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

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

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

Prevalence and etiology

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

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

Diagnosis

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

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

Treatment

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

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

Recommendations

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

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. She is an ISSWSH Fellow. The author states that she serves as a speaker and advisory board member for Shionogi and Valeant and an advisory board member for the Female Health Company.

References

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

Increasing access to comprehensive contraception: An ongoing battle to remove barriers

woman’s right to use the contraceptive method of her choice is an integral part of women’s healthcare and equality. Despite this constitutional right, barriers to contraceptive access still exist, as reflected by the high rate of unintended pregnancy in the United States each year.I believe that the federal government and state governments, not to mention insurance companies, should not have the right or the power to decide which type of contraception, if any, a woman may use. This decision should be solely up to a woman and her healthcare provider (HCP).

Statement of the problem

As a women’s health nurse practitioner for almost 20 years, I have educated reproductive-aged women about a variety of birth control methods. Although many of my patients know a lot about these methods, others are inadequately informed and undecided about them. As their HCP—and therefore their mentor and advocate—I teach them about all of the contraceptives available and guide them in making the best choices for them.

Through comprehensive contraceptive counseling, women are empowered to make their own decisions about their reproductive lives, including whether and when to have children. Even if women are adequately informed, many of them still face a daunting obstacle to accessing birth control—a lack of health insurance coverage for the particular contraceptive they want to use. It is not unusual to hear a patient say, “My insurance won’t cover that pill” or “The co-pays are too high for certain types of pills in my plan.”

Some women try several types of oral contraceptives before finding one that suits them. It is discouraging when a patient complains that she received a letter from her insurance company stating that it will “no longer cover pill X; you are being dispensed pill Y instead.” But after the patient switches to pill Y, she starts to have side effects that she never experienced with pill X. Many brand-name hormonal contraceptive products are not covered under insurance plans or they require high co-pays. If a woman wants to use a given product, she may need to get prior authorization for it, and prove that she is unable to tolerate alternative products. For a woman who chooses a long-acting reversible contraceptive (LARC), her insurance may cover the product itself but not the services of the HCP who prescribes and places it. These barriers can create undue stress and increase the risk for an unplanned pregnancy.

Overcoming the barriers

To overcome these barriers, HCPs need to advocate for complete contraceptive access for their patients. One form of advocacy involves awareness of public health policy at both the national level and the state level. HCPs can also intervene on their patients’ behalf at a very local level—in their own practices.

On the national level*

The Affordable Care Act (ACA) has a contraceptive coverage requirement giving millions of women who otherwise could not afford to pay for contraceptives the ability to make their own healthcare decisions about the use of such products and to obtain these products for free or at reduced cost. Despite this contraception coverage requirement, many insurance providers, politicians, and religious organizations have opposed the policy, creating further obstacles for women to reach full contraceptive access.

With the election and inauguration of Donald Trump and a continuing Republican majority in both the Senate and the House of Representatives, the status of the ACA was in greater jeopardy than ever. Trump’s very first act as President was to issue an Executive Order aiming to repeal and replace the ACA.But the Executive Order wasn’t sufficient to dismantle the law, and an attempt to repeal the ACA and replace it with the American Health Care Act failed. If the ACA had been repealed, more than 55 million women would have lost access to vital preventive care at no cost,4,5 including access to annual exams, birth control, cancer screening, and testing for sexually transmitted infections.

Of interest, right after the 2016 presidential election, there was a surge in contraceptive consultation visits around the country because women were concerned about the new administration’s goal to repeal the ACA.Women rushed in to get LARC methods out of fear that their insurance would drop contraceptive coverage completely.

On the state level

Some states are making it easier for underinsured or uninsured women who cannot afford to pay for healthcare visits and contraceptives to access these services and products. In 2015, I worked at a local non-profit clinic in New York where almost 18,000 women made family planning-related visits that offered full gynecologic examinations, contraceptive education, and birth control products.During this same year, these services and products were covered by a diverse payor mix: At least 50% of the patients had state-funded insurance, 26% had commercial insurance, and 16% were eligible for free services, including contraception.

An example of family planning advocacy in New York is proposed legislation to ensure that residents have access to affordable contraception. The Comprehensive Contraception Coverage Act (CCCA), an extension of the ACA, introduced by New York Attorney General Eric T. Scheiderman, would codify the requirement under the ACA that all health insurers provide cost-free contraceptive coverage as a part of their insurance policies.8,9  Under the proposal, insurance companies would have to provide cost-free coverage for at least one type of all FDA-approved contraceptives, including emergency contraception. The bill would also apply to voluntary sterilization procedures, extending coverage to both men and women, and would prohibit insurance companies from using medical management review restrictions to delay contraceptive coverage. In addition, the measure would allow patients to receive a 12-month supply of contraceptives at a time.8,9

In 2010, New York was among the top three states in the nation in terms of the rate of unintended pregnancy.10 Public health policies such as the CCCA, which would improve access to contraception, could help reduce unintended pregnancy and abortion and improve health outcomes. As of January 2017, the New York State Assembly voted to pass this critical piece of reproductive healthcare legislation ensuring access to affordable contraception.9 This situation in New York State exemplifies why we need to continue to lobby our legislators on behalf of our patients to ensure their constitutional right to acquire contraception and ultimately uphold and protect their reproductive freedom.

On the local level

Healthcare providers can use certain strategies on their own to try to reduce economic barriers for their patients. For some of my patients who have commercial insurance with high co-pays, I’ve asked pharmaceutical representatives who promote hormonal and non-hormonal contraceptive products to provide discounts and/or coupons to help reduce the cost burden. I also ask the representatives to provide product starter samples, if available, to help reduce the annual cost of contraception. However, these starter samples are of minimal use if a woman cannot afford to pay full price for the product itself once the samples are gone. I also continue to encourage pharmaceutical representatives to provide cost-containment measures for their products if possible—again, to improve contraceptive access for as many women as possible.

Conclusion

It is disheartening that, in our current times, women still have the ongoing fight for reproductive freedom and have a government that creates barriers to this fundamental right. I am proud to live and work in a state that acknowledges the importance of safeguarding women’s health. Creating full access to reproductive health services is a human right that should never have to be challenged or placed in jeopardy by politicians or laws.

Rewa N. Thompson is a women’s health nurse practitioner at Planned Parenthood of Nassau County, Hempstead, New York, and a Clinical Assistant Professor at Stony Brook University, School of Nursing, Stony Brook, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Disclaimer

The findings and conclusions in this article are those of the author and do not necessarily represent the views of Planned Parenthood Federation of America, Inc. The author is an employee of Planned Parenthood of Nassau County.

* Addendum: As this issue of the journal goes to press, we know that the House of Representatives has voted to repeal and replace the Affordable Care Act with the American Health Care Act. The measure now goes to the Senate.

References

  1. Center for Reproductive Rights. Contraceptive Access in the United States. n.d.
  2. Center for Reproductive Rights. The Contraception Controversy: A Comprehensive Reply. April 2012.
  3. National Law Review. Status of the Affordable Care Act Repeal Efforts. January 23, 2017.
  4. Center for American Progress. How Women Would Be Hurt by ACA Repeal and Defunding of Planned Parenthood. January 18, 2017. americanprogress.org/issues/ women/news/2017/01/18/296705/how-women-would-be-hurt-by-aca-repeal-and-defunding-of-planned-parenthood/
  5. Planned Parenthood. Why Americans Are So Angry About Threats to Repeal Obamacare. March 2, 2017.
  6. PBS News Hour. Trump’s Vow to Repeal Obamacare Spurs Women’s Rush to Get Birth Control. November 22, 2016.
  7. Planned Parenthood of Nassau County. 2015 Annual Report.
  8. Comprehensive Contraception Coverage Act (CCCA).
  9. Assembly to Pass Legislation Protecting Women’s Reproductive Health Rights and Access to Affordable Family Planning.
  10. Guttmacher Institute. Unintended Pregnancy in the United States. September 2016.

Infertility evaluation and treatment

How common is infertility?

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

What are the causes of female infertility?

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

What are the causes of male infertility?

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

How is female infertility evaluated?

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

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

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

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

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

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

How is male infertility evaluated?

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

How is female infertility treated?

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

How is male infertility treated?

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

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

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

Editor-in-chief ’s message

Dear Colleagues,

In January 2017, the NPWH Board of Directors approved our position statement on human sex trafficking, which is published in this issue of the journal. The work of the writing group on the position statement started in October 2016. It seems that, nearly every week since that time, I see something in the media about human trafficking.

At our annual conference last year in New Orleans, Dr. Kimberly Chang gave a highly informative and impassioned presentation on human trafficking. Dr. Chang is nationally known for her advocacy in the prevention of trafficking and the care of trafficking survivors. Along the way, she has provided me with a variety of resources on both sex and labor trafficking that I want to share with all of you.

One of these resources is HEAL – Health, Education, Advocacy, and Linkages. HEAL is an independent network of multidisciplinary professionals dedicated to ending human trafficking and supporting its survivors—from a public health perspective. At the HEAL Trafficking website, you can find educational resources, as well as access a protocol toolkit for healthcare settings.

The Office on Trafficking in Persons (OTIP) is housed within the U.S. Department of Health and Human Services (DHHS). At the OTIP website, you can find factsheets, brochures, and posters supporting DHHS’s Look Beneath the Surface campaign, which can be used to increase community awareness about human trafficking. In addition, the website has information on victim assistance services and training resources, and it provides reports on trafficking from other federal agencies.

The Polaris Project provides trafficking statistics, offers information on a variety of trafficking prevention initiatives, and sponsors the National Human Trafficking Hotline (1-888-373-7888) and the BeFree Textline (text HELP to 233733 [BEFREE]). You can find out more on the Polaris Project website.

If you want in-depth and up-to-date information on a variety of trafficking issues, I recommend the textbook Human Trafficking Is a Public Health Issue: A Paradigm Expansion in the United States (2017). This book has 24 chapters covering topics such as Sex Trafficked and Missed, LGBTQ Youth and Vulnerability to Sex Trafficking, Physical Health of Human Trafficking Survivors: Unmet Essentials, Caring for Survivors Using a Trauma-Informed Care Framework, The Ignored Exploitation: Labor Trafficking in the USA, and Human Trafficking: Perspectives on Prevention. You can download individual chapters or purchase the complete book.

NPWH will continue to provide leadership and collaborate with other organizations and agencies to deliver education to increase knowledge and provide resources for NPs to identify, assess, and respond to the needs of trafficked individuals. Furthermore, we will advocate for policies and public health campaigns that will help stop trafficking.

Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle

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

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

Why is a maternal mental health bundle important?

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

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

Where can HCPs find information about the bundle?

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

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

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

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

Recommendations

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

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

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

References

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

Message from the CEO

Happy Spring! We have jumped into high gear here at NPWH!

To celebrate National Women’s Health Week, May 14-20, 2017, we participated in the Coalition for Women’s Health Equity’s planning of their first-ever Women’s Health Empowerment Summit. NPWH partnered with Women Against Alzheimer’s to plan the panel, Women’s Health for All Ages: New Trends & Perspectives. Our panelists included NPWH’s Susan Hoffstetter, Immediate Past Chair of the Board of Directors; Mary Worstell, Senior Advisor to the Director, HHS Office of Women’s Health; Jill Lesser, President, Women Against Alzheimer’s; Athena Cross-Edge, Board Member, Black Women’s Health Imperative; and Lynn Yeakel, Director of Drexel University College of Medicine’s Institute for Women’s Health and Leadership and Founder and President, Vision 2020.

Our annual Women’s Sexual Health Course for NPs is in its fourth year, and we are expecting to reach capacity once again for this educational activity. The Vulvoscopy Workshop that we added last year was so popular that we are offering it again this year. The Women’s Sexual Health Course, the only course designed specifically for NPs, has been extremely well received. This course enhances NPs’ ability to promote women’s sexual health and increases their confidence in evaluating, diagnosing, and managing female sexual dysfunction.

We are thrilled to announce that we are in the process of developing our new Patient Portal. This portal will be accessed on our website and will facilitate patient–NP communication. The portal will include information promoting health, as well as information about the specific needs of women with common health conditions and about management of conditions unique to women. In addition, this portal will provide women with direct access to women’s health topics. We will keep you updated on our progress.

This is the 20th year that NPWH will be offering its Annual Premier Women’s Healthcare Conference, and we are excited to be in Seattle, Washington, once again! This year’s presentations will cover topics such as colposcopy, menopause, preeclampsia, hereditary breast and ovarian cancer, and professional development (e.g., writing for publication), just to name a few. New this year is the SOAR Training, which was developed by the U.S. Department of Health and Human Services for recognizing victims of human trafficking. Check out the program guide to see all of our presentations, which cover the very latest developments in women’s health. Please plan to join us; you won’t want to miss this year’s conference!

Implementation of the Female Sexual Function Index adaptation for breast cancer patients in an outpatient surgical breast practice

The average woman has a 12.3% lifetime risk of being diagnosed with breast cancer.1 The number of breast cancer survivors continues to increase because of advancements in early detection and successful treatment of the disease.1 This rise in survival rate is generating greater attention on post-treatment effects and the importance of evaluating quality of life (QOL) for these patients. Many women treated for cancer experience problems related to sexual health and intimacy in particular.High levels of evidence support screening breast cancer survivors for sexual dysfunction, which can improve patient satisfaction and QOL.3,4

Purpose

Sexual dysfunction is recognized as a major problem following cancer treatment, which leads to increased distress and decreased QOL.2,4 The primary goal of this scholarly project was to implement the Female Sexual Function Index adaptation for breast cancer patients (FSFI-BC), an evidence-based, validated tool to screen for sexual dysfunction among breast cancer survivors.3 The FSFI-BC is a 33-item screening tool that uses Likert-scale questions to assess aspects of sexual functioning such as changes after cancer, desire, lubrication, orgasm, pain, reasons for sexual inactivity, and distress regarding sexual functioning. Use of this screening tool gives breast cancer survivors the opportunity to identify a sexual problem they may be having, discuss it with their healthcare provider (HCP), and begin treatment for it if indicated.

Method

The institutional review board approved this quality improvement project. Patients meeting inclusion criteria received an information letter discussing the screening tool and project purpose at their clinic visit check-in. Inclusion criteria included female gender; English speaker; age, 18-80 years; reader on at least a fifth-grade level; and a personal history of breast cancer diagnosed at least 1 year previously. Participants could be of any race, ethnic group, marital status, or socioeconomic status. Consenting participants completed the screening tool and demographic information sheet (de-identified to maintain confidentiality) prior to seeing the HCP. The project leader scored the data based on clinical interpretation guidelines3 and shared results with participants during their visit. Participants who screened positive for sexual dysfunction were given the opportunity to discuss treatment options and referral to appropriate specialists.

Outcomes

During a 3-week data collection period, 49 of 66 patients who met inclusion criteria participated in the project. Among the 49 participants, 4 (8.2%) were excluded because of missing data and 5 (10.2%) had  sexual functioning that was equal or superior to that prior to their diagnosis. The remaining 40 participants (81.6%) met criteria for further evaluation based on FSFI-BC scores. Among these 40 participants, 22 (55%) were not distressed about their sexual functioning, 12 (30%) were distressed about their sexual functioning at least half the time,  and 6 (15%) were excluded for missing data regarding distress (Figure).

Limitations

The project was limited by the short interval for implementation and by incomplete surveys, which limited comparison of different facets of sexual dysfunction. In addition, the limited time frame for implementation did not allow for follow-up evaluation of outcomes for treatment recommendations or referrals made.

Implications for women’s health

Advanced practice nurses (APNs) serve a critical role in the comprehensive care and support of breast cancer survivors. Identification of sexual dysfunction is key to the evaluation and management necessary for survivors’ improved health outcomes. This project supports use of the FSFI-BC by APNs in identifying survivors with sexual dysfunction. In addition, APNs who perform this screening should have the knowledge and skills to address sexual function concerns and/or make appropriate referrals.

Stefani E. Davis is an advanced practice provider at OhioHealth Breast & Cancer Surgeons in Columbus, Ohio. Karen A. Hande is Assistant Professor and Ginny Moore is Assistant Professor and Director for the Women’s Health Nurse Practitioner Specialty, both at Vanderbilt University School of Nursing in Nashville, Tennessee. 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. Desantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013. CA Cancer J Clin. 2013;64(1):52-62.

2. Dizon DS, Suzin D, McIlvenne S. Sexual health as a survivorship issue for female cancer survivors. Oncologist. 2014;19(2):202-210.

3. Bartula I. Sherman KA. Development and validation of the female sexual function index adaptation for breast cancer patients (FSFI-BC). Breast Cancer Res Treat. 2015; 152(3):477-488.

4. Jeffery DD, Barbera L, Andersen BL, et al. Self-reported sexual function measures administered to female cancer patients: a systematic review, 2008-2014. J Psychosoc Oncol. 2015;33(4):433-466.

5. Cole CF. Breast cancer survivor satisfaction with NP-delivered follow-up care. Womens Healthcare. 2013; 1(1):16-21.

My adoption story

My family’s journey to adoption began 8 years before my son came home to us on April 27, 2004—a day now celebrated annually in our household as “Gotcha Day” and “Big Sister Day.” However, as in any journey, there were several surprising twists and turns along the way. My husband and I, like many young professionals, had placed our educational and career goals ahead of our goal to have a family one day. By the time we decided that the time was right to start a family, we both had obtained master’s degrees and we both had felt comfortably established in our careers. Then months of trying to become pregnant turned into years, complete with infertility workup, ovulation monitoring, scheduled sex, and multiple attempts at intrauterine insemination (IUI). After the sixth failed IUI attempt, our infertility specialist recommended that we move on to in vitro fertilization (IVF). However, our insurance company at the time wouldn’t pay for the procedure and the cost for one attempt of IVF was roughly equal to the cost of the adoption process. To us, the decision was easy.

We contacted several local adoption agencies, eventually finding one we felt comfortable with, and began our home study process. We wrote letters to prospective birth parents about ourselves and our desire to have a family. We were interviewed together and individually by a social worker who also came to visit and inspect our home. We took classes through a local social service agency to become foster parents, in the hope that we might be able to adopt an infant from the foster care system. After all, in my role as a nurse practitioner (NP), I served on our county’s Child Abuse Response Team (CART), a group of healthcare professionals who make recommendations regarding the health and well-being of children who have been removed from their homes and placed in the foster care system.

We also took advantage of my role as an NP and my contacts in the healthcare professions. On several occasions, we asked colleagues to take copies of our letter to prospective birth parents to national conferences and distribute them to the nurse-midwife and obstetric communities. One of these letters prompted a call from an obstetrician in Texas who herself had been adopted. She had a patient, a young woman, who had just delivered a healthy baby boy and then confided postpartum that she wanted to give the child up for adoption. The obstetrician shared with us that the mother had had little or no prenatal care and no knowledge of the paternal family history, but the child was healthy and beautiful. If we were interested, she wanted to give this little boy the opportunity to live in a stable and loving home that was similar to the one in which she had grown up through adoption.

I started packing while my husband began making flight arrangements to travel to Texas. Several hours later, the obstetrician called us back in tears, reporting that the hospital had intervened. Because we did not have a formalized adoption plan with this woman prior to delivery, we were not eligible to adopt the child. My husband and I were devastated. I cried for days, maybe longer. My husband, family, and friends didn’t know what to do for me. It was several weeks later that we discovered the reason for my severe emotional response; I was pregnant. After our failed IUI attempt, I had just stopped keeping track of ovulation and menses. I was 6 weeks pregnant before I figured it out. Aside from severe hyperemesis gravidarum, I had an uneventful pregnancy and on June 1, 1998, I gave birth to a beautiful baby girl.

Fast forward 6 years. Despite 6 more years of trying to conceive, we were not successful in getting pregnant again. We had moved from Tennessee to New Hampshire to be closer to our families in Maine. We both felt very strongly that we didn’t want to raise our daughter as an only child. We wanted her to have at least one sibling with whom to grow up. Our daughter also kept asking about having a baby brother. We returned to see a reproductive specialist to discuss our infertility problems and again discussed multiple options. Our current health insurance would cover IVF; however, based on my age, our chances of conception with each trial had decreased to 10%-30%.

Again, the decision was easy for us and we searched for another adoption agency and found Vermont Children’s Aid Society. We underwent another home study and had interviews with the social worker, a home inspection, and fingerprinting. We initially decided that we would pursue a domestic adoption, because our social worker had informed us that during the previous year, she had 14 families trying to adopt a child, 7 of which were able to bring home a baby. Once again, the months slowly went by. Our adoption agency was not able to complete a single domestic adoption.

During this period of time, we were required to complete a 1-day training session on adoption through a local social service agency. During the session, we spoke to several families who had adopted a child from Korea and were planning to adopt a second child from Korea. We went home and thoroughly researched Korean adoption. We liked the fact that the children from this country didn’t go into orphanages waiting for adoption but, rather, went to foster care homes where they were the only child in the home under the age of 3. This practice tends to eliminate the risk of reactive attachment disorder and other psychological problems that had been documented extensively in both the medical literature and the lay press as a common experience among children adopted from Eastern European countries.

Our change from domestic to international adoption status meant additional home study work and costs, as well as being fingerprinted by an international agency because the fingerprints we had provided at our local police station would not suffice. The Korean adoption agency also requires adoptive parents to each have a body mass index of 25 or lower because of the strong belief that obese parents raise obese and unhealthy children.

We completed our additional home study work and submitted our application to adopt a child from Korea. We were told that we could expect to have our second child in our home in the next 8-9 months. We were shocked, when, a month later, we received a call from the adoption agency along with pictures of our son! When we had filled out the forms indicating the health problems we were willing to accept in an adoptee, I was quite liberal in terms of my list because I was an NP. I was working for a large tertiary medical center and had access to some of the best medical specialists in our region. Our son’s birth mother had come to prenatal care late in her pregnancy. It was estimated that he was born 8 weeks premature. He weighed 4.4 kg and required blow-by oxygen for 24 hours. He looked perfect to us. He left the hospital after several weeks and went to his foster family.

In addition to our son’s foster mother and father, the foster family included a 21-year-old daughter who was in college but lived at home, a set of 15-year-old twin girls, and a 12-year-old son. They sent us many pictures of our son. We sent them clothes, stuffed animals, and pictures of ourselves. It took 3 months for our son to come home to us. We had decided that we would pay to have an escort bring him to the United States rather than traveling to Korea because this option seemed less disruptive to our family life. We needed to cancel a trip to Disney World that we had planned before we learned that we were going to have to wait only 4 months instead of the 8-9 months that we had originally been told. (Our son’s older sister has never stopped reminding him that his pending arrival at our home caused her to miss the trip to Disney World.) His trip to our home was delayed another 2 weeks because he had been unknowingly exposed to chicken pox.

Finally, the day arrived; we travelled to JFK airport in New York City to pick up our baby boy. It is quite surreal to arrive at JFK’s terminal 4, have an elderly woman disembark from a plane carrying a 6-month-old baby boy, have her place him in your arms, and then, just like that, he is ours. We muddled through the next days and weeks getting to know each other. It was obvious from that first day that he had been well loved and cared for. He was a happy, easy-going baby despite the fact that his world had just been turned upside down. He took it all in stride.

Twelve more “Gotcha Days” have come and gone. We now have a happy, healthy adolescent son—well, as happy as any adolescent boy can be. His childhood has been a classic small-town New England childhood. He loves baseball, plays ice hockey, and is a fearless snowboarder, taking on black diamond runs since the age of 6. He has a bright and inquisitive mind that has challenged both his parents and his teachers. We have  tried to keep him in touch with his Korean heritage. Living in close proximity to a college town, we learned of a Korean Big Brother/Big Sister program. We spent many Sunday afternoons there, learning how to cook Korean foods, play Korean games, and speak some basic Korean words and phrases. More important, our son was able to spend time with other Korean adoptees and Korean college students.

Because I teach at the college medical school, we keep him in touch with his culture through several Korean medical students as well. The students have been gracious and kind to our son. They have brought him gifts from Korea, including games and a building kit of a traditional Korean home. They have also spent time with him and shared their experiences of growing up in Korea. The downside to growing up in our small New England town is that he is one of only three or four kids of Asian heritage in his school. His minority status has been a concern for his father and me, although it wasn’t until he was in sixth grade that another child began bullying him because of his Asian heritage. When the other child called him “slant eyes,” my son initially didn’t realize it was a racial slur. The child’s racial taunting continued until my son told his teacher. The other child was disciplined. but my son didn’t think that the punishment was adequate. He wrote his principal a letter and met with him to advocate for himself and to explain how much the other child’s words had hurt him. We were very proud of the way he handled this situation.

We anticipate continued challenges in the years ahead. Our son is just a few years away from the age that, with our permission, he can find his birth mother. We have always told him we would support him in this endeavor if he chooses to explore it. The adoption agency offers “homecoming tours,” where the Korean adoptees spend 2 weeks in Korea, immerse themselves in Korean culture, and meet their birth families if they choose. We will continue to embrace whatever the years ahead will hold, as we feel blessed to have expanded our family through international adoption.

Maureen Boardman is a family nurse practitioner and Director of Clinical Quality at Little Rivers Health Care, a Federally Qualified Health Center, in Bradford, Vermont. She is also a Clinical Assistant Professor of Community and Family Medicine at Dartmouth College, Geisel School of Medicine, in Hanover, New Hampshire.

Editor-in-chief ’s message

Dear Colleagues,

I hope you are all enjoying a happy and healthy new year and are looking forward to the upcoming spring season!

The year 2016 was an excellent one for Women’s Healthcare: A Clinical Journal for NPs. Our feature-length articles, as well as our shorter department articles, covered a wide variety of topics important to women’s health. I heartily thank all the authors who wrote articles published in 2016. I also extend a special thank-you to the individuals who peer-reviewed manuscripts for us in 2016. The work of these peer reviewers helps ensure that the articles we publish are the very best:

Kelly Ackerson
Carola Bruflat
Lorraine Byrnes
Joyce Cappiello
Stefani Davis
Melanie Deal
Brenda Deeser
Rebecca Fay
Lauren Hansen
Beth Kutler
Patrice Malena
Anne Moore
Ginny Moore
Charlotte Peavie
Heather Quaile
Suzy Reiter
Beth Steinfeld
Joyce Tow

In addition, I want to recognize Joyce Cappiello and Michele R. Davidson, who are leaving our Editorial Advisory Board. I thank both of them for the important contributions that they have made to our journal. And I am pleased to welcome Barb Dehn and and Amy Levi as new members of the advisory board.

We have other accomplishments to celebrate as well, with four NPWH position statements approved by the board of directors in the past year:

The Doctor of Nursing Practice for Women’s Health Nurse Practitioners

Prevention of Alcohol-Exposed Pregnancies

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

Human Sex Trafficking

The writing group members for these NPWH position statements deserve special recognition. I extend a huge thank-you to these individuals for the time and hard work they contributed to make our position statements robust and relevant to NPs who provide healthcare to women:

Diana Drake
Megan Fredericksen
Aimee Chism Holland
Debra Ilchak
Sue Kendig
Ginny Moore
Sylvia Poe-Valesco
Stephanie Pott
Ursula Pritham
Susan Rawlins
Amanda Reynolds
Rebecca Sarabia
Diane Schadewald

I also thank all the individuals who reviewed the position statements and those who provided feedback as part of the public comment process.

Now, as we begin a brand-new year of publication of the journal, we have many outstanding articles in store for you. As always, we invite you to help us to maintain our momentum by submitting a manuscript in one of the multiple formats offered.

In case you need some topic ideas to get you started, I have some suggestions. Consider writing about bipolar disorder, borderline personality disorder, Alzheimer’s disease, epilepsy, multiple sclerosis, systemic lupus erythematosus, hypertension, hyperlipidemia, bariatric surgery, asthma, gastroesophageal reflux disease, or ulcerative colitis—from a women’s health perspective, of course—or about endometriosis, genital herpes, vaginal infections, breastfeeding issues, or autoimmune disorders in pregnancy.

Click here or visit our journal website to access our complete Guidelines for Authors. We welcome query letters about any topic and article format you are considering.

You can reach Dory Greene, our managing editor, at dgreene@healthcommedia.com, or me at bkelsey@healthcommedia.com.

Beth Kelsey, EdD, APRN, WHNP-BC

Message from the CEO

As we enter 2017, we are excited about the new opportunities and programs we have planned for the year. For example, with regard to our Well Woman Visit Mobile App, we are working on adding a Menopause section, which we know you will want to download. At the end of 2016, we completed a new edition of the App, which now includes the assessment of Irritable Bowel Syndrome. Remember, the App is free, and a very helpful tool in your practice, so please share it with your colleagues today!

We are in the process of planning four regional, 1-day, complimentary CE meetings that will cover topics such as HPV Immunizations, Contraception, Bacterial Vaginosis, Menopause, and Hereditary Cancer. Last year, we held a regional meeting in Pasadena, California. Instead of providing just didactic lectures and slides, we introduced case studies on the topics and broke into small groups. The attendees loved the format and were happy they participated. Watch for announcements of future meetings and locations.

Another project we are working on for 2017 is our Patient Portal. Over the years, we have provided nurse practitioners with toolkits comprised not only of educational materials for you, but also helpful information for your patients. In addition to the toolkits, we want to provide a place for your patients to access NPWH-vetted materials that are easy to understand, visually engaging, and easy to use, and that serve as an excellent resource for practical information regarding their health. This Patient Portal will give you, the provider, an opportunity to print the materials to give to your patients and/or direct them to our website. At a later date, we will provide this information in Spanish as well.

The year 2017 is the fourth in a row that we will be off ering the Women’s Sexual Health Course for NPs. This course will enhance your ability to promote women’s sexual health and increase your confidence in being able to evaluate, diagnose, and manage female sexual dysfunction. The course will be held on June 8-11, 2017, at the Sheraton Inner Harbor in Baltimore, Maryland.

For your convenience, we have included the program guide and registration information in this issue of the journal. Don’t miss this opportunity; register today!

Gay Johnson
Chief Executive Officer, NPWH

What NPs need to know about preventing fetal alcohol spectrum disorders — FASD

Alcohol: A teratogen

Unlike all other substances of abuse, alcohol is a teratogen. Teratogens can alter both the structure and function of fetal cellular development. The impact of alcohol use on each fetus is highly variable and can be unpredictable. It can be influenced by maternal genetics, fetal genetics, timing and dose of the alcohol, maternal nutritional status, maternal age, gravida/parity, stress level, and other medication or substance use. Prenatal alcohol exposure can result in FASDs, which are a range of lifelong physical, mental, and neurobehavioral disorders that may affect 2%-5% of the population of the U.S.1 FASDs are the leading cause of preventable intellectual disability.

What is an FASD?

Fetal alcohol spectrum disorders include fetal alcohol syndrome (FAS and partial FAS) and/or evidence of underlying non-progressive brain damage such as static encephalopathy and neurobehavioral disorder (University of Washington terms).

Fetal alcohol syndrome must meet specific medical criteria, including growth deficiency; have evidence of organic brain dysfunction; and have three cardinal facial features. Only 9%-10% of individuals with an FASD meet these criteria.

Cardinal facial features form in the 3rd week of gestation. Most individuals with an FASD have few physical signs of prenatal alcohol exposure—they may have a hidden disability.

FASDs are 100% preventable!

Who is at risk of having a child with an FASD?

An estimated 3.3 million sexually active reproductive-aged women per month are at risk of an alcohol-exposed pregnancy.2 1 in 10 pregnant women in the U.S. (aged 18-44) reports drinking in the past 30 days. In addition, 3.1% of pregnant women report binge drinking.Women who drink prior to pregnancy may be more likely to drink during pregnancy, and many women drink during the first trimester, before they are aware of the pregnancy.

Among pregnant women, alcohol use is highest among women who are:

• Aged 35-44

• College graduates

• Unmarried

No amount of alcohol has been found to be safe during pregnancy, but binge-pattern drinking increases the risk for the fetus. Binge drinking for women means having 4 or more standard drinks on any one occasion (within approximately 2 hours).

There are two ways to think about reducing alcohol-exposed pregnancies: (1) help women moderate ‘at-risk’ drinking patterns and (2) advocate effective contraception use by all reproductive-aged women who consume alcohol. ‘At-risk’ drinking patterns: more than 1 standard drink per day, more than 3 standard drinks per occasion, and/or more than 7 standard drinks per week.

For women who are not currently pregnant:

• Regularly screen women for ‘at-risk’ alcohol use and have conversations about their contraceptive use and effectiveness. Inform women about healthier drinking patterns, and follow up at each visit with women who engage in risky drinking.

• Advise women who are actively trying to conceive to abstain from alcohol.

For women who are currently pregnant:

• Reinforce the message that there is No Safe Amount, No Safe Time, and No Safe Type of alcohol, and that quitting at any time in the pregnancy can help the baby.

• For women who become pregnant unintentionally (45% of pregnancies in 2011), say to them Tell me when you last used alcohol in a matter-of-fact way. If necessary, have an honest conversation about the potential risks for their fetus, and how alcohol exposure may present in their child’s future. Don’t blame or shame them; be factual and supportive.

Abstaining from alcohol is a difficult message for many women

The message No Safe Amount, No Safe Time, and No Safe Type of alcohol is sometimes challenging to convey. As healthcare providers, you need to help women understand that consuming alcohol has absolutely no beneficial effects on a fetus, and that alcohol can cause cell death and/or alterations resulting in lifelong disabilities if consumed at any time during the pregnancy.

Give women tools to help avoid drinking during pregnancy

• Consider adopting strategies from the CHOICES program into your practice. CHOICES works with women before they become pregnant to reduce their risk of an alcohol-exposed pregnancy by helping them reconsider how they use alcohol and/or how they use contraception, or both.4

• Suggest that women socialize in alcohol-free environments.

• Suggest that women ask their partners to support them during their pregnancy by abstaining from alcohol as well.

• If a woman is struggling with abstaining, or doesn’t want to abstain at all, ask her What does alcohol mean to you? Depending on the answer, help her find ways to meet those needs in a different way while she is pregnant.

• Recommend non-alcoholic alternatives to their favorite drinks such as non-alcoholic beer or wine. Mocktails can replace cocktails. Mocktail recipes can be found online, and often taste just as good!

References

1. pediatrics.aappublications.org/content/134/5/855

2. cdc.gov/media/releases/2016/p0202-alcohol-exposed-pregnancy.html

3. cdc.gov/media/releases/2015/p0924-pregnant-alcohol.html

4. cdc.gov/ncbddd/fasd/choices-program-prevent-alcohol-exposed-pregnancies.html

Message from the CEO

This September marked NPWH’s 19th Annual Premier Women’s Healthcare Conference, and it was a huge success! The main conference began with presentations by dynamic women who set the tone for the rest of the event. First, we enjoyed Conversation with Loretta Ford, EdD, RN, PNP, FAAN, FAANP. Loretta was co-founder of the first nurse practitioner (NP) program in the United States. Loretta, along with Henry Silver, MD, inaugurated the pediatric NP program at the University of Colorado in 1965. Then in 1972, Loretta joined the University of Rochester as founding Dean of the Nursing School. Jacki Witt, Chair of the NPWH Board of Directors, and I presented Loretta with a Leadership Award with this inscription: For Extraordinary Vision, Remarkable Dedication, Passionate Commitment to Excellence in Creating the Nurse Practitioner RoleLoretta Ford is truly an inspiration to everyone who meets her.

The next two speakers were Teresa Gardner Tyson, DNP, MSN, FNP-BC, FAANP, and Paula Meade, DNP, MSN, FNP-BC, PNP-BC, FAANP. Teresa and Paula are lifelong friends who grew up in the rural Appala – chian Mountains of Virginia. They left the area to pursue their education and clinical experience, and then returned to start a free nurse-managed health clinic, The Health Wagon, for uninsured patients. These two NPs and The Health Wagon were featured in a segment on 60 Minutes, which showcased their efforts to provide access to healthcare for the poor and marginalized people of Appalachia. Their clinic also received notable recognition by Nightline, CBS Nightly News, Inside Edition, The Washington Post, and The New York Times. Teresa and Paula continue to extend their reach to underserved populations. For the past 17 years, they have provided services to the Remote Area Medical Health Expedition in Virginia, which is the largest healthcare outreach in the U.S. They currently manage two mobile units and two stationary Health Wagon clinics.

Once again, NPWH was proud to present the Inspiration in Women’s Health Award to four different NPs. The Inspiration Award Winner for Education was Sharon D. Baker, BSN, MS, CWHNP, CMP, of Georgia; the Inspiration Award Winner for Clinical was Jennifer Kurkowski, MSN, WHNP-BC, of Texas; the Inspiration Award Winner for Research was Naomi Jay, PhD, RN, NP, of California; and the Inspiration Award Winner for Policy was Denise Link, PhD, WHNP-BC, CNE, FAAN, FAANP, of Arizona. The award winners received free conference registration, travel to and from New Orleans, and accommodations for the duration of the conference, as well as an award and a scholarship to continue their great work. All of these awards were made possible through a grant from Hologic, Inc. “Inspiration” was clearly a theme throughout the conference; the sessions and symposia—notable for their captivating content and spirited speakers—were truly inspiring to the attendees.

One last thing: We are all inspired by the contributions that you make every day to the healthcare of women! Thank you, and have a happy and healthy holiday season!

Editor-in-chief’s message

Dear Colleagues,

It was wonderful to meet some NPWH members for the first time, as well as catch up with those members

I already knew, at our 19th Annual NPWH Premier Women’s Healthcare Conference in New Orleans. I have missed only one conference in these 19 years, and I can say without a doubt that they just keep getting better and better. This is the women’s healthcare conference that covers it all—contemporary issues to keep us up to date, challenging issues that we face clinically and professionally every day, and the very practical skills that we need to provide comprehensive, quality healthcare for women.

If you want to be inspired, as well as informed, this conference is always the one to attend. This year, we had the exceptional opportunity to have a conversation with Dr. Loretta Ford, founder of the nurse practitioner (NP) profession. Dr. Ford wove together the past and present for NPs. When asked what we needed to do to ensure that our profession thrives in the future, she advised us to “Keep moving!” Our keynote speakers, two NPs serving the rural Appalachian population with their health mobile, demonstrated the power of commitment and perseverance in helping those in need. As always, our four Inspiration in Women’s Health Award winners this year reminded us of the remarkable work our colleagues have accomplished.

If you attended the conference this year, you may have faced the same difficulty I did in terms of choosing among the breakout sessions. Fortunately, these sessions were recorded and are available free to conference attendees on the NPWH website E-Learning Portal. If you missed the conference, you can purchase individual recorded sessions and obtain CE credits. Each session is $10 for members and $15 for non-members.

Our annual NPWH conferences are so successful because of the extraordinary team effort of our Planning Committee, our Board of Directors, our staff members, and our CEO, Gay Johnson. We are also grateful for the meticulous behind-the-scenes work accomplished by our Education and Research Committees to ensure that the presentation and poster content is evidence based and relevant to NPs providing healthcare for women. Exhibitors at the conference afford us an opportunity to learn and get questions answered about women’s health products, services, and pharmaceuticals.

I extend a huge thank-you to everyone, including the attendees, who made this conference such a success. I want to extend a special thank-you to the New Orleans WHNPs who served on the Hospitality Committee. They greeted us at the Hospitality Booth with festive Mardi Gras beads and information on what we could see and do while in the Big Easy, as well as helping us in the break-out session rooms.

I am already looking forward to our 20th Annual NPWH Premier Women’s Healthcare Conference, which will take place on October 11-14, 2017, in Seattle. I hope to have the opportunity to meet more of you, as well as catch up again with the many colleagues I have already met.

The holidays are upon us! I wish you all happy time spent with family and friends as we move into the new year!

The adolescent with irregular menses

NM is a 16-year-old female who presents to the clinic with concerns about irregular periods. She tells the nurse practitioner (NP) that she had her first period when she was 14 and that her cycles have never been regular, ranging from 1 to 3 months. Her last menstrual period was about 2 months ago and she thinks that she has had only four or five periods over the past year. In addition, NM is interested in discussing contraception.

What else is helpful to know about NM?

Because NM has come to the clinic for the first time, the NP takes a comprehensive health history. Given NM’s report of irregular periods, the NP obtains a thorough gynecologic, sexual, endocrine, medication, and lifestyle history. The NP also takes a family history to discern any relevant endocrine disorders.

The NP learns that most of NM’s periods are light, with no cramping. On occasion, she has a heavy period that requires a super tampon change every hour and that is associated with moderate cramps. She says she can predict a heavy period because she has breast tenderness and feels moody right before it starts.

NM and her boyfriend started to have sex 6 months ago and have been consistently using condoms. She has never been pregnant but has never been tested for a sexually transmitted infection (STI). She has not noticed any unusual vaginal discharge or pelvic pain. She has completed the HPV vaccination series.

NM does not smoke, drink alcohol, or use illicit drugs. She denies food binging or food-restricting behaviors. Her exercise is limited to participating in gym class twice a week. She sleeps 7-8 hours each night without problem. She has no major stressors at school, at home, or with peers.

The patient takes no medications other than occasional over-the-counter (OTC) pain remedies for menstrual cramps or head aches. NM reports that the headaches occur only prior to her heavy periods, are sometimes severe enough to keep her from her usual activities, and are relieved by rest and OTC medications. The headaches are not preceded by an aura or other neurologic signs or symptoms (S/S). NM relates an additional concern—acne—which has been worsening over the past 4-6 months. OTC acne medications have provided only minimal improvement.

In a review of systems, the NP further explores any S/S that might suggest that an endocrine disorder is causing or contributing to NM’s menstrual irregularity. NM denies hair loss, unusual hair growth, weight changes, heat or cold intolerance, fatigue, change in headaches, visual changes, breast nipple discharge, or bowel function changes. Her family history is positive for hypothyroidism and type 2 diabetes in her mother and infertility in an older sister.

Which differential diagnoses are you considering at this point?

NM is experiencing infrequent periods that are most likely anovulatory. Ovulatory cycles are typically characterized by regular intervals (28-32 days) and cramping and are often preceded by moliminal symptoms such as breast tenderness and moodiness. Menstrual irregularities in adolescents are usually related to aberrations in the hypothalamic–ovarian–pituitary axis and fall into one of two distinct categories, hypothalamic menstrual disorders or endocrinopathies. Hypothalamic menstrual disorders are usually associated with alterations in stress, diet, exercise, and/or body weight. Endocrinopathies associated with menstrual irregularities include thyroid disorders, hyperprolactinemia, hyperandrogenic anovulation or polycystic ovary syndrome (PCOS), adult-onset congenital adrenal hyperplasia (CAH), and Cushing syndrome.1

Based on NM’s history, her menstrual irregularity cannot be ascribed to changes in stress, diet, exercise, or body weight. She has no S/S of a thyroid disorder or hyperprolactinemia other than the menstrual irregularity. The combination of menstrual irregularity and acne, albeit common in adolescents, alerts the NP to possible hyperandrogenism associated with PCOS. As such, the NP will look for physical examination findings and choose laboratory tests in consideration of possible hyperandrogenism. Adrenal disorders such as CAH and Cushing syndrome are uncommon but will be explored if indicated.

Which elements do you include in your physical examination?

NM’s blood pressure is 128/78 mm Hg and her body mass index (BMI) is 26.3 kg/m2. A urine hCG is negative. She has moderate inflammatory acne with a combination of comedones, papules, pustules, and some faint scars along the jaw line and upper back. Scalp and body hair distribution is normal. She has no signs of hirsutism. The thyroid is normal sized with no tenderness or nodularity. Breasts are Tanner stage 5. Palpation of the abdomen indicates no tenderness, masses, or hepatosplenomegaly. An external genital exam shows no clitoromegaly or lesions. Pubic hair distribution is Tanner stage 5, with no expanded escutcheon. No speculum or bimanual exam is indicated.2 A self-collected vaginal swab specimen is obtained for chlamydia and gonorrhea testing.3 

Based on the history and physical examination findings, what are your working diagnoses?

Infrequent menses, or oligomenorrhea, is defined as cycles longer than 38 days. Irregular menses is defined as a variation of cycle length greater than 20 days.Many adolescents have menses that meet these criteria in the first 1-2 years postmenarche. About 75% of adolescents have an average menstrual cycle of 21-45 days within 1 year postmenarche and about 90% are in this range within 4 years postmenarche.NM reached menarche 2 years ago. Her cycles range from 1 to 3 months. Most adolescents become ovulatory over time, but half of girls with infrequent menses or secondary amenorrhea have a permanent ovulatory disorder.6

Moderate to severe acne affects 15%-20% of 15- to 17-year-olds.The exact cause of acne is unknown. Genetic influences may determine acne susceptibility and severity. Main contributory factors are excessive sebum production, hyperkeratinization of pilosebaceous follicles causing blockage and mixing dead skin cells with sebum, and proliferation of the bacterium Propionibacterium acnes. Inflammatory acne develops when the wall of these follicles ruptures and sebum enters the surrounding dermis. Pustules form when inflammation is close to the surface, and papules and cystic nodules form when inflammation is deeper, causing mild to severe scarring.Although most cases of acne regress spontaneously during later adolescence, some may persist into adulthood.

Production of adrenal androgen increases in early puberty in girls, contributing not only to pubic and axillary hair growth but also to increased sebum production and acne. However, acne in adolescent girls should be evaluated not in isolation but, rather, in the context of each patient’s family history and menstrual history and in the absence or presence of hirsutism.

Which laboratory tests are indicated?

Because infrequent menses or amenorrhea may be the only presenting sign in adolescents with thyroid dysfunction or hyperprolactinemia, laboratory testing for these disorders is indicated. Normal serum thyroid-stimulating hormone (TSH) and prolactin levels rule out these two conditions. After PCOS, non-classic CAH is the second most common cause of hyperandrogenic anovulation.Non-classic CAH can be excluded with a carefully timed 17-hydroxyprogesterone measure, which is checked in the early morning, during the follicular phase or an anovulatory cycle.

Although a diagnosis of hyperandrogenism can be made clinically in typical presentations of adult PCOS, adolescents should undergo a serologic evaluation because of the prevalence of acne in teens with normal androgen levels.  About 50% of adolescents with acne have no biochemical evidence or other clinical findings associated with hyperandrogenism.10 If a lab can assure accuracy in females, a total testosterone level, best drawn in the morning, can be checked as a cost-effective test for hyperandrogenemia. If rapid-onset or severe hirsutism is noted, the level of dehydroepiandrosterone sulfate is measured to detect adrenal hyperandrogenism caused by unusual virilizing disorders. Absence of serologic hyperandrogenism in an adolescent can exclude a diagnosis of PCOS.

NM’s lab findings include TSH, 2.4 mIU/L (normal range, 0.4-4.0 mIU/L); prolactin, 16 ng/mL (normal range in nonpregnant females, 2-29 ng/mL; normal range in pregnant females, 10-209 ng/mL); and total testosterone, 84 ng/dL (normal range for girls aged 12-16 years, <7-75 ng/dL).

Which additional study or studies can help make the diagnosis?

Ultrasonography (USG) of the ovaries is needed in NM’s case. The presence of clinically insignificant polycystic ovaries is high in the general adolescent population,11 suggesting that multifollicular ovaries may be a normal developmental variant. Overall ovarian volume may be a stronger determinant of PCOS in adolescents than subjective qualities of the ovary, which are often limited by the transabdominal USG technique frequently used in adolescent girls.12

NM’s USG shows bilaterally enlarged ovaries with numerous follicles, and a mean ovarian volume of 11.3 cm3. Based on the constellation of infrequent menses, serologic evidence of hyperandrogenism, absence of other endocrinopathies, and the USG findings, a diagnosis of PCOS is made.

What are the official diagnostic criteria for PCOS in adolescents?

The diagnostic criteria for PCOS have not been firmly established. The National Institutes of Health calls for evidence of hyperandrogenism and oligoamenorrhea; ovarian USG is not needed to make the diagnosis.13 The Rotterdam criteria consider various phenotypes of PCOS based on a combination of any two of these three findings: hyperandrogen ism, menstrual irregularity, and polycystic ovaries on USG.14 The Androgen Excess and the PCOS Society emphasize hyperandrogenism, with additional findings of menstrual irregularity and/or polycystic ovaries on USG being diagnostic.15

Whereas the diagnostic criteria for PCOS may have broadened for women, inclusion of adolescents is problematic. Transitory findings of clinical hyperandrogenism (i.e., acne) and perimenarchal menstrual irregularity may lead to a premature diagnosis of PCOS in adolescents. Such a diagnosis can contribute to unnecessary treatment, psychological distress, body image concerns, and undue worry about future fertility. However, true PCOS in adolescents is a marker for future metabolic syndrome and should be treated and monitored accordingly.16

The 2012 consensus report of the two largest fertility societies, the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine suggests that all three Rotterdam criteria, with stipulations specific to adolescents, be present to accurately diagnose PCOS in this population10:

• Hyperandrogenism, defined by serologic testing;

• Oligoamenorrhea, present for at least 2 years; and

• Polycystic ovaries by USG, with an ovarian volume >10 cm3.

The Figure provides an algorithm designed by the author that is based on these diagnostic criteria.

What are NM’s treatment options?

Treatment of PCOS is judged appropriate in NM’s case. Goals of her treatment include S/S management and prevention and detection of subsequent chronic conditions for which she is at higher risk. These conditions include metabolic syndrome, infertility, and endometrial cancer. NM should have an annual assessment of her lipid levels, HbA1C or glucose tolerance, BMI, and BP.

The NP and NM discuss treatment options related to NM’s goals. NM wants to have regular periods—or no periods—and reduced acne, and she wants to start using an effective contraceptive. She may be able to reach all these goals with one pharmacologic agent, a combined hormonal contraceptive (CHC). No contraceptive method is specifically contraindicated in patients with PCOS.17 Correction of NM’s hyperandrogenism through use of a CHC, specifically a combined oral contraceptive (COC), may be the most effective treatment for her acne, while offering reliable contraception and endometrial cancer protection at the same time. By suppressing ovarian production of testosterone, COCs reduce free or circulating androgens. All COCs can help improve acne.18 Little research is available on the effectiveness of transdermal or vaginal CHCs in this regard.19 COCs containing drospirenone (DRSP), relative to those containing other progestins, may have superior efficacy against acne because of DRSP’s antiandrogenic, spironolactone-like effect.

For many women, the spironolactone equivalent of 25 mg of DRSP contained in COCs is not a high enough dose to adequately control acne. One study found that adding 100 mg of spironolactone to a DRSP-containing COC was well tolerated and resulted in near-resolution of acne in 85% of subjects.20 Although DRSP has androgen-blocking potential, NPs must be cautious in prescribing DRSP-containing COCs for obese women because of a potentially increased risk for venous thromboembolism.21

Long-acting reversible contraceptives (LARC) such as intrauterine devices (IUDs) and implantable progestin rods are first-line contraceptive choices for adolescents.22 Although both the levonorgestrel-containing intrauterine system (LNG-IUS) and the progestin implant offer endometrial cancer protection, neither produces reliable androgen suppression. Some studies of the LNG-IUS and the progestin implant show improvement of baseline acne, whereas others show onset or worsening of acne.23-25 If a LARC method is deemed the most acceptable contraceptive for a given patient, it can be paired with spironolactone to treat hyperandrogenic acne. Because of its potentially teratogenic effects, spironolactone is contraindicated in sexually active women who are not using a reliable contraceptive. LNG-IUS and progestin implant users may experience irregular bleeding during the first several months of use and possibly amenorrhea after 6 months to 2 years of use.26

NM decides to take a COC in a continuous regimen so as to avoid having her period and perhaps her menstrual headaches as well. The NP encourages NM to continue condom use along with the COC for STI risk reduction. In addition, because COCs can take 3-6 months to control acne,27 NM is started on a regimen of topical clindamycin and tretinoin. Topical tretinoins are vitamin A derivatives that act by normalizing keratinocyte development, decreasing sebum production, and reducing inflammation. Their use in combination with topical antibiotics such as clindamycin is more effective for moderate acne than either agent used alone.28

The NP refers NM to an online guide about PCOS for teens provided by the Center for Young Women’s Health of Boston Children’s Hospital.29 She gives NM a prescription for regular exercise and nutrition counseling, with a goal of keeping her BMI below 26.

Conclusion

Irregular menses and acne are common findings in adolescent girls; NPs need to use evidence-based guidelines to aid these girls by distinguishing PCOS from normal physiologic variants. In NM’s case, the findings of oligomenorrhea, serologic hyperandrogenism, and polycystic, enlarged ovaries confirm a diagnosis of PCOS. Once the diagnosis is made, treatment is focused on the adolescent’s goals and need for S/S management. Long-term monitoring for associated chronic diseases is included in the ongoing plan of care. With appropriate monitoring and lifestyle modifications, PCOS can be effectively managed with minimal longterm complications.

Beth A. Kutler is Director of Women’s and Sexual Health Services, Gannett Health Services, at Cornell University in Ithaca, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article. The author also acknowledges that she has discussed off-label use of medications and/or devices in this article.

References

  1. Gibbs R, Karlan B, Haney A, Nygaard I. Danforth’s Obstetrics and Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
  2. American Congress of Obstetricians and Gynecologists. Well-Woman Recommendations. 2016.
  3. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(RR3):1-137.
  4. Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Sem Reprod Med. 2011;29(5):383-390.
  5. Rosenfield R. Adolescent anovulation: maturational mechanisms and implications. J Clin Endocrinol Metab. 2013;98(9):3572-3583.
  6. Wiksten-Almströmer M, Hirschberg A, Hagenfeldt K. Prospective follow-up of menstrual disorders in adolescence and prognostic factors. Acta Obstet Gynecol Scand. 2008;87(11):1162-1168.
  7. Williams H, Dellavalle R, Garner S. Acne vulgaris. Lancet. 2012;379(9813):361-372.
  8. McCance KL, Huether SE. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 7th ed. Atlanta, GA: Elsevier, Inc; 2014.
  9. Trapp C, Oberfield S. Recommendations for treatment of nonclassic congenital adrenal hyperplasia (NCCAH): an update. Steroids. 2012;77(4):342-346.
  10. Fauser B, Tarlatzis B, Rebar R, et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012;97(1):28-38.
  11. Mortensen M, Rosenfield R, Littlejohn E. Functional significance of polycystic-size ovaries in healthy adolescents. J Clin Endocrinol Metab. 2006;91(10):3786-3790.
  12. Carmina E, Oberfield S, Lobo R. The diagnosis of polycystic ovary syndrome in adolescents. Am J Obstet Gynecol. 2010;203(3):201.e1-201.e5.
  13. Zawadzki JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: towards a rationale approach. In: Dunaif A, Givens JR, Haseltine F, Merriam GR, eds. Polycystic Ovary Syndrome. Boston, MA: Blackwell Scientific Publications; 1992:377-384.
  14. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41-47.
  15. Azziz R, Carmina E, Dewailly D, et al. Criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society Guideline. J Clin Endocrinol Metab. 2006;91(11):4237-4245.
  16. Roe A, Prochaska E, Smith M, et al. Using the Androgen Excess–PCOS Society Criteria to Diagnose polycystic ovary syndrome and the risk of metabolic syndrome in adolescents. J Pediatr. 2013;162(5):937-941.
  17. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. 2016.
  18. Arowojolu A, Gallo M, Lopez L, Grimes D. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2012;7:CD004425.
  19. Zaenglein A, Pathy A, Schlosser B, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-973.
  20. Krunic A, Ciurea A, Scheman A. Efficacy and tolerance of acne treatment using both spironolactone and a combined contraceptive containing drospirenone. J Am Acad Dermatol. 2008;58(1):60-62.
  21. Jick S, Hernandez R. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data. BMJ. 2011;342:d2151.
  22. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. Obstet Gynecol. 2012;120(4):983-988.
  23. Urbancsek J. An integrated analysis of nonmenstrual adverse events with Implanon®. Contraception. 1998;58(6):109S-115S.

Zika virus infection: Latest recommendations for providers caring for reproductive-aged women

The Zika virus, a mosquito-borne flavivirus,is becoming a growing concern for U.S. women in their childbearing years. The dramatic increase in the number of cases of Zika virus infection (ZVI), as well as its correlation with neurologic deficits (e.g., microcephaly in newborns), has made it crucial for healthcare providers (HCPs) to know as much as possible about identifying, treating, and preventing ZVI. This article offers up-to-date information for HCPs caring for reproductive- aged women—particularly those who are considering pregnancy or who are already pregnant— about when to test for ZVI, whom to test, and how to best inform patients about ZVI transmission and prevention.

CDC guidance for caring for pregnant women2

All pregnant women in the U.S. and U.S. territories should be assessed for possible Zika virus exposure at each prenatal care visit. Pregnant women should not travel to an area with active Zika virus transmission. Pregnant women who must travel to one of these areas should strictly follow steps to prevent mosquito bites during the trip. In addition, to avoid contracting ZVI, pregnant women whose sex partner has traveled to or resides in an area with active Zika virus transmission should use condoms or other barrier methods or abstain from sex for the duration of the pregnancy.

Part of the concern about ZVI is the lack of signs and symptoms (S/S) in up to 80% of persons infected and the vague, mild, flulike symptoms in the remaining portion, which makes identifying the disease so difficult. When S/S of ZVI do occur, they typically include rash, low-grade fever, arthralgia, fatigue, headache, and conjunctivitis.The rash, which tends to be the most prominent sign, is usually pruritic and maculopapular. It begins proximally and spreads to the extremities, with spontaneous resolution in 1-4 days.1

Symptomatic pregnant women

Pregnant women who report S/S of ZVI should be tested for it (Figure). Testing recommendations are the same regardless of the circumstances of possible exposure; however, the type of testing recommended depends on the time of evaluation relative to symptom onset. Testing of serum and urine by real-time reverse transcriptase polymerase chain reaction (rRT-PCR) is advised for pregnant women who seek care less than 2 weeks after symptom onset. This recommendation extends the previous recommendation for testing of serum from less than 1 week after symptom onset to less than 2 weeks. A positive rRT-PCR result confirms the diagnosis of recent maternal ZVI. Women with a negative rRT-PCR result should undergo both Zika virus IgM and dengue virus IgM antibody testing. If either antibody test yields positive or equivocal results, a plaque reduction neutralization test (PRNT) should be performed on the same IgM-tested sample or a subsequently collected sample to rule out false-positive results.

Pregnant women who seek care 2-12 weeks after symptom onset should first undergo Zika virus and dengue virus IgM antibody testing (see the Figure). If the Zika virus IgM antibody testing yields positive or equivocal results, reflex rRT-PCR testing should be automatically performed on the same serum sample to determine whether Zika virus RNA is present. A positive rRT-PCR result confirms the diagnosis of recent maternal ZVI. If the rRT-PCR result is negative, a positive or equivocal Zika virus IgM antibody test result should be followed by PRNT. Positive or equivocal dengue IgM antibody test results with a negative Zika virus IgM antibody test result should also be confirmed by PRNT.

Asymptomatic pregnant women

Testing recommendations for asymptomatic pregnant women with possible Zika virus exposure differ based on the circumstances of possible exposure (i.e., ongoing vs. limited exposure) and the elapsed interval since the last possible Zika virus exposure (see the Figure). Asymptomatic pregnant women living in areas without active Zika virus transmission who are evaluated less than 2 weeks after possible Zika virus exposure should be offered serum and urine rRT-PCR testing (see the Figure). A positive rRT-PCR result confirms the diagnosis of recent maternal ZVI. However, because viral RNA in serum and urine declines over time and depends on multiple factors, asymptomatic pregnant women with a negative rRT-PCR result require additional testing to exclude infection. These women should return 2-12 weeks after possible Zika virus exposure for Zika virus IgM antibody testing. A positive or equivocal IgM antibody test result should be confirmed by PRNT.

Asymptomatic pregnant women living in an area without active Zika virus transmission, and who seek care 2-12 weeks after possible Zika virus exposure, should be offered Zika virus IgM antibody testing (see the Figure). If the Zika virus IgM antibody test yields  positive or equivocal results, reflex rRT-PCR testing should be performed on the same sample. If the rRTPCR result is negative, PRNT should be performed.

As recommended in previous guidance, IgM antibody testing is recommended as part of routine obstetric care during the first and second trimesters for asymptomatic pregnant women who have an ongoing risk for Zika virus exposure (i.e., residence in or frequent travel to an area with active Zika virus transmission) (see the Figure). Reflex rRT-PCR testing is recommended for women who have a positive or equivocal Zika virus IgM antibody test result because rRT-PCR testing provides the potential for a definitive diagnosis of ZVI. Negative rRT-PCR results after a positive or equivocal Zika virus IgM antibody test result should be followed by PRNT. The decision to implement testing of asymptomatic pregnant women with ongoing risk for Zika virus exposure should be made by local health officials based on information about levels of Zika virus transmission and laboratory capacity.

Symptomatic and asymptomatic pregnant women who seek care more than 12 weeks after symptom onset or possible Zika virus exposure

For these women, IgM antibody testing might be considered. If fetal abnormalities are present, rRT-PCR testing should also be performed on maternal serum and urine. However, a negative IgM antibody test or rRT PCR result more than 12 weeks after symptom onset or possible exposure does not rule out recent ZVI because IgM antibody and viral RNA levels decline over time. Given the limitations of testing beyond 12 weeks after symptom onset or possible exposure, serial fetal ultrasonography should be considered.

Management

Management of confirmed ZVI is supportive, and includes rest, fluids, fever control, and analgesics.1 The Table provides recommendations for prenatal and postnatal management of pregnant women with laboratory evidence of confirmed or possible ZVI.

CDC guidance for HCPs caring for women of reproductive age3

Reproductive-aged women and their partners need counseling and education in accordance with their pregnancy intentions.

For couples who are not pregnant and are not planning to become pregnant in the near future

Healthcare providers should discuss strategies to prevent unintended pregnancy with these couples. When helping women choose a contraceptive method, its safety, effectiveness, availability, and acceptability should be considered. Women should be counseled to select the most effective method that they can use correctly and consistently. Long-acting reversible contraceptives, including subdermal implants and intrauterine devices, provide highly effective reversible birth control.

Couples in whom one partner has had possible Zika virus exposure will want to maximally reduce their risk for sexually transmitting Zika virus to the uninfected partner. They should use condoms consistently and correctly or abstain from sex for at least 6 months for men or 8 weeks for women after symptom onset (if symptomatic) or after the last possible Zika virus exposure (if asymptomatic). Some couples may choose to use condoms or abstain from sex for a shorter or longer period than recommended depending on their individual circumstances and risk tolerance.

For couples planning to conceive who do not live in areas with active Zika virus transmission

These couples should consider avoiding nonessential travel to areas with active Zika virus transmission. Women who have had possible Zika virus exposure through travel or sexual contact and do not have ongoing risks for exposure should wait at least 8 weeks from symptom onset (if symptomatic) or their last possible exposure (if asymptomatic) to attempt conception. Women who wait at least 8 weeks to conceive may have an increased likelihood that Zika virus no longer presents a risk for maternal–fetal transmission.

The CDC recommends that men with possible Zika virus exposure, regardless of symptom status, wait at least 6 months from symptom onset (if symptomatic) or their last possible exposure (if asymptomatic) before attempting conception with their partner. The recommendation to wait at least 6 months for asymptomatic men, as opposed to the previous recommendation to wait at least 8 weeks, is based on the range of time after symptom onset that Zika virus RNA has been detected in semen of symptomatic men and the absence of definitive data that the risk for sexual transmission differs between symptomatic and asymptomatic men. Zika virus has not been definitively cultured from semen more than 3 months after symptom onset. It is unknown whether detection of Zika virus RNA in semen indicates presence of infectious virus and the potential for transmission.

For couples who want to conceive, in which one or both partners live in areas with active Zika virus transmission

For these couples, any partner who experiences symptoms of ZVI should be tested for it. Men with results that indicate recent ZVI or unspecified flavivirus infection should wait at least 6 months from symptom onset to attempt conception with their partner; women with results that indicate recent ZVI or unspecified flavivirus infection should wait at least 8 weeks from symptom onset to attempt conception. Partners who have had symptoms of ZVI with negative Zika virus test results should talk with their HCP about timing of conception in the setting of ongoing risk for possible exposure.

Couples living in an area with active Zika virus transmission should be counseled on the possible risk for ZVI during the periconception period. The CDC has developed tools to assist HCPs with preconception counseling. HCPs should provide counseling about the potential consequences to the fetus associated with ZVI during pregnancy, such as microcephaly and other serious brain abnormalities. Women should discuss their reproductive life plans with their HCP, in the context of potential and ongoing Zika virus exposure. HCPs should review factors that might influence pregnancy timing (e.g., unknown duration of Zika virus outbreak, fertility, age, reproductive history, health history, personal values and preferences). For couples who choose to conceive, HCPs should emphasize the use of mosquito bite prevention strategies while attempting pregnancy and during pregnancy.

Conclusion

The Zika virus has been declared a public health emergency because of the ease of transmission, the relatively benign and asymptomatic viral infection it causes, and its correlation with major neurologic complications in newborns whose mothers contracted ZVI during pregnancy. A continued response from government agencies, local health officials, HCPs, and researchers remains underway to shed new light onto this growing concern. As this epidemic continues to unfold, it remains crucial to educate women of childbearing age and their partners about the inherent risks of the Zika virus and avoidance of infection.

Jessica L. Isnetto is a faculty member at Kaplan University in Orlando, 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. Ploudre AR, Bloch EM. A literature review of Zika virus. Emerg Infect Dis. 2016;22(7):1185-1192.

2. CDC. Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure — United States, July 2016.

3. CDC. Update: Interim Guidance for Preconception Counseling and Prevention of Sexual Transmission of Zika Virus for Persons with Possible Zika Virus Exposure — United States, September 2016.

Ten questions patients are being encouraged to ask (are you proactively answering them?)

The communication gap between healthcare providers (HCPs) and patients has been met with its fair share of commentary, research, and critique. One thing we can likely all agree on:

For patients to safely use their medications—and reap the most benefit—they need a clear understanding of how and when to take them and what to be on the lookout for in terms of potential risks and side effects. Studies have shown that all too commonly, patients lack key information or are not aware of risks associated with the medications they take. Clear communication at the start of a new drug regimen can help maximize the helpful effects and minimize possible adverse effects of medications.

With the ultimate goal of reducing adverse drug reactions and improving medication adherence, the National Council on Patient Information and Education (NCPIE), in collaboration with the FDA, launched the Talk Before You Take (TBYT) public education initiative to increase medication safety communications between HCPs and patients. TBYT encourages patients to proactively ask, and HCPs to proactively address, 10 questions about all new medications prescribed:

1. What’s the name of the medicine, and what is it for?

2. How and when do I take it, and for how long?

3. What side effects should I expect, and what should I do about them?

4. Should I take this medicine on an empty stomach or with food?

5. Should I avoid any activities, foods, drinks, alcoholic beverages, or other medicines while taking this prescription?

6. If it’s a once-a-day dose, is it best to take it in the morning or in the evening?

7. Will this medicine work safely with any other medicines I’m taking, including over-the-counter medicines?

8. When should I expect the medicine to begin to work, and how will I know if it’s working?

9. How should I store it?

10. Is there any additional written information I should read about the medicine?

Do you and your teams proactively address these questions with patients when a new medicine is prescribed?  Initiatives to improve medication safety, such as

Talk Before You Take, are most effective when HCPs are aware and involved. NPWH serves on NCPIE’s advisory board and supports its activities to educate and mobilize consumers around safe use of medications. To facilitate clear conversations about medication use, the campaign provides information for HCP offices and handouts for patients, all available at TalkBeforeYouTake.org.

W. Ray Bullman is Executive Vice President of the National Council on Patient Information and Education.

Drugs in pregnancy, lactation, and reproductive health: Standards for prescribers

In June 2015, the FDA updated its recommendations for the labeling of drugs with respect to their use by pregnant women, lactating women, and females and males of reproductive potential. Healthcare providers caring for these populations, many of whom are taking prescription medications and biologics, need to be alert to these labeling changes.

Between 64% and 94% of pregnant women use a prescribed medication during their gestation.1,2 Among pregnant women who take prescribed medications, 80% do so during the first trimester,3 when fetal organ systems and structures are being formed. For many women who are managing chronic diseases, discontinuing the medications is not an option. In addition, because more than 50% of pregnancies in the United States are unintended,4 a large group of women are exposing their fetus to medications before they even realize that they are pregnant.

For postpartum patients on medications for chronic conditions, the choice to breastfeed their infant may pose a dilemma. Many of these women are advised to bottle-feed their infants instead, even if they are using medications safely taken by lactating women.5 Likewise, women who become ill during the lactation period may be counseled to stop breastfeeding their child if they need to take certain medications. According to the Centers for Disease Control and Prevention, 77% of infants born in the United States in 2010 were breastfed.6 During the same year, breastfeeding rates were 49% at 6 months and 27% at 1 year. Because many breastfeeding mothers are using prescription medications, these statistics translate to hundreds of thousands of infants potentially being exposed to these same medications for prolonged periods of time.

For reproductive-aged women who could become pregnant, counseling with regard to the potential impact of prescription or over-the-counter medications on pregnancy is often lacking. In the case of drugs that are known teratogens, past research indicates that women who had them prescribed, compared with women for whom safer medications were prescribed, did not receive contraceptive counseling in greater numbers.7 The impact of certain drugs on fertility, including chemotherapeutic medications, may not be discussed unless the effects are catastrophic. Finally, there is scant information on the need for reproductive health counseling for men in terms of medication use. Available counseling has often focused on the impact of illicit drugs on male factor infertility.8

Role of the FDA

The thalidomide tragedy, as it developed in the late 1950s and early 1960s in Europe, provided the impetus for tighter regulation of drugs by the FDA in the United States. In 1979, the FDA adopted a labeling system  hat rated drugs for pregnant women using the well-known letter system: A, B, C, D, or X. At the time, the FDA did not provide a risk classification system for drugs taken during lactation. Pregnant women and nursing mothers were considered under the precaution areas of the counseling for medication use.9

Early in 1996, the FDA determined that the letter system was too simplistic.3 In addition, many drugs were allocated to different risk categories, depending on how the results of safety studies were being interpreted,10 resulting in confusion for healthcare providers (HCPs) and patients alike. The Teratology Society asked the FDA to develop a more comprehensive risk counseling strategy that would encompass all stages of the childbearing process.Changes to the system were proposed in 2008, and multiple public hearings and comment periods ensued. The Pregnancy and Lactation Labeling Rule (PLLR) was adopted and published in December 2014. Immediate compliance with the labeling rule has been required for all prescription drug and biologic products submitted to the FDA after June 30, 2015; phased-in compliance over 3-5 years is required for previously approved prescription drugs and biologics.11

The 2015 Pregnancy and Lactation Labeling Rule.12

The PLLR requires changes to the content and format for information presented in prescription drug labeling in the Physician Labeling Rule format to assist HCPs in assessing benefit versus risk and in subsequent counseling of pregnant women and nursing mothers who need to take medication, thereby enabling them to make informed decisions for themselves and their children. Subsections for pregnancy, lactation, and females and males of reproductive potential are required in the Use in Specific Populations section. Pregnancy letter categories have been removed.

Pregnancy subsection

Specific subheadings required in the pregnancy subsection include contact information for a pregnancy exposure registry for the drug (if one is available), a risk summary, clinical considerations, and available human and animal data. Some subheadings may be excluded if no relevant information is available.

Risk summary

This subheading is always required. If a drug is contraindicated in pregnancy, this fact must be listed first. Statements that describe risks for adverse developmental outcomes based on relevant human data, animal data, and the drug’s pharmacology are required. A cross-reference to additional details in the data subheading is included when applicable. Drugs not absorbed systemically following a particular route of administration include a statement that maternal use is not expected to result in fetal exposure to the drug. Drugs with more than one route of administration must include information related to each route.

Clinical considerations

This subheading provides information to further assist HCPs in prescribing decisions and risk–benefit counseling. When relevant, this subheading includes information about disease-associated maternal and/or embryo/fetal risk, dose adjustments during pregnancy and postpartum, maternal adverse reactions, fetal/neonatal adverse reactions, and labor/delivery. Inclusion of any disease -associated maternal and/or embryo/fetal risks is important for patient counseling and informed decision making. After all, HCPs and patients need to weigh the risks and benefits of not treating a disease/condition in pregnancy (e.g., depression, hyperlipidemia) versus the risks and benefits of taking a given drug during pregnancy.

When pharmacokinetic data support dose adjustment during pregnancy and/or postpartum, a summary of this information is provided. When applicable, cross-referencing to other labeling sections (e.g., Clinical Pharmacology, Dosage and Administration) for additional information is included.

Drug-associated adverse reactions that are unique to pregnancy or that occur with increased frequency or severity in pregnant women are described. When available, information on any clinical interventions to monitor or reduce maternal drug-associated adverse reactions is provided.

The fetal/neonatal adverse reactions described in this subsection are those based on the drug’s pharmacologic activity. The potential severity and reversibility of the adverse reaction, as well as interventions for monitoring and mitigation of the adverse reaction, are included.

If a drug is expected to affect labor or delivery, the labeling must provide available information about the drug’s effects on the mother, the fetus/neonate, and the duration of labor and delivery. An example is the use of an opioid during labor that may cause respiratory depression in the neonate. The labeling information includes the effect of dose, timing, and duration of exposure on the risk to the neonate and the use of naloxone to mitigate the reaction.

Data

Data that provide the scientific basis for the information in the risk summary and clinical consideration subheadings are included. Human and animal data are presented separately. Data regarding adverse developmental outcomes, adverse reactions, and other adverse events related to the drug must be included.

Lactation subsection

This subsection must include a risk summary, applicable clinical considerations, and any available human and animal data. The term lactation refers to the biologic state during which the body produces and excretes milk. The term breastfeeding is used to refer to all human milk, whether received directly from the breast or as expressed milk.

Risk summary

This subheading is always required. If a drug is contraindicated during breastfeeding (e.g., radioisotopes), this fact must be stated first. Drugs not absorbed systemically by the mother following a particular route of administration must include a statement that maternal use is not expected to result in the child’s exposure to the drug during breastfeeding. Drugs with more than one route of administration must include information related to each route. For drugs absorbed systemically, available information on whether the drug and/or its active metabolites are present in human milk, effects of the drug on the breastfed child, and effects of the drug on milk production and/or excretion must be included. If a drug and/or its active metabolites are present in human milk, detailed information on actual or estimated infant daily dose based on exclusive breastfeeding  must be provided. The risk summary must acknowledge when data are lacking.

Clinical considerations

A description of ways to minimize exposure of the breastfed child to systemically absorbed drugs that are used intermittently, in a single dose, or short term must be included. This description may include information on timing of administration of the drug relative to feeding, pumping sessions, or expressing for discarding. Specified time periods are based on the half-life of the drug and/or its active metabolite(s). Information on monitoring for adverse reactions must be included if available.

Data

As with the pregnancy subheading, data on which the risk summary and clinical considerations are based for lactation and breastfeeding are provided.

Females and males of reproductive potential subsection

This subsection is included if there are human or animal study data of potential drug-associated effects on fertility and/or pre-implantation loss. Recommendations for pregnancy testing and/or contraception may be based on concerns for adverse developmental outcomes if the drug is taken during pregnancy.

Relevance to practice

Healthcare providers can use the information provided in the new labeling to be better informed and enhance discussions about the benefits and risks of specific drugs with women who are pregnant or lactating or with patients of reproductive potential. The information contained in the PLLR may or may not be the same as that included in patient drug information.

Providers can utilize websites, mobile apps, and reference texts to focus counseling or answer patients’ questions (Table). These resources may be especially useful until the PLLR changes are fully implemented, as well as for supplemental information. As always, HCPs can consult with pharmacists regarding the pharmacokinetics and pharmacodynamics of a drug.

Kathleen M. Mahoney is a perinatal clinical nurse specialist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. 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. Ramoz LL, Patel-Shori NM. Recent changes in pregnancy and lactation labeling: retirement of risk categories. Pharmacotherapy. 2014;34(4):389-395.

2. Fantasia H, Harris A. Changes to pregnancy and lactation risk labeling for prescription drugs. Nurs Womens Health. 2015;19(3):266-270.

3. Mazur-Amirshahi M, Samiee-Zafarghandy S, Gray G, Van den Anker JN. Trends in pregnancy labeling and data quality for US-approved pharmaceuticals. Am J Obstet Gynecol. 2014;211(6):690e1-11.

4. Guttmacher Institute. Unintended Pregnancy in the United States. March 2016.

5. Saha MR, Ryan K, Amir LH. Postpartum women’s use of medicines and breastfeeding practices: a systemic review. Int Breastfeed J. 2015;10(28):1-10.

6. Centers for Disease Control and Prevention. Breastfeeding Report Card, 2013.

7. Schwartz EB, Postlethwaite DA, Hung YY, Armstrong MA. Documentation of contraception and pregnancy when prescribing potentially teratogenic medications for reproductive age women. Ann Intern Med. 2007;147(6): 370-376.

8. Fronczak CM, Kim ED, Barqawi AB. The insults of illicit drug use on male fertility. J Androl. 2012;33(4):515- 528.

9. Mosley JF 2nd, Smith LL, Dezan MD. An overview of upcoming changes in pregnancy and lactation labeling information. Pharm Pract (Granada). 2015;13(2):605.

10. Addis A, Sharabi S, Bonati M. Risk classification systems for drug use during pregnancy: are they a reliable source of information? Drug Saf. 2000;23(3):245-253.

11. Food and Drug Administration. Pregnancy and Lactation Labeling (Drugs) Final Rule. December 3, 2014.

12. Food and Drug Administration. Pregnancy, Lactation, and Reproductive Potential: Labeling for Human Prescription Drug and Biological Products — Content and Format. Washington, DC: Food and Drug Administration; 2015.

Web resources

A. reprotox.org

B. toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

C. mothertobaby.org/fact-sheets-parent

Recognition and prevention of stroke in women

Stroke is a debilitating event with lifelong implications for patients and their families. The sooner that symptoms of a stroke are recognized and treatment is initiated, the greater the likelihood that long-term sequelae can be mitigated or even prevented. Even better is preventing stroke before it happens in persons who are at risk.

A stroke is a syndrome of neurologic deficit arising from a vascular disorder that causes brain injury.1 In an ischemic stroke, which accounts for 87% of all strokes, arterial blood flow to the brain is interrupted as a result of a cerebral thrombosis or embolism.1 A transient ischemic attack (TIA) is caused by temporary clots that may presage a full-blown stroke in the future if preventive measures are not instituted. With a TIA, symptoms occur over a short period of time and resolve on their own. A hemorrhagic stroke, which accounts for 13% of all strokes, occurs when a weakened blood vessel ruptures in the setting of hypertension (HTN), an aneurysm, or an arteriovenous malformation.1

Incidence

In the United States, 6.8 million persons are stroke survivors; among these stroke survivors, 3.8 million are women.2 Stroke is the fifth-leading cause of death for men, but the third-leading cause for women.2 In the U.S., more than half (53.5%) of the estimated 795,000 new or recurrent strokes occur in women each year, resulting in about 55,000 more strokes in women than in men. Also, women who have a stroke, compared with their male counterparts, are institutionalized more often and have a poorer recovery and a worse quality of life.2

Symptoms

The National Stroke Association describes stroke symptoms as:

Sudden numbness or weakness of the face, arm, or leg, usually on one side;

Sudden confusion, difficulty with speech, or difficulty understanding speech;

Sudden difficulty seeing with one or both eyes;

Sudden difficulty walking, dizziness, or loss of balance or coordination; and/or

Sudden severe headache with no known cause.3 

Warning symptoms of a stroke should be known by both healthcare providers (HCPs) and the general public. One measure to promote stroke awareness is the FAST method (Sidebar).4 The key is to quickly recognize a stroke and call 9-1-1 for assistance as needed.

Risk factors

Many risk factors for stroke, including higher age, physical inactivity, prior cardiovascular disease, obesity, poor diet, smoking, and metabolic syndrome,  have a similar prevalence in women and men.2 Other stroke risk factors, including HTN, diabetes mellitus (DM), atrial fibrillation (AF), migraine with aura, depression, and psychosocial stress, are more prevalent and/or more dangerous in women than in men.Stroke risk factors that are specific to women include pregnancy, pre-eclampsia, gestational diabetes, combined oral contraceptive (COC) use, and possibly postmenopausal hormone therapy (HT) use.2 

Strategies for stroke prevention

These general measures can be taken, as needed, to reduce modifiable stroke risk factors2,5,6:

Smoking cessation: Smoking cessation is one of the best measures for stroke prevention.

Lifestyle changes: Following a healthful diet (e.g., Mediterranean diet or DASH diet) and increasing physical activity (at least 40 minutes 3-4 days/week) can help reduce body weight and levels of low-density lipoprotein cholesterol.

Statin pharmacotherapy: This regimen is recommended for patients with a high 10-year risk for a cardiovascular or cerebrovascular event. HCPs can access a risk calculator here.

Blood pressure reduction: HTN, more prevalent in women than in men after age 55, is considered the most modifiable risk factor for stroke. Maintaining a normal blood pressure (BP), and undergoing regular screening and treatment of HTN—with lifestyle changes and medication, as needed—are crucial to primary stroke prevention.

Blood glucose control: DM is a risk factor for stroke.

Atrial fibrillation control: Depending on a woman’s AF type and risk for hemorrhagic complications, she should be on anticoagulant therapy and possibly low-dose aspirin therapy.

Avoidance of exogenous estrogen use: This recommendation depends on a woman’s risk/benefit profile.

At-risk pregnant women

To prevent pre-eclampsia, women with chronic primary or secondary HTN or previous pregnancy-related HTN should take low-dose aspirin from the 12th week of gestation until delivery.1 Oral calcium supplementation (≥1 g/day) should be considered for women with low dietary intake of calcium (<600 mg/day). Women with severe HTN in pregnancy should be treated with safe and effective antihypertensives such as methyldopa, labetalol, or nifedipine. Consideration should be given to treating women with moderate HTN in pregnancy—again, with safe and effective antihypertensives. Atenolol, angiotensin receptor blockers, and direct renin inhibitors are contraindicated during pregnancy.

Combined oral contraceptive users

Aggressive therapy of additional stroke risk factors may be reasonable in COC users. Although routine screening for pro-thrombotic mutations before initiation of hormonal contraception is not useful, BP measurement is recommended. COC use may be harmful in women with stroke risk factors such as cigarette smoking or a history of thromboembolic events and should be reconsidered.

Hormone therapy users

Hormone therapy (e.g., conjugated equine estrogens,  alone or with medroxyprogesterone) should not be used for primary or secondary prevention of stroke in postmenopausal women. Selective estrogen receptor modulators such as raloxifene and tamoxifen should not be used for primary prevention of stroke.

Migraineurs with aura

Because of the link between higher migraine frequency and stroke risk, treatments to reduce migraine frequency may be reasonable, although evidence is lacking that this approach reduces the risk of a first stroke. Because of the increased stroke risk seen in female migraineurs with aura who smoke, smoking cessation in this group is strongly advised.

Women with atrial fibrillation

Considering the increased prevalence of AF with age and the higher risk of stroke in elderly women with AF, active screening (in particular of women older than 75 years) in primary care settings using pulse taking followed by an ECG is recommended. Oral anticoagulation is not recommended in women aged 65 years or younger with AF alone and no other risk factors. Antiplatelet therapy is a reasonable therapeutic option for selected low-risk women. New oral anticoagulants are a useful alternative to warfarin for prevention of stroke and systemic thromboembolism in women with paroxysmal or permanent AF and pre-specified risk factors who do not have a prosthetic heart valve or hemodynamically significant valve disease, severe renal failure, lower weight, or advanced liver disease.

Women with depression or psychosocial stress

No specific recommendations regarding stroke prevention were provided for this group. More research is needed to establish which women are at greater risk for stroke and which interventions, if any, may be helpful in reducing stroke risk.

Conclusion

Both women and their HCPs need to be able to recognize stroke symptoms and take action as quickly as possible if an ongoing stroke is suspected. For women at risk for stroke, implementing measures that will reduce stroke risk is vital. HCPs caring for women should be particularly alert to the risks that are more prevalent and dangerous in women and those that are specific to women, and should guide these women accordingly in terms of recommending appropriate prophylactic measures.

Janis R. Guilbeau and Cynthia Watson are nursing faculty at the University of Louisiana at Lafayette. 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. Grossman S. Porth C. Porth’s Pathophysiology: Concepts of Altered Health States. 9th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2014.

2. Bushnell C, McCullough LD, Awad IA, et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Guidelines for the Prevention of Stroke in Women: A Statement for Healthcare Professionals From the American Heart Association/ American Stroke Association. Stroke. 2014;45(5):1545-1588.

3. National Stroke Association. Reducing Risk and Recognizing Symptoms. August 2009.

4. National Stroke Association. Act FAST. 2016.

5. CDC. Preventing Stroke: Healthy Living. Page last updated April 30, 2015.

6. Meschia JF, Bushnell C, Boden-Albala B, et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Functional Genomics and Translational Biology, and Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(12):3754-3832.

Position Statement: The Doctor of Nursing Practice for Women’s Health Nurse Practitioners

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports a pragmatic approach for the continuing evolution to the Doctor of Nursing Practice (DNP) degree as entry level for women’s health nurse practitioners (WHNPs). During the transition, study of the impact of DNP education on quality, access, and cost of healthcare should be ongoing. Policies must be in place to ensure that currently practicing WHNPs are not disenfranchised from practice in any way. Furthermore, NPWH advocates for concerted strategies to maintain an adequate number of highly qualified WHNPs to meet the healthcare needs for individuals and communities.

Background

In October 2004, the American Association of Colleges of Nursing (AACN) published a position paper with the recommendation to transition the entry-level degree for advanced practice registered nurses (APRNs) from the master’s degree to the DNP by the year 2015.The AACN position paper outlined several trends to support the need for a practice doctorate for advanced nursing practice. These trends included continuing expansion of scientific knowledge, technology and informatics advances, increasing complexity of healthcare systems, the need for improved patient outcomes, and the need for parity with other healthcare professionals.

The Institute of Medicine (IOM) 2011 report, The Future of Nursing: Leading Change, Advancing Care, recognized that more would be expected of the APRN as the healthcare system grows in complexity, scientific knowledge continues to expand, and technology advances.2 APRNs would need competence in aspects of healthcare that require additional coursework and aligned clinical experiences. Further, the IOM report recognized the importance of DNP-prepared APRNs as clinical scholars who translate research and positively affect individual and population health outcomes at organizational and systems levels.

Based on the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice, DNP curricula go beyond that of master’s programs.3 DNP programs prepare APRNs as leaders in evidence- based practice, quality improvement, systems thinking, and clinical scholarship. DNP curricula provide critical learning in the areas of informatics and technology, healthcare policy and advocacy, population health, and inter-professional collaboration to improve healthcare.

In 2015, the National Organization of Nurse Practitioner Faculties (NONPF) reaffirmed a commitment to advancing the DNP degree as entry level for the NP role.4 Further, NONPF recommended that all NP programs provide a postbaccalaureate to DNP with a seamless, integrated curriculum that prepares graduates with NP core competencies,population-focused  competencies,and competencies of the DNP Essentials.3

Significance to women’s healthcare and WHNP practice

NPWH affirms that master’s and certificate programs have fully prepared WHNPs with the competencies required to provide safe, quality healthcare for women. NPWH also recognizes the growing complexity of healthcare environments and the continuously expanding body of scientific knowledge regarding women’s health and healthcare needs. DNP education provides WHNPs with advanced competencies significant to providing women’s healthcare and enhancing NP practice.

Women benefit when WHNPs are prepared with the highest level of scientific knowledge and the ability to translate that knowledge quickly and effectively into practice. Proficiency in leading quality improvement strategies that create and sustain positive change at organizational and policy levels leads to improved health outcomes. Advanced preparation in the inter-professional dimension of healthcare enables WHNPs to facilitate collaborative team functioning. DNP-prepared WHNPs provide a critical interface between practice, research, and policy, with a focus on women’s health.

NPWH also recognizes challenges that must be addressed regarding the move to the DNP as entry level for WHNP practice. The DNP degree will require longer educational programs that add to educational costs. Longer educational programs may also slow the number of WHNPs prepared to meet national healthcare shortages. Financial gain for the WHNP prepared at the DNP level is not guaranteed.

NPWH recommendations

DNP education must include availability for preparation in the WHNP population focus.

• The DNP curriculum for the WHNP population focus must incorporate the WHNP Guidelines for Practice and Education.7

NPWH and other APRN organizations must collaborate to address the challenges presented in making the transition to the DNP as entry into practice for APRNs in an informed and equitable manner.

NPWH and other APRN organizations must participate in and support research to study the impact of DNP education on quality, access, and cost of healthcare.

NPWH will continue to advocate at organizational and legislative levels to ensure that policies and regulations support the practice of all WHNPs. NPWH will support only those policies and regulations for NP practice, education, and reimbursement that do not disenfranchise WHNPs without DNP degrees.

References

1. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. October 2004.

2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

3. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. 2006.

4. National Organization of Nurse Practitioner Faculties. The Doctorate of Nursing Practice NP Preparation: NONPF Perspective. 2015.

5. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies. 2012.

6. Population Focused Competencies Task Force. Population-Focused Nurse Practitioner Competencies2013.

7. National Association of Nurse Practitioners in Women’s Health. Women’s Health Nurse Practitioner: Guidelines for Practice and Education. 7th ed. 2014.

Message from the CEO

As I am sure many of you know, NPWH always strives to provide you with tools and information that you can use to further your professional development and your education. I am proud to announce that NPWH has developed the Women’s Health Nurse Practitioner Certification Exam Review Course and Women’s Health Update! This 22-module package provides a comprehensive review course that will help new WHNP graduates prepare for the National Certification Corporation (NCC) WHNP certification examination. In addition, the review course package includes a module on test-taking strategies, with more than 200 review questions that are presented in the NCC question format.

This course is designed to meet the needs of not only new WHNP graduates but also students and practicing NPs. In addition, current WHNP students can use selected modules to supplement course content as they progress through their academic program. The added benefit of this review course is that WHNPs will earn continuing education credit and pharmacology hours for each module.

These modules have been created and presented by 15 NCC-certified WHNPs who are experts in women’s health. All presenters of the modules either currently teach or have taught in WHNP programs and were chosen specifically because they specialize in the topic. Exposure to multiple WHNP experts enables participants to experience a variety of presenting styles that will keep them engaged throughout the course.

As a final important note, each module was reviewed by two external NPs with a range of experience, from recent graduates to veteran WHNPs.

For more information on how to purchase the entire review course or selected modules, please visit www.npwh.org and click on E-Learning and then Curriculum.

We hope to see you in New Orleans for our 19th Annual PremierWomen’s Healthcare Conference, which will be held from September 28 through October 1, 2016. This conference promises to be an exciting event in a fabulous location! Visit our website for more information.

– Gay Johnson

Chief Executive Officer, NPWH

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.

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.

Collaboration in practice: A framework for team-based care

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

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

Team-based care and collaboration

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

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

Core concepts: Application to women’s health practice

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

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

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

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

Conclusion

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

The aforementioned Executive Summary of the Collaboration in Practice document provides an overview of the process and key points. All of the essential elements of the work, including recommendations for implementing an equitable, accessible, reimbursable, patient-centric model of care, are elaborated in the full report. The Collaboration in Practice team invites you to consider how the full report can be used to enhance your practice and improve patient outcomes.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri- St. Louis; a consultant at Health Policy Advantage,LLC, in St. Louis, Missouri; and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH). She served as the NPWH delegate to ACOG’s Collaborative Practice Task Force. She can be reached at 314-629-2372 or at skendig@npwh.org.

References

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

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

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

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

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

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

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

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

Sexuality in the aging population: Statement of the problem

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

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

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

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

Sexual dysfunction in older patients

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

Sexual interest/arousal disorders

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

Genito-pelvic pain/penetration disorder

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

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

Sexually transmitted infections

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

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

Conclusion

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

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she serves as a speaker and advisory board member for Shionogi and Actavis and as an advisory board member for Valeant.

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Early pregnancy loss management for nurse practitioners and midwives

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

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

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

Causes of early pregnancy loss

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

Management of early pregnancy loss

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

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

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

Expectant management

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

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

Medication management

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

Aspiration management

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

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

Resources

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

Message from the CEO

In case you haven’t noticed, NPWH is striving to provide more and more educational offerings for nurse practitioners. We just completed our complimentary continuing education (CE) 1-day regional course, Managing Women’s Health Issues Across a Lifespan, in Pasadena, California. I am pleased to report that the attendees found the content very informative and the expert faculty highly inspiring. They felt it was worthwhile to give up a Saturday in order to learn more about long-acting reversible contraceptives, endometriosis, genitourinary syndrome of menopause, and obesity, and to earn free CE credits. We are working toward providing more of these regional courses covering additional hot topics in women’s health next year.

Another update: We are building out our Well Woman Visit mobile app to include assessment and treatment options for irritable bowel syndrome. Stay tuned for the announcement indicating that this updated app is available to download. For those of you who haven’t already downloaded our mobile app, please visit npwh.org or go to the Apple Store and download it for free. The app is available for both Apple’s iOS and Google’s Android operating systems. We have received praise from members of organizations such as the American Association of Nurse Practitioners, who recognize that our WWV app is easy to use, is scientifically sound, and serves as a handy and immediate reference during a patient visit.

And here’s more good news: Registration is still open for the Women’s Sexual Health Course for NPs, which will be held on June 23-26, 2016, in San Diego, California. This is the only post-graduation educational offering on women’s sexual health for nurse practitioners. You will receive not only CEs but also a Certificate of Completion, which documents that you have gained knowledge in the area of women’s sexual health.

And, finally, the 19th Annual NPWH Premier Women’s Healthcare Conference, our national clinical conference, is almost here! This year, our conference takes place in the vibrant city of New Orleans on September 28-October 1, 2016. The conference program guide, which appears on pages 23-26 of this issue, reveals the variety of leading-edge topics we are offering this year, along with courses covering essential primary skills to incorporate into your practice. You’ll want to register early to take advantage of the discount; the complete program guide, including the registration form, is available at npwh.org. As always, NPWH takes great pride in offering up-to-date women’s health content imparted by experts in their fields so that you can gain the knowledge and skills you need to provide high-quality healthcare to women of all ages.

Gay Johnson

Chief Executive Officer, NPWH

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.

Editor-in-chief‘s message

Dear Colleagues,

I am excited to now serve as Publication Coordinator for NPWH along with my continuing role as Editor-in-Chief of the journal. In the role of Publication Coordinator, I work with the Board of Directors (BOD), our Chief Executive Officer (CEO) Gay Johnson, and our staff to expand the benefits NPWH brings to its members. It is my pleasure to share with you some of the activities with which I am engaged.

One of the responsibilities of my new role is to coordinate the development of position statements for NPWH. Position statements provide an explanation, justification, or recommendation for a course of action that reflects the organization’s stance regarding a specific issue or concern. Position statements can be used to facilitate development and advocacy for health policies, direct educational activities, promote evidence-based practice, support research, and/or encourage collaboration with other agencies and organizations. In keeping with the mission of NPWH, position statements for the organization always advocate for women’s health and the practice of WHNPs and other nurse practitioners who provide women’s healthcare.

With input from the membership, the NPWH BOD and professional staff are charged with identifying priority issues and concerns. The process for writing position statements is inclusive, and requires active involvement of NPWH members—from identifying issues, to participating as a writing group member, to reviewing and providing feedback on drafts.

We have collaborated with Sigma Theta Tau International Honor Society of Nursing to establish collections in both the “Nursing Organizations—Events” and the “Nursing Organizations—Resource Papers” communities on the Virginia Henderson Global Nursing e-Repository. The NPWH events collection will enable our conference research and innovative clinical project poster and podium presenters to have abstracts posted in the e-Repository, making their work available to nurses around the globe. The resource papers collection will provide another avenue for NPWH to reach nurses and other constituents with our position statements, guidelines, and other important documents to promote women’s health. Watch for our entries in both of these collections later this summer.

We have been hard at work on the online NPWH Certification Review Course for WHNPs and are pleased to let you know that it will be available early this summer. The course will have 21 modules covering the topics outlined in the NCC WHNP certification examination guide, with review questions at the end of each module. Continuing education credit will be provided.

I am looking forward to continuing to work enthusiastically with the NPWH BOD, our CEO, our staff, and our members to support our organization’s mission and goals.

Beth Kelsey, EdD, APRN, WHNP-BC

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.

Sexual enhancers: Lubricants, aids, and toys

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

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

Moisturizers and lubricants

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

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

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

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

Supplements

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

Sexual accessories

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

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

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

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

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

General recommendations

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

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

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. Susan Kellogg-Spadt is Director of Female Sexual Medicine, Academic Urology Center for Pelvic Medicine, in Bryn Mawr, Pennsylvania, and has multiple academic titles and affiliations. Ms. Faught reports that she is a speaker and/or advisory panel member for Shionogi, Actavis, and Female Health Company. Dr. Kellogg-Spadt reports that she is a consultant for NeoGyn, Lelo, and Nuelle.

Websites

pureromance.com

goodvibes.com

adamandeve.com

middlesexmd.com

lelo.com

fiera.com

References

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

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

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

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

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

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

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

Expedited partner therapy for chlamyida

You may have chlamydia. If you do, you need to be treated for it. Your sex partner was recently treated for chlamydia, an infection you can get if you have sex with a person who is already infected. Many people with chlamydia do not know they have an infection because they feel fine.

Your partner may have given you a prescription or pills (azithromycin; also called Zithromax or a Z-Pak) for you to take. This medicine was given to your partner by a healthcare provider to treat you. This type of treatment is sometimes called expedited partner therapy. It’s better for you to go to your own provider to get tested for chlamydia and other sexually transmitted diseases (STDs). But if you can’t go to get tested, then you should take the medicine in this package.

If you are a female and have symptoms of belly or pelvic pain, especially during sex, you should go see a healthcare provider to make sure that you do not have pelvic inflammatory disease (PID). PID can be very dangerous and lead to infertility, pregnancy problems, or pain that lasts a long time.

If you have any questions, please call your healthcare provider. If you think you may be having a bad reaction to this medicine, call your provider or drugstore. If you are having a serious reaction, such as trouble breathing, which is very rare, go to your nearest emergency room and bring the empty medicine packet with you.

Directions for taking azithromycin (Zithromax) 250 mg tablets

This medicine is very safe. However, you should not take it if you ever had an allergic reaction (such as a rash, trouble breathing, closing of your throat, swelling of the lips and tongue, or hives) after taking any medicines. If you are unsure about whether you have ever had an allergy to any medicines, call your provider or drugstore before taking this medicine. If you have a serious, longterm illness such as kidney disease, liver disease, heart disease, or stomach problems, talk to your provider before taking this medicine.

Swallow all of the enclosed pills. These pills should be taken one after another at the same time, not on separate days. Some people have a mild upset stomach, which does not last long, after taking this medicine.

After taking the medicine, do not have sex for at least 7 days. Do not share this medicine or give it to anyone else. It is important to tell any person with whom you’ve have had sex in the past 60 days to go to a healthcare provider and get tested for chlamydia.

Adapted from the Partner Study, Public Health – Seattle & King County and the STD Treatment Guidelines, CDC.

Gonorrhea is another STD for which expedited partner therapy is available. To find out more about gonorrhea, log on to cdc.gov. To find out more about chlamydia, log on to cdc.gov.

*Healthcare providers need to conform to their state legal requirements with respect to the use of expedited partner therapy. If the information in this Patient education page is applicable to the patients in your state and in your practice, then you are invited to photocopy the page and distribute it to patients who can benefit from this information.

Dyspareunia for a dozen years in a young woman

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

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

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

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

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

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

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

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

Which differential diagnoses would you consider at this point?

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

• Vulvitis;

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

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

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

• Vaginismus; and

• Vulvodynia.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What types of pharmacologic agents are appropriate?

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

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

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

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

When is surgery an option?

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

Reflection for practice

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Message from the CEO

February may have been the shortest month of the year, but all of us at NPWH made the most of it by preparing for a busy and productive year. We welcome a new board chair, Jacki Witt, who is from Kansas City, Missouri, and three new board members: Diana Drake, from Minneapolis, Minnesota; Shelagh Larson, from Fort Worth, Texas; and Jordan Vaughan, from Nashville, Tennessee. We are also pleased to announce that Beth Kelsey, Editor-in-Chief of this journal, has added a new role: NPWH Publication Coordinator. Congratulations to all!

In January, we launched “Women’s Health Wisdom,” NPWH’s own blog! The purpose of the blog is to share thoughts, updates, and new information and opportunities related to women’s health policy, primary care, sexual health, pregnancy, pre-conception, postpartum concerns, heart health, mental health, overactive bladder, and many other topics. You can access the new blog by clicking here or by logging on to the NPWH website.

In April, we are offering a new regional CE course, Managing Women’s Health Issues Across a Lifespan. This live, interactive, 1-day meeting will be held at the Sheraton Pasadena Hotel in Pasadena, California. The course will include topics such as LARC, endometriosis, obesity, and genitourinary syndrome of menopause. You can register for this course here. See the back cover of this issue for much more information. And we proudly present the third annual Women’s Sexual Health Course for NPs on June 23-26, 2016, at the Sheraton Mission Valley San Diego Hotel in San Diego, California. New to the sexual health course this year will be a post-conference session for hands-on vulvoscopy training. The program guide for the Women’s Sexual Health Course for NPs appears on pages 8-12 in the journal; registration is available at npwh.org.

Make the most of this exciting year of 2016 by joining NPWH! You won’t want to miss out on all the exciting activities we have planned. And you will want to take advantage of the membership discounts and value-added features that we provide throughout the year.

– Gay Johnson

Chief Executive Officer, NPWH

Editor-in-chief’s message

Dear Colleagues,

I hope you’re all enjoying a happy and healthy new year and looking forward to the upcoming spring season!

Women’s Healthcare: A Clinical Journal for NPs is now entering its third year of publication! We are looking forward to providing you, our readers, with another year of up-to-date, useful information as you continue your important work of providing high-quality healthcare to women.

We have many excellent feature-length articles, as well as a large number of shorter articles (in our departments), coming up in 2016. You’ve likely noticed that we’ve expanded our journal departments in response to your request for shorter articles that still provide timely and relevant information to meet your clinical and professional needs. Our departments now include Assessment & Management, On the Case, Clinical Resources, Professional Development, Patient Education, DNP Projects: Spotlight on Practice, Policy & Practice Points, Commentary, and Focus on Sexual Health.

I hope that you will help us keep the momentum going by submitting a manuscript in one of the multiple formats we offer. We are especially interested in the shorter articles for our journal departments. As always, we welcome feature-length manuscript submissions as well.

Click here to visit our journal website to access the complete Guidelines for Authors. In case you need inspiration, please consider writing about topics such as abnormal uterine bleeding, adolescent health, cancer in women, coding for ob/gyn diagnoses, contraception for women with chronic health conditions, human trafficking, male reproductive health, older women’s health, or pregnancy complications. We welcome query letters about any topic and article format you are considering; you can reach us at bkelsey@healthcommedia.com and dgreene@healthcommedia.com. Even if you’re not quite ready to write for us, please let us know if you have a particular topic that you want to see covered in the journal.

In this first journal issue of 2016, I extend a special thank-you to the individuals who peer-reviewed manuscripts for us in 2015:

Kelly Ackerson, Cynthia Adams, Ivy Alexander, Carola Bruflat, Lorraine Byrnes, Joyce Cappiello, Helen Carcio, Janie Daddario, Melanie Deal, Brenda Deeser, Linda Dominguez, Caroline Hewitt, Susan Hoffstetter, Amy Levi, Patrice Malena, Anne Moore, Suzy Reiter, Michelle Schramm, Beth Steinfeld, Carolyn Sutton, and Jordan Vaughan.

In the November 2015 issue, I wrote about the opportunity to become a peer reviewer for our journal. I was happy to hear from many of you. Please click here for an application form to join this fine cadre of nurse practitioners and nurse midwives who have helped to make the articles we publish the very best!

Beth Kelsey, EdD, APRN, WHNP-BC

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.

References

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

2. FDA Patient Safety News: Show #16, June 2003.

3. National Cancer Institute. HPV Testing to Screen for Cervical Cancer.

4. Centers for Disease Control and Prevention. CDC Vital Signs. Cervical cancer is preventable. November 2014.

5. Cox JT, Castle PE, Behrens CM, et al; Athena HPV Study Group. Comparison of cervical cancer screening strategies incorporating different combinations of cytology, HPV testing, and genotyping for HPV 16/18: results from

the ATHENA HPV study. Am J Obstet Gynecol. 2013;208(3):184.e1-184.e11.

6. Saslow D, Solomon D, Lawson HW, et al; ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. J Low Genit Tract Dis. 2012;16(3):175-204.

7. American Society for Colposcopy and Cervical Pathology (ASCCP). Cervical Cancer Screening Recommendations. PowerPoint Presentation. 2012.

8. Kelsey B. The role of HPV testing: co-test or primary screen? Womens Healthcare. 2015;3(2):29-32.

9. Gibb RK, Martens MG. The impact of liquid-based cytology in decreasing the incidence of cervical cancer. Rev Obstet Gynecol. 2011;4(suppl 1):S2-S11.

10. Bosch FX, Lorincz A, Muñoz N, et al. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55(4):244-265.

11. de Sanjose, S, Quint WG, Alemany L, et al; Retrospective International Survey and HPV Time Trends Study Group. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol. 2010;11(11):1048-1056.

12. Khan MJ, Castle PE, Lorincz AT, et al. The elevated 10-year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J Natl Cancer Inst. 2005; 97(14):1072-1079.

13. Abreu ALP, Souza RP, Gimenes F, Consolaro MEL. A review of methods for detect human Papillomavirus. Virol J. 2012;9:262.

14. HC2 High-Risk HPV DNA Test® Package Insert (B). Kaiser Study Data. Test Performance Versus Consensus Histology Results (CIN2-3+) Ages <30.

15. Arbyn M, Roelens J, Cuschieri K, et al. The APTIMA HPV assay versus the Hybrid Capture 2 test in triage of women with ASC-US or LSIL cervical cytology: a meta-analysis of the diagnostic accuracy. Int J Cancer. 2013; 132(1):101-108.

16. Aptima® HPV Assay Package Insert.

17. United States Preventive Services Task Force. Screening for Cervical Cancer. 2012.

18. Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 131: screening for cervical cancer. Obstet Gynecol. 2012;120(5):1222-1238.

19. Bosch FX, Broker TR, Forman D, et al. Comprehensive control of human papillomavirus infections and related diseases. Vaccine. 2013;31(31 suppl 7):H1-H31.

20. American Congress of Obstetricians and Gynecologists. Practice Bulletin Number 157. Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016;127(1):185-187.

21. Cox JT, Castle P, Behrens C, et al. Comparison of cervical cancer screening strategies incorporating different combinations of cytology, HPV testing, and genotyping for HPV 16/18: results from the ATHENA HPV study. Am J Obstet Gynecol. 2013;208(3): 184.e1-c11.

22. Wright TC, Stoler M, Behrens C, et al. Primary cervical cancer screening with human papillomavirus: end of study results from the ATHENA study using HPV as the first-line screening test. Gynecol Oncol. 2015; 136(2):189-197.

23. U.S. Food and Drug Administration. FDA approves first human papillomavirus test for primary cervical cancer screening. FDA News Release April 24, 2014.

24. Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol. 2015; 125(2):330-337.

25. Blatt AJ, Kennedy R, Luff RD, et al. Comparison of cervical cancer screening results among 256,648 women in multiple clinical practices. Cancer Cytopathol. 2015;123(5):282-288.

26. de Cremoux P, Coste J, Sastre-Garau X, et al; French Society of Clinical Cytology Study Group. Efficiency of the hybrid capture 2 HPV DNA test in cervical cancer screening. A study by the French Society of Clinical Cytology. Am J Clin Pathol. 2003; 120(4):492-499.

27. Naucler P, Ryd W, Tørnberg S, et al. Efficacy of HPV DNA testing with cytology triage and/or repeat HPV DNA testing in primary cervical cancer screening. J Natl Cancer Inst. 2009;101(2):88-99.

28. Li Z, Austin RM, Guo M, Zhao C. Screening test results associated with cancer diagnoses in 287 women with cervical squamous cell carcinoma. Arch Pathol Lab Med. 2012;136(12): 1533-1540.

29. Zhao C, Li Z, Austin RM. Cervical screening test results associated with 265 histopathologic diagnoses of cervical glandular neoplasia. Am J Clin Pathol. 2013;140(1):47-54.

30. Dillner J, Rebolj M, Birembaut P, et al; Joint European Cohort Study. Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening: joint European cohort study. BMJ. 2008;337:a1754.

31. Katki HA, Kinney WK, Fetterman B, et al. Cervical cancer risk for women undergoing concurrent testing for human papillomavirus and cervical cytology: a population-based study in routine clinical practice. Lancet Oncol. 2011;12(7):663-672.

32. Gage JC, Schiffman M, Katki HA, et al. Reassurance against future risk of precancer and cancer conferred by a negative human papillomavirus test. J Natl Cancer Inst. 2014;106(8).

33. Ronco G, Dillner J, Elfström, EM, et al; International HPV screening working group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383(9916):524-532.

34. Doorbar J. Molecular biology of human papillomavirus infection and cervical cancer. Clin Sci (Lond). 2006;110(5):525-541.

35. Lie AK, Kristensen G. Human pap illomavirus E6/E7 mRNA testing as a predictive marker for cervical carcinoma. Expert Rev Mol Diagn. 2008; 8(4):405-415.

36. Sawaya G, Kuppermann M. Identifying a “range of reasonable options” for cervical cancer screening. Obstet Gynecol. 2015;125(2):308-310.

37. Sharp L, Cotton S, Cruickshank M, et al; TOMBOLA Group. The unintended consequences of cervical screening: distress in women undergoing cytologic surveillance. J Low Genit Tract Dis. 2014;18(2):142-150.

38. Sutthichon P, Kietpeerakool C. Perioperative complications of an outpatient loop electrosurgical excision procedure: a review of 857 consecutive cases. Asian Pac J Cancer Prev. 2009;10(3):351-354.

39. Kyrgiou M, Koliopoulos G, Martin- Hirsch P, et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and metaanalysis. Lancet. 2006;367(9509): 489-498.

40. Ørtoft G, Henriksen TB, Hansen ES, Petersen LK. Preterm birth and previous conisation of the cervix. Br J Obstet Gynaecol. 2010;117(9):1158-1169.

41. Arbyn M, Kyrgiou M, Simoens C, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ. 2008;337:a1284.

42. Kinney W, Wright TC, Dinkelspiel HE, et al. Increased cervical cancer risk associated with screening at longer intervals. Obstet Gynecol. 2015; 125(2):311-315.

43. Kulasingam SL, Havrilesky LJ, Ghebre R, Myers ER. Screening for cervical cancer: a modeling study for the US Preventive Services Task Force. J Low Genit Tract Dis. 2013; 17(2):193-202.

Sexually transmitted diseases: An update on retesting guidelines and reinfection prevention strategies

Approximately 20 million new sexually transmitted diseases (STDs) occur in the United States each year.1 To help healthcare providers (HCPs) treat these infections and prevent new infections, the

CDC has issued Sexually Transmitted Diseases Treatment Guidelines, 2015, an update of its 2010 report.2 These updated guidelines include nine new topics, one of which entails retesting to detect repeat infection—the topic of this article.

At least 1 in 10 females becomes reinfected after treatment for chlamydia or gonorrhea and up to 1 in 6 becomes reinfected after treatment for trichomoniasis.3,4 Untreated chlamydia or gonorrhea can increase a woman’s risk for developing pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. In fact, women with chlamydia or gonorrhea reinfection may have an even higher risk for PID and ectopic pregnancy than those with a first infection.Untreated trichomoniasis can increase the risk for premature delivery.5

Retesting several months after diagnosis and treatment of chlamydia, gonorrhea, or trichomoniasis can detect repeat infection early on, and can be used to improve population-based prevention efforts.6, 7 The CDC recommends that any female or male who tests positive for chlamydia or gonorrhea and any female who tests positive for trichomoniasis be retested 3 months after treatment.

Of note, retesting for reinfection and a test of cure (TOC) are not the same. A TOC is performed 3-4 weeks after treatment if concern exists regarding persistence of infection despite treatment. A TOC is recommended if symptoms of infection persist or if lack of adherence to the treatment regimen is suspected. TOC is also recommended after treatment of chlamydia during pregnancy.

Retesting for repeat infection may occasionally detect persistent infection. In most cases, however, infections found on retesting are reinfections, transmitted by either an untreated prior partner or an infected new partner.4, 8, 9 Retesting allows for earlier treatment of reinfection, which can prevent complications and further transmission. In addition, retesting, regardless of whether results are positive or negative, provides the opportunity for HCPs to revisit the topic of STD risk reduction with patients.

Is retesting enough? How can HCPs treat their patients, and their patients’ partners, to reduce the risk for reinfection?

One of the CDC’s major strategies for prevention and control of STDs is to encourage HCPs to conduct an accurate STD risk assessment and counsel patients about ways to avoid these diseases—by changing their sexual behaviors and by using recommended prevention services. HCPs can use the CDC pamphlet, A Guide to Taking a Sexual History, specifically with respect to the five P’s of sexual health—Partners, Practices, Protection from STDs, Past History of STDs, and Prevention of Pregnancy—to assess patients’ STD/HIV behavioral risk.10

A second important strategy is evaluation, treatment, and counseling of sex partners of persons with an STD. Time spent counseling patients on the importance of notifying partners is associated with improved notification outcomes.11 Some evidence suggests that providing patients with written information to share with sex partners can increase rates of partner treatment.12 When possible, HCPs should ask patients to bring their primary sex partner with them when returning for treatment so that both persons can be treated concurrently. Although this approach can be effective for a main partner,13 it may not be feasible for additional sex partners.14

Expedited partner therapy (EPT),15 also termed patient-delivered partner therapy, is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea. HCPs offer medications or prescriptions to the patients, who then give the medications or prescriptions to their sex partners, thereby obviating the need for the partners to see an HCP. Three U.S. clinical trials of heterosexual men and women with chlamydia or gonorrhea have shown that more partners are treated when EPT is utilized.16-18 All three trials reported declines in reinfection, with two demonstrating significant declines. Across trials, chlamydia prevalence decreased by about 20% and gonorrhea, by about 50%, at follow up.

The preferred approach to EPT is to provide patients with appropriately packaged medication. Data on the efficacy of EPT using prescriptions are limited; in fact, many persons do not fill the prescriptions given to them by a sex partner. Medications or prescriptions provided for EPT should be accompanied by treatment instructions, appropriate warnings about taking medications (e.g., if a partner is pregnant or has an allergy to the medication), general health counseling, and a statement advising that partners seek healthcare evaluation for any symptoms of an STD, particularly PID. Please see the patient education page on expedited partner therapy for chlamydia in this issue.

Unless prohibited by law or other regulations, HCPs should routinely offer EPT to heterosexual patients with chlamydia or gonorrhea when HCPs cannot confidently ensure that all of a patient’s sex partners will seek treatment on their own. Parameters for treatment include all sex partners from the previous 60 days or the most recent partner if the patient has not had sex in the 60 days prior to diagnosis.

Most states have legalized EPT, but HCPs should obtain the most up-to-date guidelines for their state, as well as determine whether their state health department has EPT patient handouts available.19 Also, HCPs should be aware of the clinical limitations of EPT use. Because a person using EPT is not seeing an HCP for this treatment, this person cannot receive the preferred regimen for gonorrhea: single doses of intramuscular ceftriaxone and oral azithromycin.19 Instead, this person will take an oral regimen of cefixime 400 mg and azithromycin 1 g. If at all possible, HCPs should urge patients to request that their sex partners from the preceding 60 days be evaluated by an HCP and treated with the preferred regimen for gonorrhea. If pharyngeal gonorrhea is a possibility, persons treated with the oral antibiotic regimen should be encouraged to return 14 days after treatment for a TOC.

Data on the use of EPT for chlamydia or gonorrhea among men who have sex with men (MSM) are limited. Published studies suggest that more than 5% of MSM without a previous HIV diagnosis have a new diagnosis of HIV infection when evaluated as partners of patients with chlamydia or gonorrhea.20, 21 EPT should not be used routinely by MSM. HCPs should try to ensure that these sex partners are tested and, if applicable, treated, for HIV infection and other STDs.22, 23

Although existing data suggest that EPT may have a role in partner treatment for trichomoniasis, no evidence suggests that it is any more effective at reducing reinfection than treatment onsite or by referral. No data support the use of EPT for syphilis.24, 25 

Healthcare providers play a critical role in primary prevention of STDs through patient risk assessment and risk reduction counseling. HCPs are also encouraged to implement CDC-recommended strategies for early identification and effective treatment of infected persons, treatment of sex partners, and appropriate follow-up to detect reinfection and provide early treatment.

Rewa Thompson is Clinical Assistant Professor at Stony Brook School of Nursing in Stony Brook, New York, and a women’s health nurse practitioner at Planned Parenthood of Nassau County. 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. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187-193.
  2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep. 2015;64(No. RR-3):1-137.
  3. Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with chlamydia and gonorrhea among females: a systematic review of the literature. Sex Transm Dis. 2009;36(8):478-489.
  4. Peterman TA, Tian LH, Metcalf CA, et al; RESPECT-2 Study Group. High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening. Ann Intern Med. 2006;145(8):564-572.
  5. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Fact Sheet: Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States.
  6. Khan A, Fortenberry D, Juliar B. et al. The prevalence of chlamydia, gonorrhea, and trichomonas in sexual partnerships: implications for partner notification and treatment. Sex Transm Dis. 2005;32(4):260-264.
  7. Wilson TE, Hogben M, Malka ES, et al. A randomized controlled trial for reducing risks for sexually transmitted infections through enhanced patient-based partner notification. Am J Public Health. 2009;99(suppl 1):S104-S110.
  8. Fung M, Scott KC, Kent CK, Klausner JD. Chlamydial and gonococcal reinfection among men: a systematic review of data to evaluate the need for retesting. Sex Transm Infect. 2007;83(4):304-309.
  9. Kissinger PJ, Reilly K, Taylor SN, et al. Early repeat Chlamydia trachomatis and Neisseria gonorrhoeae infections among heterosexual men. Sex Transm Dis. 2009;36(8):498-500.
  10. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. Atlanta, GA: U.S. Department of Health and Human Services, CDC.
  11. Turner AN, Feldblum PJ, Hoke TH. Baseline infection with a sexually transmitted disease is highly predictive of reinfection during follow-up in Malagasy sex workers. Sex Transm Dis. 2010;37(9):559-562.
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  13. Yu YY, Frasure-Williams JA, Dunne EF, et al. Chlamydia partner services for females in California family planning clinics. Sex Transm Dis. 2011;38(10):913-918.
  14. Mickiewicz T, Al-Tayyib A, Thrun M, Rietmeijer C. Implementation and effectiveness of an expedited partner therapy program in an urban clinic. Sex Transm Dis. 2012;39(12):923-929.
  15. Centers for Disease Control and Prevention. Expedited Partner Therapy. Page updated March 18, 2015.
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  17. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis. 2003;30(1):49-56.
  18. Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis. 2005;41(5):623-629.
  19. Centers for Disease Control and Prevention. Legal Status for Expedited Partner Therapy (EPT). Page updated June 4, 2015.
  20. Stephens SC, Bernstein KT, Katz MH, et al. The effectiveness of patient-delivered partner therapy and chlamydial and gonococcal reinfection in San Francisco. Sex Transm Dis. 2010;37(8):525-529.
  21. Kerani RP, Fleming M, DeYoung B, Golden MR. A randomized, controlled trial of in SPOT and patient-delivered partner therapy for gonorrhea and chlamydial infection among men who have sex with men. Sex Transm Dis. 2011;38(10):941-946.
  22. Stekler J, Bachmann L, Brotman RM, et al. Concurrent sexually transmitted infections (STIs) in sex partners of patients with selected STIs: implications for patient-delivered partner therapy. Clin Infect Dis. 2005;40(6):787-793.
  23. McNulty A, Teh MF, Freedman E. Patient delivered partner therapy for chlamydial infection—what would be missed? Sex Transm Dis. 2008;35(9):834-836.
  24. Kissinger P, Schmidt N, Mohammed H, et al. Patient-delivered partner treatment for Trichomonas vaginalisinfection: a randomized controlled trial. Sex Transm Dis. 2006;33(7):445-450.
  25. Schwebke JR, Desmond RA. A randomized controlled trial of partner notification methods for prevention of trichomoniasis in women. Sex Transm Dis. 2010;37(6):392-396.