the optimal screening strategy

Faculty

Kim Choma, DNP, APN, WHNP-BC, is a Part-time Lecturer at Rutgers University School of Nursing in Camden, New Jersey.

Charles F. Dubin, MD, is a Assistant Clinical Professor at the UCLA David Geffen School of Medicine, University of California at Los Angeles in Los Angeles, California.

Intended audience

This continuing education (CE) activity has been designed to meet the educational needs of women’s health nurse practitioners (NPs), adult NPs, family NPs, and certified nurse midwives (CNMs) involved in women’s health.

CE approval period

Now through March 31, 2017

Estimated time to complete this activity

1 hour

CE approval hours

1.0 contact hour of CE credit

Needs assessment

The essence of the cervical cancer screening (CCS) dilemma is which screening test(s) to use and how frequently to screen. Major national health organizations may differ somewhat in terms of their specific recommendations, but their

general objectives are to prevent morbidity and mortality from cervical cancer (Saslow et al, 2012 [this article presents recommendations from the American Cancer Society, the American Society of Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology]; U.S. Preventive Services Task Force, 2012; American College of Obstetrics and Gynecology, 2012) and to prevent overzealous management of precursor lesions that most likely will regress or disappear.

Educational objectives

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

1.Understand the importance of maximizing the benefits of cervical cancer prevention while minimizing the harms associated with overtreatment.

2. Evaluate current available options for CCS: cervical cytology, primary HPV testing, and co-testing.

3.Determine the optimal interval for CCS for each patient.

Accreditation statement

This activity has been evaluated and approved by the Continuing Education Approval Program of the National Association of Nurse Practitioners in Women’s Health (NPWH), and has been approved for 1.0 contact hour of CE credit.

Faculty disclosures

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

Kim Choma, DNP, APN, WHNP-BC, has disclosed that she serves on the Speakers’ Bureau and advisory board of Hologic.

Charles Dubin, MD, reports that he serves on the Speakers’ Bureau of Hologic, Myriad Genetics, and Phenogen Sciences.

Disclosure of unlabeled use

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

Disclaimer

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

Successful completion of this activity

Successful completion of this activity, J-16-01, requires participants to:

1. “Sign In” at the top right-hand corner of the page (npwh.org/courses/home/details/559) if you have an NPWH account. You must be signed in to receive credit for this course. If you do not remember your username or password, please follow the “Forgot Password” link and instructions on the sign-in page. If you do not have an account, please click on “Create an Account.”

2.Read the learning objectives, disclosures, and disclaimers on the next page.

3.Check “Agree to Terms” on the next page and then click the “Continue” button.

4. Study the material in the learning activity during the approval period (now through March 31, 2017).

5.Complete the posttest and evaluation. You must earn a score of 70% or better on the posttest to receive CE credit.

6.Print out the CE certificate if successfully completed.

Commercial support: This activity is supported by educational grants from Hologic.

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

The authors evaluate current available options for cervical cancer screening (CCS), with an emphasis on the importance of maximizing the benefits of cancer prevention while minimizing the harms associated with overtreatment. Two major dilemmas are addressed: Which CCS method is recommended for women aged 30-65? and What is the optimal interval between screenings for women in any age group?

Cervical cancer screening (CCS) has been one of the most successful screening programs in United States history, reducing cervical cancer-related incidence and mortality by 45% and 49%, respectively, since 1980.1 Until fairly recently, yearly cytology testing was recommended to maximize detection of pre-cancerous lesions. The discovery that infection with the human papillomavirus (HPV) underlies the pathophysiology of nearly all cervical cancers led to the incorporation of HPV testing in general screenings of women aged 30 years or older, starting in 2003.2, 3

Unlike few other forms of cancer, cervical cancer is nearly always

preventable.4 Under optimal circumstances, each potential case of cervical cancer can be forestalled by identifying and treating

disease that progresses, at most, to the high-grade cancer precursor stage.5, 6 At the same time, healthcare professionals (HCPs) want to minimize the harms associated with overtreatment of benign

lesions not destined to become cancerous.6

The cervical cancer screening dilemma

The essence of the CCS dilemma is which screening test(s) to use and how frequently to screen. Major national health organizations may differ somewhat in their specific recommendations, but their general objectives are to prevent morbidity and mortality from cervical cancer and to prevent overzealous management of precursor lesions that most likely will regress or disappear.6, 7

Which cervical cancer screening tests are available?

Two tests, cervical cytology and the HPV test, are used to screen for cervical cancer. In essence, though, HCPs have three CCS options: cytology alone, the HPV test alone (known as the primary HPV test), and co-testing with both methods.

Cervical cytology

A sample of cervical cells is examined under a microscope to screen for premalignant cells that could signal the presence of cancer precursors.8 Cervical cells collected by an HCP are smeared on a glass slide (traditional or conventional cytology—that is, the Pap test) or added to a preservative fluid (liquid-based thin-layer test). Liquid-based cytology, because of its greater sensitivity than conventional cytology in detecting disease, enables extension of the screening interval from 1 year to up to 3 years—without significantly diminishing CCS effectiveness.9

HPV testing

The causal role of persistent HPV infection in the development of cervical cancer and its precursors has been well documented.10 A landmark 2010 study showed that, over a 60-year study period, the 8 most common HPV types identified were (in descending order of frequency) 16, 18, 45, 33, 31, 52, 58, and 35.11 Together, these genotypes account for 91% of all cases of cervical cancer. HPV 16, 18, and 45 were found in 75% of the most common type of cervical cancer (squamous cell) and in 94% of the second most common form (adenocarcinoma). A study of more than 20,000 women showed that those infected with HPV types 16 and/or 18, versus those infected with other high-risk types, had a 10 times greater risk of developing cervical cancer.12 Because HPV cannot be cultured, in most cases its accurate identification relies on molecular biology techniques.13 Molecular assays use primers and probes that identify a region of HPV DNA or HPV mRNA. Of note, HPV tests used in clinical practice need to be FDA approved for validity.6

Co-testing

Recent incorporation of HPV DNA testing into CCS strategies offers the benefits of increasing early disease detection (up to 100% sensitivity) 14 and increasing the length of the interval between screenings—thereby lessening harms such as the adverse psychosocial impact of screening positive, the need for additional visits and procedures, and the treatment of lesions that would have resolved on their own.6 Even more recently, HPV infection can be identified by HPV mRNA testing, which, like standard HPV DNA testing, has up to 100% sensitivity15 but also offers improved specificity, with a 24% reduction in false-positive results.16

Which approaches to screening are recommended for women aged 21-29?

According to guidelines issued in 2012 by the American Cancer Society (ACS), the American Society of Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP), CCS should begin at age 21.6 Women aged 21-29 should undergo cervical cytology every 3 years.6 The same year, the U.S. Preventive Services Task Force (USPSTF) and the American Congress of Obstetricians and Gynecologists (ACOG) issued similar recommendations.17, 18 These organizations all advised against HPV co-testing in women younger than 30; although HPV is commonly present in women in this age group, most of them successfully fight off the infection within a few years.19 An updated Practice Bulletin from ACOG published in January 2016 reinforces the recommendations for women aged 21-29 based on level A evidence: Co-testing in these women and annual cytology should not be performed.20 Until more longterm, level A evidence studies are available to support future updates to the 21-29 age group, HCPs are encouraged to follow the consensus guidelines.6 Although primary HPV testing was not recommended at the time of the ACS/ASCCP/ASCP, USPSTF, and ACOG updates in 2012—in fact, its use was specifically discouraged in women in their 20s—the body of evidence supporting this CCS approach has grown. Findings from the Addressing the Need for Advanced HPV Diagnostics (ATHENA) study (2008-2012) supported the safety and effectiveness of primary HPV testing.21, 22 In 2014, the FDA approved the use of the cobas HPV test as a primary screen for cervical cancer in women aged 25 years or older.23 As a result, interim clinical guidance issued by the Society of Gynecologic Oncology (SGO) and the ASCCP in 2015 supported primary HPV testing as a possible alternative to cytology-based screening and co-testing, but starting no sooner than age 25.24

Which approaches to screening are recommended for women aged 30-65?

Again, HCPs have three CCS options: cervical cytology, primary HPV testing, and co-testing. The ACS/ASCCP/ASCP recommends cytology alone every 3 years or cotesting every 5 years.6 The USPSTF endorses cytology every 3 years, with co-testing as an option in women who want to extend their screening interval to 5 years.17 ACOG supports the options of cytology at 3-year intervals and co-testing at 5-year intervals, with the latter preferred.18 None of these organizations advocates the use of primary HPV testing as an alternative to cytology or co-testing.

Co-testing for women aged 30 or older was approved by the FDA in 2006. But how does co-testing compare with primary HPV testing— as advocated in the interim guidance report—and with cervical cytology alone in predicting outcomes in women in the 30- to 65-year age group?

Studies supporting co-testing 

Blatt et al25 conducted a retrospective study to assess the sensitivity of various testing options for biopsy-proven cervical intraepithelial neoplasia grade 3 or worse (CIN3+). The authors evaluated 256,648 cervical biopsies from women aged 30-65 who had undergone a co-test and colposcopy within 1 year of each other (colposcopy was performed a mean of 54 days after the co-testing result). Among the samples, 4,090 (1.6%) exhibited CIN3+. A positive co-test result was 98.8% sensitive for diagnosing CIN3+, compared with the 94% sensitivity of a positive HPV test result and the 91.3% sensitivity of a positive cytology result. Looked at another way, in this group of women, use of cytology alone would have missed 8.7% of the CIN3+ cases and use of the HPV test alone would have failed to catch 6% of the CIN3+ cases, whereas co-testing would have missed only 1.2% of these cases. Therefore, co-testing identified 80% of the CIN3+ cases that would have been missed by screening with the primary HPV test. Of the 526 confirmed cases of cervical cancer in this study, 98 (18.6%) were HPV test negative and 64 (12.2%) were cytology negative, whereas only 29 (5.5%) were cotest negative. Co-testing identified 70% of cervical cancers that would have been missed by screening with the HPV test alone.

Additional studies conducted over the past 11 years showed that primary HPV testing missed a substantial proportion of cervical cancers, and were in concordance with the landmark study by Blatt and colleagues.11, 26-29

Studies supporting primary HPV testing

The aforementioned interim guidance from the SGO/ASCCP was based, in large part, on the results of several large trials demonstrating that a negative HPV test result provides greater reassurance of low CIN3+ risk than does a negative cytology result. For example, Dillner et al30 evaluated primary data from seven HPV screening studies in six European Union countries, each investigating the predictive value of primary HPV testing for future CIN3+. The cumulative incidence rate of CIN3+ after 6 years was considerably lower among women negative for HPV at baseline (0.27%) than among women with negative results on cytology (0.97%). The cumulative incidence rate among women who were cytology-negative/HPV-positive rose continuously over time, reaching 10% at 6 years, whereas the rate among women who were cytologypositive/HPV-negative remained below 3%.

Other recent studies provided evidence that a negative HPV test result, as compared with a negative cytology result, offers greater reassurance that a woman will be free of CIN3+ over time.31-33 In these studies, participants underwent co-testing. In essence, the investigators found that the HPV test results, relative to the cytology results, were more predictive of outcomes over 3-5 years. That is, the cytology portion of the cotest did not add much information to the HPV portion, suggesting, to some at least, that HPV testing could be used by itself.

The first dilemma: Which CCS method is recommended for women aged 30-65?

The findings of the studies supporting primary HPV testing are open to interpretation. For example, Gage et al32 compared the risks of CIN3+ and of cervical cancer alone for HPV testing every 3 years, cytology testing every 3 years, and co-testing every 5 years among more than 1 million women in the Kaiser Permanente population who were aged 30-64 years and who tested HPV-negative and/or cytology-negative in routine screening. Investigators found that 3-year risks following an HPV-negative result were lower than 3-year risks following a cytology-negative result (CIN3+, 0.069% vs. 0.19%; P <.0001; cancer, 0.011% vs. 0.020%; P<.0001) and 5-year risks following an HPV-negative/Pap-negative co-test result (CIN3+, 0.069% vs. 0.11%; P <.0001; cancer, 0.011% vs. 0.014%; P = .21). That is, the 3- year safety (i.e., reassurance against future risk of pre-cancer and cancer) conferred by a negative HPV test result exceeded the 3-year safety conferred by a negative cytology result or the 5-year safety conferred by a negative cotest result. However, a closer look at the data shows that if HPV testing had been compared with cotesting at the 3-year checkpoint instead of the 5-year checkpoint (the recommended interval), negative co-testing results at baseline were slightly more reassuring than negative HPV results at baseline for CIN3+ and for cancer.

In addition, as HPV-infected cervical cells progress toward cervical cancer, HPV DNA levels decline.34 Depending on the age at which CCS begins and the frequency with which it is performed, relying initially, solely, or mainly on the results of HPV DNA screening tests might miss fastgrowing cancers. Although as HPV integrates itself into the human genome and HPV DNA levels decrease, HPV E6/E7 mRNA levels increase, suggesting that the assay that particularly targets this protein, as compared with the HPV DNA assays, is more specific in indicating lesion severity.35 

Furthermore, with cytology alone, adenocarcinoma and its precursors are difficult to identify— simply because of the cervical anatomy and the detection methods used. Cervical adenocarcinoma is usually farther away from the transformation zone, the area targeted most readily with the use of cervical sampling devices. Cytology alone has been relatively ineffective in identifying glandular lesions associated with adenocarcinoma. Addition of HPV testing to cytology—that is, co-testing—should enhance identification of adenocarcinoma and its precursor, adenocarcinoma in situ (ACIS).18

At this point in time, co-testing seems a reasonable option in women aged 30-65 years because it offers optimal sensitivity and specificity in identifying cervical cancer precursors.

What is the optimal screening interval for cervical cancer screening?

The 2012 ACS/ASCCP/ASCP and ACOG guidelines’ recommended screening intervals are 3 years for liquid-based cytology testing and 5 years for co-testing.6, 18 The updated Practice Bulletin from ACOG states that co-testing every 5 years is preferred, but that screening with cytology alone every 3 years is acceptable.20 ACOG recommends against annual testing. The USPSTF recommends cytology every 3 years for women younger than 30.17 For women aged 30-65 who want to extend their screening interval to 5 years, adding HPV testing is advised. The interim guidance provided by the SGO/ASCCP recommends that re-screening after a negative primary HPV test result occur no sooner than every 3 years—but only in women aged 25 years or older.24

For decades in the past, women underwent conventional Pap testing every year—their single best option for identifying cervical cancer precursors in a timely fashion. But there was a distinct downside to this yearly testing, which often yielded results—atypical squamous cells of undetermined significance (ASCUS) or a higher-grade lesion—that would lead to colposcopy and, depending on the results of the cervical biopsies, a loop electrosurgical excision procedure or conization. Most of these cytologic abnormalities, as well as the HPV infections underlying them, resolve on their own. Screening women every year, then, is bound to lead to unnecessary diagnostic and therapeutic procedures. These procedures are, at the very least, unpleasant and worrisome and at worst, harmful.36-41

The second dilemma: What is the optimal interval between screenings for women in any age group? 

Since the CCS guidelines were published in 2012 and the interim guidance was published last year, a different perspective on the CCS interval has been offered. According to a commentary by Kinney et al,42 which was based on a modeling study for the USPSTF that was published in 2013,43 women who comply with the CCS recommendations and increase the co-testing interval from 3 years to 5 years are increasing their risk for unfavorable consequences, with an additional 1/369 diagnosed with cancer in her lifetime and 1/1,639 dying of cancer. Adoption of a 3-year co-testing interval instead of a 5-year co-testing interval between screenings would “cost” 409 additional colposcopies and 14.3 additional women treated for each cancer death prevented. Many women and their HCPs might argue that the extra screenings, tests, treatments, and related harms are worth it to save even a small number of lives. In  addition, as noted in the discussion of the first CCS dilemma, results of the study by Gage et al32 suggest that the optimal interval for co-testing may be 3 years, not 5 years. Finally, there is considerable clinician resistance to the 5-year screening interval recommended for a negative co-test result.42

Based on what is known to date, HCPs should consider the optimal CCS screening interval to be 3 years, both for cytologic testing in women aged 21-29 or older and for co-testing in women aged 30-65. 

At what age can cervical cancer screening safely be stopped?

According to the ACS/ASCCP/ASCP, CCS can safely be stopped in women older than 65 who have had adequate negative prior screening (three consecutive negative cytology results or two negative co-test results within the previous 10 years, with the most recent test performed within the past 5 years) and no history of CIN2+ within the past 20 years.6 The USPSTF and ACOG are in general agreement with these criteria.17, 18 For women older than 65 with a history of CIN2, CIN3, or ACIS, routine screening should continue for at least 20 years.6, 18 According to the USPSTF, women older than 65 who have never been screened, women who do not meet the criteria for adequate prior screening, or women for whom the adequacy of prior screening cannot be accurately accessed or documented should undergo routine CCS.17 Likewise, routine screening should continue for at least 20 years after spontaneous regression or appropriate management of a highgrade pre-cancerous lesion, even if this extends screening past age 65.

Conclusion

The best approach to prevent cervical cancer entails screening and vaccination. The goals of maximizing benefits and minimizing harms for patients are guiding principles at the forefront of CCS. To this end, using the evidence to date, which includes the 2012 guidelines, the interim guidance published last year, and the updated ACOG practice bulletin, cytology screening every 3 years in women aged 21-29 and co-testing every 3 years in women aged 30-65 are reasonable recommendations to balance patient harms and clinician resistance to 5- year screening intervals.

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