Assessment & Management

Statin treatment considerations for cardiovascular disease prevention

Current evidence-based guidelines support the use of statin drugs for primary prevention of cardiovascular (CV) events based on individual CV risk profiles rather than on target cholesterol levels. The purpose of this article is to increase awareness of the impact of CV disease in women and to discuss evidence-based guidelines for the use of statin drugs to decrease CV events in this population. Continue reading »

Mycoplasma genitalium-related infection: An STI not quite ready for prime time

Mycoplasma genitalium has been designated by the CDC as an emerging concern among sexually transmitted pathogenic bacteria. Although M. genitalium-related infections are becoming more prevalent worldwide, and more is being learned about them, many questions about the pathogenesis and management of these infections remain unanswered. Until clear clinical guidelines are established, what should healthcare providers know about M. genitalium-related infections? Continue reading »

Digital assessment of the pelvic floor muscles: A neglected technique

By Helen A. Carcio, MS, MEd, ANP-BC

Clinical evaluation of the pelvic floor muscles (PFMs) should be an integral part of a comprehensive well-woman examination because it can aid in identifying bladder dysfunction and pelvic organ prolapse. Digital assessment of the PFMs, a simple but neglected technique that should be part of every clinical evaluation of the pelvic musculature, is described in detail in this article. Continue reading »

PrEP for prevention: Practice update

According to the Centers for Disease Control and Prevention (CDC), about 1.2 million persons are living with HIV in the United States, and about 20% of them are unaware of it.1 Lack of awareness of HIV status contributes to viral transmission. Healthcare providers (HCPs) play a vital role in the screening, diagnosis, and treatment of HIV infection, but they can also play an important role in HIV prevention. This article focuses on pre-exposure prophylaxis (PrEP), a safe and effective intervention that is rapidly becoming a major tool in HIV transmission prevention. The article also provides an overview of the assessment and management of patients prior to and during the use of PrEP.

The CDC estimates that 50,000 persons in the United States are newly infected with HIV every year.1 Most of the new cases involve men who have sex with men (MSM) (n = 30,689), but African-American women represent a disproportionate number of new infections (n = 5,300) when compared with white non-Hispanic women (n = 1,300) and Hispanic/Latina women (1,200).2

The birth rate among HIV-infected women has increased from 6,000-7,000 live births in 2000 to 8,700 live births in 2006, the last year reported.3 This increase in births may be related to the increased availability and use of antiretroviral medications, which significantly decrease mother-to-child transmission risk. Other factors are also in play. Study data suggest that women who are HIV positive and desire children, including those who disclose their seropositive status to their partners, may not be using condoms consistently.4,5 Little is known about birth rates in women who are HIV negative, desire children, and are in a relationship with an HIV-positive partner.

Pre exposure prophylaxis is the most recent intervention in the effort to fight the HIV epidemic. PrEP is a combination of two antiretrovirals, tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg, taken once daily. This treatment has been shown to reduce transmission risk by upwards of 92%.6 PrEP is available to adult men and women who are HIV negative but have an increased risk of exposure to HIV through sexual and/or injection drug use. PrEP is not approved for use in children or adolescents. Guidelines for PrEP were released in 2014 by the U.S. Public Health Service.<sup.6

Assessment

Health history
To identify and reduce their patients’ risk for contracting HIV infection, HCPs need to take a sexual history as part of primary care and specialty care services. Studies have shown that many HCPs do not ask about risky sexual behaviors and many patients do not disclose them.4,5,7 Assessment of patients’ sexual behaviors and their potential contribution to HIV risk should be part of every healthcare encounter. The 5 P’s of sexual health—partners, practices, protection from sexually transmitted infections (STIs), past history of STIs, and prevention of pregnancy—provide a framework to assess each patient.8

Many patients are not comfortable talking about their sexual practices, partners, and history. HCPs can facilitate this discussion by informing patients that they routinely take a sexual history so that they can provide appropriate sexual health care, and that all information provided is confidential. HCPs can begin by asking these questions, as recommended in the 2014 PrEP guidelines.6 In the past 6 months:

  • Have you had sex with men, women, or both?
  • How many men/women have you had sex with?
  • How many times did you have vaginal or anal sex when neither you nor your partner wore a condom?
  • How many of your sex partners were HIV-positive?
  • If you did have sex with HIV-positive partners, how many times did you have vaginal or anal sex without a condom?
  • Do you have sex with partners who do not know their HIV status?

Next, HCPs need to inquire about any past history of STIs, treatment, past or current symptoms, their partner(s)’ history of STIs, and whether they would like to be tested for HIV during this healthcare encounter. In addition, HCPs can ask patients if they have ever injected drugs not prescribed by their HCP. If the answer is yes, patients are asked whether they have shared injection or drug preparation equipment or been in a drug treatment program in the past 6 months.

If this assessment suggests that a given patient is at high risk for HIV infection, the HCP initiates a discussion about PrEP. Adult MSM who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative man are potential candidates if they have had anal sex with a male (receptive or insertive) without a condom and/or have had an STI diagnosed in the past 6 months. Adult men and women who are heterosexually or bisexually active who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative partner are potential candidates if they infrequently use condoms during sex with partner(s) of unknown HIV status who are at substantial risk for HIV infection. Any individual who is HIV negative and in an ongoing sexual relationship with an HIV-positive partner is a potential candidate. In addition, individuals who have used illicit injection drugs in the past 6 months that included sharing injection and drug preparation equipment or who have been in a drug treatment program in the past 6 months are potential candidates. If a patient found to be a potential candidate is interested in PrEP, then further evaluation is needed to determine whether this intervention is appropriate for him or her.

Physical examination and lab screening/testing
No specific physical examination is required prior to initiation of PrEP. However, HCPs should recognize and further investigate fever, rash, and cervical adenopathy as potential clinical signs of acute HIV infection. These findings are especially relevant if a patient reports having experienced viral infection symptoms such as fatigue, myalgia, headache, night sweats, and diarrhea in the prior 4 weeks.

Laboratory tests for prospective PrEP recipients include HIV testing, hepatitis B virus (HBV) screening, and renal function tests. HIV testing is done within 1 week of initiating PrEP. If the test result is positive, PrEP is not initiated because it does not provide adequate therapy for HIV; in addition, there is some concern about the development of drug resistance. If the test result is indeterminate, PrEP initiation is postponed until further testing determines HIV status.

Both TDF and FTC suppress replication of HBV as well as HIV, so the PrEP intervention may offer an additional benefit if a patient has active HBV infection. Reactivation of HBV infection may occur if PrEP is discontinued or taken inconsistently. If screening indicates that a patient is not infected by HBV or immune to it, HBV vaccination is recommended. Patients who have significantly reduced renal function should not take PrEP.

Pregnancy testing is done if indicated. Although data regarding the use of TDF/FTC in terms of fetal health and growth are limited, the FDA has approved PrEP use during pregnancy. No evidence exists of harm to fetuses exposed to TDF or FTC when used for treatment of HIV during pregnancy.6

Management

PrEP must be taken on a consistent basis for maximum prevention benefit. PrEP is safe and effective but may cause a loss of appetite, mild gastric upset, or mild headaches initially. HCPs need to counsel patients about these side effects and inform them about over-the-counter drugs that may lessen these effects. Patients are asked to contact their HCP if the side effects do not subside. PrEP reaches maximum intracellular concentrations in about 20 days; therefore, patients should be advised that effectiveness is not immediate.

All other medications that patients are taking should be reviewed. Drug interaction data are available for TDF, but not for FTC. TDF has no significant effect on oral contraceptive hormone levels. Serum concentrations of some drugs (e.g., acyclovir, valacyclovir, aminoglycosides) or of TDF may be increased when these agents are combined.6

Regardless of whether or not a patient decides to take PrEP, HCPs and patients need to discuss other ways to reduce HIV infection risk (e.g., limiting the number of sexual partners, always using a condom). For some individuals, multi-session behavioral counseling may be required. Women who have the potential to become pregnant should receive counseling and provision of contraception if they do not want to become pregnant, and pre-conception counseling if they are considering a pregnancy. Patients who report substance abuse should receive referrals for appropriate treatment.

Patients should receive information on the signs and symptoms of acute HIV infection and should be advised to contact their HCP if these occur. In addition, those patients who are taking PrEP need to know that they should not discontinue the regimen without first discussing it with their HCP.

Patients taking PrEP are seen for follow-up at least every 3 months. At these visits, HCPs need to assess them for side effects, medication adherence, and HIV risk behaviors, as well as for signs and symptoms of acute HIV infection. HIV testing is repeated at each follow-up visit. A pregnancy test is performed for women who could become pregnant, and STI tests are done as indicated. Renal function tests are conducted every 6 months.

These follow-up visits provide an important opportunity to reinforce the need for consistent medication use and to support HIV risk-reduction behaviors. Discussion about continuing PrEP should take into account personal preference, change in risk profile, and ability to adhere to the daily dosing regimen. PrEP must be discontinued if a patient’s HIV test result is positive or if renal function is significantly impaired.

Conclusion

PrEP is a safe and effective pharmacologic intervention for women and men at high risk for HIV infection. HCPs have the opportunity to improve the lives of their patients and provide preventive care in the fight against HIV.

Lorraine Byrnes is Associate Professor at Hunter Bellevue School of Nursing, Hunter College, City University of New York, in New York City. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Resources

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

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

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

4. Sanders LB. Sexual behaviors and practices of women living with HIV in relation to pregnancy. J Assoc Nurses AIDS Care. 2009;20(1):62-68.

5. Sullivan K, Voss J, Li D. Female disclosure of HIV-positive serostatus to sex partners: a two-city study. Womens Health. 2010;50(6):506-526.

6. Centers for Disease Control and Prevention. Pre-Exposure Prophylaxis (PrEP). 2015. cdc.gov/hiv/prevention/
research/prep

7. Bernstein KT, Liu KL, Begier EM, et al. Same sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches. Arch Intern Med. 2008;168(13):1458-1464.

8. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. cdc.gov/STD/treatment/
SexualHistory.pdf

Best practice recommendations for male sexual and reproductive healthcare

Healthcare providers (HCPs) working in the field of women’s sexual and reproductive healthcare (SRH) are accustomed to having a large body of clinical guidelines that establish the standard of care for women. With the advent of a national agenda to improve male SRH, it became critical to identify which services should be provided to which males and when—based on the best evidence available. A new publication from the Male Training Center (MTC) provides evidence-based and expert-informed recommendations for core clinical preventive care services for men of reproductive age.

Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice, a recent groundbreaking publication by the MTC, presents an expansive rubric under which male SRH services are defined and recommendations for best practice are offered.1 After conducting systematic reviews of the literature and examining current practice guidelines from professional organizations, the MTC developed these recommendations in response to the lack of systematized standards for SRH services for men. The complete recommendations and detailed supporting discussions can be found on the MTC website. This article is a brief summary of the recommended male SRH core services.

Health history

In addition to a customary health history, a comprehensive SRH history includes not only the five P’s (partners, practices, protection from sexually transmitted infections [STIs], past history of STIs, and prevention of pregnancy) but also the development of a reproductive life plan, which helps direct pregnancy preparation and/or identify male fertility concerns. Assessment for gonadal toxins and excessive heat exposure is recommended. Exploration of factors that may compromise sexual function or responsible sexual decision making (e.g., depression; alcohol, drug, or tobacco use) should occur. Probes for difficulty with sexual function (e.g., premature ejaculation, erectile dysfunction [ED]) and intimate partner/sexual violence are suggested as standard practice. Determination of immunization needs is based on risk: HPV vaccination for all males aged 11-26 years; hepatitis B vaccination for males younger than 19 and those with a risk for acquiring the disease from intravenous (IV) drug use or sexual exposure; and hepatitis A vaccination for males with exposure risks.

Physical examination

Core components of the physical exam include height, weight, body mass index, and blood pressure (BP). An external genital exam is recommended to determine that normal adolescent development has occurred, to identify genital problems such as hydrocele and varicocele, to detect signs of an STI, and to serve as part of a male infertility evaluation. During the exam, hair distribution and skin qualities are assessed, and inguinal nodes, the penis, and the scrotal contents are palpated both to confirm presence of the vas deferens and epididymis and to identify common structural anomalies or signs of infection. In males who engage in receptive anal sex, evaluation of the perianal area is recommended. In asymptomatic males, routine screening for testicular cancer and the teaching of testicular self-exam are not recommended. No evidence suggests that these practices result in improved health outcomes; in fact, they are considered potentially harmful. In addition, hernia screening is no longer recommended as part of the routine physical exam unless a clinical indication exists.

Laboratory screening/testing

Chlamydia
At-risk males younger than age 25 should be screened using urine-based nucleic-acid amplification tests (NAATs). Individuals at risk include men who have sex with men (MSM) and those who reside in a community with a high prevalence of chlamydia (e.g., correctional institution, military barracks). All men diagnosed with chlamydia are advised to be re-screened 3 months after treatment to assess for re-infection. Men who have had anal-receptive sex should be screened for rectal infection using an NAAT rectal swab. Screening for pharyngeal infection is not recommended.

Gonorrhea
Routine screening for gonorrhea is not recommended unless men are at risk for this infection by virtue of their being MSM, having multiple sex partners, or having sex associated with illicit drug use. MSM should be screened annually for urethral, anal, and/or pharyngeal infection depending on sites of exposure. MSM with multiple or anonymous partners should be screened every 3-6 months. Men diagnosed with gonorrhea should be re-screened 3 months after treatment to assess for re-infection.

Syphilis
Routine syphilis screening is recommended only among high-risk populations such as MSM, commercial sex workers, males exchanging sex for drugs, and individuals residing in correctional facilities or high-prevalence communities. Screening schedules are based on the degree of risky sexual behavior and may be as frequent as every 3-6 months.

HIV/AIDS
All males aged 13-64 years should be screened for HIV/AIDS, and those considered to be at high risk should be screened at least annually. In addition to engaging in the high-risk sexual behaviors discussed earlier, having sex partners with HIV/AIDS or who use IV drugs greatly increases men’s risk for acquiring HIV/AIDS. The MTC guidelines support the CDC recommendation that HIV/AIDS testing be on an “Opt Out” basis.2

Hepatitis C
One-time testing for hepatitis C is recommended for persons born between 1945 and 1965 because of the high disease prevalence among this population. Men considered at increased risk for hepatitis C because of sexual practices, known exposure, or IV drug use should undergo routine testing based on risk exposure.

Hepatitis B, herpes simplex
Routine screening for hepatitis B and herpes simplex among asymptomatic males is not recommended.

Other tests
In addition to screening for infections, the MTC guidelines recommend screening for diabetes in adult males with sustained BPs >135/80 mm/Hg. The MTC follows the recommendation from the U.S. Preventive Services Task Force to not screen routinely for prostate cancer using a prostate-specific antigen (PSA) test, but it acknowledges the alternative recommendations from the American Urological Association, American Cancer Society, and American College of Preventive Medicine, all of which advise various screening schedules using PSA tests and digital rectal exams based on age or risk factors. Other tests to be excluded from routine screening—based on recommendations from healthcare organizations serving males—include urinalysis and hemoglobin/
hematocrit. Insufficient evidence exists to support routine screening of males for trichomonas or HPV or to support anal cytologic screening.

Sexual and reproductive healthcare counseling

A substantial portion of the MTC recommendations focuses on core elements of SRH counseling. One of the most important core elements entails education about condom use. In particular, the counseling guidelines detail how to teach men to put on and remove condoms, choose the right type of condom, and avoid substances that might destroy the integrity of the latex and result in an increased risk for STI transmission. In addition, recommendations are made for behavioral counseling (through a series of visits) designed to reduce high-risk sex practices. HIV pre-exposure and post-exposure prophylaxis may be considered for individuals at high risk.

Counseling and support strategies for males struggling with sexuality concerns are outlined in the MTC guidelines, and include a sexuality assessment tool and a sample assessment approach. Elements of respect, safety, support, individuality, equity, acceptance, honesty/trust, and communication are explored in this framework. In addition, indications and warning signs of an unhealthy relationship are offered to assist men in identifying and addressing relationship problems.

Counseling regarding pregnancy planning or prevention is another core element of male SRH. A review of all contraceptive methods, for males and for females, should be provided, with attention to safety, efficacy, and correct and consistent use in a patient-centered reproductive life plan. Included in the discussion of contraceptive methods is prevention of STIs and pregnancy. Men who are planning a pregnancy with a partner should undergo pre-conception counseling. This counseling should include discussions about optimizing their partnership (to ensure that all pregnancies are desired) and about enhancing parenting practices (to ensure best outcomes for their children). Strategies to help men achieve optimal fertility should be offered as well.

For men seeking an infertility evaluation, the assessment/counseling process includes a problem-specific history and a physical exam if a pregnancy does not occur within a year of unprotected sexual intercourse—or sooner if the man is known to have bilateral cryptorchidism or suspected infertility potential or if his partner has infertility risks. However, any man, regardless of his present partner, should be able to seek information about his fertility status. Counseling and referral should be available for semen analysis or for medical evaluation if a possible endocrine or urinary disorder is suspected.

Acknowledging that male sexual dysfunction encompasses a common group of disorders that require multidisciplinary care, the MTC recommends specific resources that provide evaluation and treatment guidelines for ED, Peyronie’s disease, priapism, and problems related to libido, orgasm, and ejaculation. Of note, ED can be a sign of early cardiovascular disease (CVD); recommendations for assessment of cardiovascular status are provided along with suggestions for healthy lifestyle interventions that can favorably affect ED as well as CVD.

Conclusion

The MTC’s new document provides a comprehensive resource useful to HCPs who want to provide SRH for men that is evidence based and expert informed. This document provides a foundational framework upon which HCPs can build research to close knowledge gaps and move closer to reproductive healthcare equity for all.

Wendy D. Grube is a Practice Assistant Professor and Director of the Women’s Health Gender-Related Nurse Practitioner Program at the University of Pennsylvania School of Nursing in Philadelphia. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article. She participates on the Men’s Health Technical Panel.

References
1. Marcell AV and the Male Training Center for Family Planning and Reproductive Health. Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice. Philadelphia, PA: Male Training Center for Family Planning and Reproductive Health and Rockville, MD: Office of Population Affairs; 2014.

2. Centers for Disease Control and Prevention. 2010 STD Treatment Guidelines. Clinical Prevention Guidance. Updated January 28, 2011. www.cdc.gov/std/treatment/2010/
clinical.htm

Assessment, diagnosis, and management of headache

Healthcare providers caring for women can use advanced clinical skills in assessment and accurate diagnosis of headaches. Accurate diagnosis is imperative in providing effective management and making appropriate referrals. The overall goal is to make the correct diagnosis, adequately treat the headaches, and minimize the frequency and severity of headaches in the future.

About 45 million individuals in the United States complain of headaches to their healthcare provider (HCP), accounting for nearly 8 million clinical visits per year.1 The female preponderance of headaches emerges at puberty, with females, relative to males, having a 1.5-fold greater risk of headaches and 1.7- fold greater risk of migraine.2 The most common primary headaches are migraine, tension, cluster, and chronic daily headache.3 Secondary headaches are symptoms of diseases or conditions that can be relatively minor (e.g., sinusitis) or quite serious or even life threatening (e.g., meningitis, brain tumor, cerebral aneurysm, head trauma).3  HCPs must use keen skills to evaluate each woman’s symptoms, formulate a diagnosis, and devise a management plan.

Assessment

Health history

A complete history is key in making the diagnosis. Although symptoms of various types of headache may overlap, a detailed history helps the HCP determine whether a secondary cause needs to be further investigated or if the symptoms fit with one of the primary headache types. The HCP needs to ask the patient about the following3-5:

onset, location, frequency, duration, severity, and character (e.g., throbbing versus constant) of the headache(s);

existence of any aura or prodrome;

any association between the headaches and sleep patterns, emotional factors, or food or alcohol intake;

any associated symptoms with the headache;

precipitating and alleviating factors;

a family history of headache;

any changes in vision;

any history of trauma;

any relationship between the headaches and the menstrual cycle or a change in the method of birth control;

use of illicit drugs including cocaine and methamphetamine; and

current medications, including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and glucocorticoids.

Answers to these questions will enable the HCP to  rule out certain types of headaches.3-5

Red flags in the history require that further evaluation be done for secondary causes. Sudden onset of a severe, intractable headache may suggest an intracranial disorder such as subarachnoid hemorrhage or meningitis.3 Severe headache triggered by sexual intercourse, cough, or exertion may be caused by an intracranial mass or subarachnoid hemorrhage.5 New onset of headaches in persons older than 50, new onset of severe headaches during pregnancy or postpartum, or new headache types in patients with cancer or immunosuppression are of particular concern.3,5  Any headache described as the “worst headache ever” requires immediate attention.

Physical examination

Physical examination of a patient presenting with a chief complaint of headache includes a general survey, vital signs, focused assessment of the head and neck, and a full neurologic exam.5-7 The focused exam begins in a systematic manner starting with the scalp, which is assessed for swelling and tenderness. The temporal arteries are palpated. Nodularity, tenderness, and a diminished or absent pulse on one side are considered abnormal findings consistent with temporal arteritis.5,7,8

Next, the HCP assesses the temporomandibular joint for tenderness or crepitance, 6,7 the eyes for lacrimation and conjunctival injection, and the periorbital area for eyelid swelling, ptosis, or miosis.5,6,9 Visual acuity, extra-ocular movements, visual fields, and pupillary size and response to light are checked for abnormalities and fundi are assessed with an ophthalmoscope for presence of spontaneous venous pulsations and/or papilledema.5-7The nares are assessed for purulence, the sinuses palpated for tenderness, and the oropharynx examined for presence of purulence, erythema, and swelling.10 Assessment includes percussion of dentition for presence of tenderness.6 The HCP examines the patient’s neck utilizing flexion (unless contraindicated) to assess for discomfort and/or stiffness,6 and listens for bruits in the neck, which may suggest arteriovenous malformation. 3The cervical spine is palpated to assess for tenderness.6

Red flags in the physical examination include, but are not limited to, fever, weight loss, altered mental status, weakness, papilledema, focal neurologic deficits, proximal artery tenderness, and meningismus. 6 All pertinent negative and positive physical exam findings, along with history findings, help the HCP further differentiate between primary and secondary headaches.

Diagnosis and treatment

Because of overlapping symptomatology among the different headache types, the diagnosis of a particular headache type can be challenging. In addition, the HCP must discern between a primary headache, which, although painful, is usually not harmful, and a secondary headache such as subarachnoid hemorrhage or transient ischemic attack, which could lead to a stroke.1

Migraine

Migraines present as severe, disabling, unilateral headaches often described as pulsating in nature. 11 Symptoms may worsen with routine physical activity. Sensitivity to light, sound, and smells is often present, as are nausea and stiff neck.11 Some migraineurs describe having prodromal symptoms (e.g., drowsiness, restlessness, decreased concentration, gastrointestinal upset) that may last for hours to days before the migraine.7 Twenty percent to 30% of migraineurs experience an aura. Aura consists of fully reversible visual, sensory, or speech disturbances that develop gradually before the headache and that last no longer than 60 minutes.7,11 Despite all these symptoms, neurologic examination findings in patients with migraine headache are negative or normal.

Migraines are 2-3 times more common in women than in men and vary in severity. 11 In females, prevalence of migraines diminishes after age 50 or after menopause unless estrogen replacement therapy is used.11

Treatment for migraine is either abortive, halting an existing headache, or preventive, lessening the frequency and severity of the headaches. First-line abortive therapy for mild to moderate, non-disabling migraine includes simple analgesics, combination analgesics, and NSAIDs.7,12 Metoclopramide may be added for nausea relief and may promote absorption of oral pain medications. 7Abortive therapy for moderate to severe headaches and those not relieved by analgesics may include drugs that affect serotonin, including the triptans (oral, intranasal, subcutaneous), combination triptan/NSAIDs, ergotamine tartrate, dihydroergotamine, and acetaminophen-isometheptene- dichlor alphen a zone.7, 12,13 A weak opioid analgesic such as a butalbital compound or acetaminophen- codeine may be tried if the aforementioned agents are ineffective.12,13

Prevention includes elimination or reduction of identified triggers (e.g., aged cheeses, red wine, monosodium glutamate, artificial sweeteners, caffeine overuse or withdrawal, too much or too little sleep).7 Pharmacologic prophylaxis is considered when migraineurs have more than one headache per week. 7,12,13 Drug classes that have proved useful in preventive therapy include beta blockers, calcium channel blockers (CCBs), antidepressants, anti-seizure medications, and some antihistamines.7,12,13

Cluster headache

Cluster headaches usually occur at night and are severe and unilateral.14 Although cluster headaches have been found to be 6 times more prevalent in males than in females, more and more women—typically between ages 20 and 40—are being diagnosed with this condition. 14,15 Cluster headaches are frequently misdiagnosed as migraine, sinusitis, or allergies. 5 The patient may describe sharp, unilateral orbital, supraorbital, or temporal pain accompanied by autonomic symptoms on the affected side (e.g., teary eye, nasal congestion or runny nose, ptosis, eyelid swelling, conjunctival injection).1,7,9,14 Unlike migraineurs, who prefer to remain at rest in a dark room, patients with cluster headache tend to be restless.14

Episodes may last 15-180 minutes, and may occur once every other day to as often as 8 times daily.7.9,14 These headaches typically occur daily for several weeks, followed by a period of remission.7.9 Treatment entails alleviating pain at the onset of the attack and instituting preventive strategies such as smoking and alcohol cessation.16 Following onset of an acute attack, oxygen therapy and sumatriptan injection have been found to be the most effective treatment modalities. 16 The CCB verapamil can be started at the beginning of a cluster headache, continued until the patient is headache-free for at least 7-14 days, and then slowly tapered and discontinued.7-9

Tension headache

Tension headaches can be episodic (usually associated with a stressful event) or chronic (usually associated with muscular contraction in the neck and scalp).17 Definitive diagnosis includes two of these traits: pressing or tightening pain; occipitofrontal location; bilateral pain, with mild to moderate intensity; and lack of effect of physical activity 17 These head aches are typically self-limiting and non-debilitating and have no associated symptoms. Physical exam findings are normal. Relief is generally achieved with acetaminophen or NSAIDs.7,12  Treatment modalities for chronic tension headache include lifestyle modifications such as regular exercise, stretching, stress management, relaxation techniques, and adequate sleep. Other treatments include use of hot or cold packs, ultrasound, improvement of posture, trigger point injections, and occipital nerve blocks.7.17

Chronic daily headache

This type of headache occurs on 15 or more days per month for at least 3 months and is typically related to medication overuse, although it may represent chronic (transformed) migraine.12,18,19Medication overuse headache results from taking acute headache medication for 2-3 days per week.12,18 Treatment for chronic daily headache includes preventive medications to decrease reliance on acute medications, and assistance with withdrawal symptoms such as nausea, vomiting, and restlessness. 18Transformed migraine is a constant (24-hour) headache with intermittent, superimposed migraine symptoms.19As many as 80% of patients with transformed migraine have coexisting depression; treatment focuses on counseling and biofeedback in addition to medication needed to treat depression.19

“Choosing Wisely” initiative

With regard to headache assessment, diagnosis, and management, the American Headache Society endorses the “Choosing Wisely” initiative.20 The initiative lists five suggestions:

Avoid neuroimaging studies in patients with stable headaches that meet criteria for migraine.

When indicated, magnetic resonance imaging is preferred over computed tomography except in emergency settings when hemorrhage, acute stroke, or head trauma is suspected.

Do not recommend surgical deactivation of migraine trigger points outside of a clinical trial.

Do not prescribe opioid- or butalbital-containing medications as first-line treatment for recurrent headache disorders.

Do not prescribe frequent or long-term use of over-the-counter medications for headache.

Conclusion

Headaches are common occurrences in women;  skilled HCPs are positioned to assess, diagnose, treat, and prevent headaches in these individuals. Familiarity with various types of headaches and their causes, appropriate treatment modalities, and preventive strategies can assist HCPs in management of women presenting with headache. =

Janis R. Guilbeau and Christy M. Lenahan are Assistant Professors 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. Winland-Brown JE, Keller MB. Neurological problems. In: Dunphy LM, Winland-Brown JE, Porter BO, Thomas DJ. Primary Care: Art and Science of Advanced Practice Nursing.  4th ed. Philadelphia, PA: F.A. Davis; 2015:77-148.

  2. International Association for the Study of Pain. Epidemiology of Headache. 2011. www.iasp-pain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/HeadacheFactSheets/1-Epidemiology.pdf

  3. Bautista C, Grossman S. Somatosensory function, pain, and headache. In: Grossman SC, Porth CM. Porth’s Pathophysiology: Concepts of Altered Health States. 9th ed. Philadelphia, PA: Wolters Kluwer; 2014:422-451.

  4. Bajwa ZH, Wootton RJ. Evaluation of headache in adults. UptoDate. December 10, 2014. www.uptodate.com/contents/evaluation-of-headache-in-adults

  5. Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013;87(10):682-687.

  6. Silberstein SD. Approach to the patient with headache. Merck Manual. April 2014. www.merckmanuals.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache

  7. Hale N, Paauw DS. Diagnosis and treatment of headache in the ambulatory setting: a review of classic presentations and new considerations in diagnosis and management. Med Clin North Am.  2014;98(3):505-527.

  8. Docken WP, Rosenbaum JT. Clinical manifestations of giant cell (temporal) arteritis. UpToDate.  March 18, 2015. www.uptodate.com/contents/clinical-manifestations-ofgiant-cell-temporal-arteritis

  9. Weaver-Agostoni J. Cluster headache. Am Fam Physician. 2013;88(2):122-128.
  10. Brook I. Chronic sinusitis clinical presentation. Medscape. April 7, 2014. http://emedicine.medscape.com/article/232791-clinical
  11. International Association for the Study of Pain. Migraine. 2011. www.iasp-pain.org/files/ContenContentFolders/GlobalYearAgainstPain2/HeadacheFact-Sheets/2-Migraine.pdf

  12. Freitag FG, Schloemer F. Medical management of adult headache. Otolaryngol Clin North Am. 2014;47(2):221-237.

  13. Cunha JP. Migraine headache. Emedicine Health. March 16, 2015. www.emedicinehealth.com/migraine_headache/article_em.htm
  14. American Headache Society Committee on Headache Education. Cluster Headache and Other Medical Conditions. 2011. www.achenet.org/resources/cluster_headache_and_other_medical_conditions/

  15. Cleveland Clinic Foundation. Diseases & Conditions: Cluster Headaches. 2014. http://my.clevelandclinic.org/health/diseases_conditions/hic_Cluster_Headaches

  16. Simon H. Headaches – cluster. University of Maryland Medical Center. September 18, 2013. http://umm.edu/health/medical/reports/articles/headaches-cluster

  17. Blanda M. Tension headache clinical presentation. Medscape. October 1, 2014. http://emedicine.medscape.com/article/792384-clinical
  18. Silberstein SD. American Headache Society. Medication Overuse Headache. www.americanheadachesociety.org/assets/1/7/Stephen_Silberstein_-_Medication_Overuse_Headache.pdf

  19. National Headache Foundation. Transformed Migraine 2015. http://www.headaches.org/2007/10/25/transformed-migraine-more-commonly-known-as-chronicmigraine/

  20. Loder E, Weizenbaum E, Frishberg B, Silberstein S; American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.

Standardizing care for sexual assault survivors

Across the United States, women seek immediate care following sexual assault can expect to receive thorough and uniform care in a variety of clinical settings. This approach to the acute care of sexual assault survivors comes as a result of the evolving and growing role of sexual assault nurse examiners (SANEs)—nurses who are educated and prepared to follow standardized guidelines and criteria. However, the follow-up care that sexual assault survivors receive from their regular healthcare providers (HCPs) can vary greatly. Many women receive inadequate post-assault care, which may compromise their recovery and even exacerbate the aftereffects of an already harrowing experience. Ensuring that follow-up examinations are every bit as thorough and uniform as the initial care should be a priority for HCPs.

Incomplete or inadequate care in the weeks and months following a sexual assault can lead to longtermphysical and mental sequelae. To limit these sequelae, clear-cut standardized clinical guidelines are needed. Using current national recommendations and reports from experts in the field,1-12 together with her own clinical experience and input and advice of 17 community-based advanced practice nursing colleagues who comprised a focus group, the author developed and copyrighted a clinical practice guideline tool that can be used in primary care practices. This tool—a Clinical Flow Sheet Post Sexual Assault©—incorporates all aspects of a patient’s recovery and well-being to support a holistic recuperation. =

Jennifer A. Korkosz is Assistant Professor at the Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, in Bethesda, Maryland. The views expressed in this project are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the U.S. government.

References

1. Ackerman DR, Sugar NF, Fine DN, Eckert LO. Sexual assault victims: factors associated with follow-up care. Am J Obstet Gynecol. 2006;194(6):1653-1659.

2. Bates CK. Patient Information: Care After Sexual Assault (Beyond the Basics). 2012. http://www.uptodate.com/contents/care-after-sexual-assault-beyond-the-basics

3. Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med. 2002;23(4):260-268.

4. Kapur NA, Windish DM. Health care utilization and unhealthy behaviors among victims of sexual assault in Connecticut: results from a population-based sample. J Gen Intern Med. 2011;26(5):524-530.

5. Linden JA. Clinical practice: care of the adult patient after sexual assault. N Engl J Med. 2011;365(9):834-841.

6. McCall-Hosenfeld JS, Freund KM, Liebschutz JM. Factors associated with sexual assault and time to presentation. Prev Med. 2009;48(6):593-595.

7. Mishel MH. Theories of uncertainty in illness. In: Smith MJ, Liehr PR, eds. Middle Range Theory for Nursing. 3rd ed. New York, NY: Springer Publishing Company; 2014:53-86.

8. Wadsworth P, Van Order P. Care of the sexually assaulted woman. J Nurse Pract. 2012;8(6):433-440.

9. Zinzow HM, Resnick HS, Barr SC, et al. Receipt of post-rape medical care in a national sample of female victims. Am J Prev Med. 2012;43(2):183-187.

10. Prins A, Ouimette P, Kimerling R. Primary Care PTSD Screen (PC-PTSD). 2003. http://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp

11. Maurer DM. Screening for depression. Am Fam Physician. 2012;85(2):139-144.

12. Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med. 2006;166:1092-1097.

Preconception care for women with diabetes

Preconception care for women with diabetes mellitus (DM) is essential in terms of fostering good preg- nancy outcomes. The authors discuss elements of preconception care, which include assessment for complications of DM, identification and discontinuation of teratogenic medications, and optimization of blood glucose control before attempts at pregnancy are made.

Diabetes mellitus (DM) is present in nearly 10% of women of childbearing age, and about 1% of all pregnancies are complicated by the disease.Uncontrolled DM during pregnancy increases the risks for maternal, fetal, and neonatal complications, including pre-eclampsia, miscarriage, fetal demise, congenital defects, and neonatal hypoglycemia and hyperbilirubinemia.Therefore, preconception care should be a routine part of healthcare for reproductive-aged women with DM who have the potential to become pregnant.1-3

Reproductive life planning

Women with DM are at increased risk for adverse health outcomes as a result of pregnancy, especially when pregnancy is unintended. DM increases the risk for cardiovascular disease (CVD) and renal disease, which may be exacerbated by pregnancy. Many drugs used in the treatment of DM and its complications are teratogenic, and prolonged hyperglycemia further increases the risk for fetal developmental abnormalities.1 Therefore, effective contraception is essential to prevent unintended pregnancy or to delay conception while treatment of DM is optimized to improve pregnancy outcomes.1,2 Women who express concern about the safety of contraceptives should be advised that the risks of unplanned pregnancy outweigh those of any contraceptive method.2,4

Until they are ready to become pregnant, women with DM who are of childbearing age and sexually active should use the most reliable form of contraception that is acceptable to and appropriate for them.1,2,4 Long-acting reversible contraceptives (LARC), including subdermal implants and intrauterine contraceptives, are the most effective forms of reversible contraception available. These methods do not rely on user compliance and are appropriate for most females, including adolescents and nulliparous women.4 Depot medroxyprogesterone acetate (DMPA); contraceptive pills, patches, and vaginal rings; and diaphragms are effective when used consistently and correctly but have higher typical-use failure rates than LARC.4 Condoms, spermicides, withdrawal, and fertility awareness methods are the least reliable forms of contraception, but condoms should be used in addition to a more reliable method to reduce the risk of acquiring a sexually transmitted infection.4

Long-acting reversible contraceptive methods and progestin-only pills are safe and appropriate for use in women with DM regardless of disease duration or presence of cardiovascular or other complications.4 Combined hormonal contraceptives (CHCs) and DMPA are safe for use in women with DM of less than 20 years’ duration without retinopathy, nephropathy, neuropathy, or other vascular disease.4 CHCs and DMPA must be avoided in women with any of these conditions or DM of greater than 20 years’ duration.4 Healthcare providers (HCPs) prescribing contraceptives for women with DM should refer to the U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 for specific information about the efficacy and safety of each method.4

These recommendations apply to sexually active adolescents with DM, who may be unaware of the risks of DM during pregnancy.5 Under ideal circumstances, parents of female adolescents with DM, who are instrumental in guiding their daughters in self-care, should participate in preconception counseling sessions.5

Preconception counseling and evaluation

Preconception counseling improves DM knowledge, enhances patient engagement and self-efficacy, and improves pregnancy outcomes.6 HCPs should explain to patients the benefits of a team approach, and offer referral to a certified diabetes educator, registered dietician (RD), or others who can address their particular needs and concerns.6 Specific goals of preconception counseling include education about the risks of poorly controlled DM during pregnancy and about strategies to achieve and maintain glycemic control prior to conception and throughout pregnancy.3

When pregnancy is desired or anticipated, every effort should be made to achieve hemoglobin A1C values as close to normal as is safely possible.1,2 In addition, HCPs need to assess for women’s use of teratogenic medications, and change or discontinue these agents prior to discontinuing contraception.2 Preconception evaluation for women with DM also includes assessment for nephropathy, retinopathy, and neuropathy, which may progress during pregnancy; CVD or CVD risk; and thyroid disease.2,3

Preconception management

Medical nutrition therapy (MNT) is a cornerstone of DM management.3 In the preconception period, MNT goals are to meet women’s nutritional needs and to achieve and maintain glycemic control and a healthy body weight.2 Referral should be made to an RD with expertise in MNT in women with DM, both before and during pregnancy.3 The U.S. Preventive Services Task Force recommends that all women planning or capable of pregnancy take a daily supplement containing 400-800 mcg of folic acid to prevent neural tube defects (NTDs) in infants.7 Presence of DM increases NTD risk.The American Diabetes Association (ADA) recommends that women with DM who are planning a pregnancy take a prenatal vitamin containing at least 400 mcg of folic acid.2

Glycemic control

An elevated glucose level increases the risk for fetal developmental abnormalities in the first trimester.For women who maintain good glycemic control prior to and throughout the first trimester of pregnancy, the risk for complications is similar to that of women without DM.3 Glycemic targets are individualized based on health status and risk for hypoglycemia.2 The ADA recommends achieving an A1C <6.5%, or as low as can be safely achieved without hypoglycemia, prior to conception.2

Insulin

Insulin is the preferred medication for managing type 1 or type 2 diabetes mellitus during pregnancy; HCPs may consider initiating insulin prior to conception when indicated.2,3 Data from human studies indicate that most insulins are safe to use in pregnancy.2,8 Glulisine and degludec have not been studied in humans, however8; HCPs should consider switching women using either of these agents to an insulin that has been studied in humans prior to conception.2

Metformin

Human data suggest that metformin is safe for use in pregnancy and is less likely than insulin or some other oral antidiabetics to cause hypoglycemia.2,8 Women using metformin before conception may continue the drug but should understand that it may be insufficient to maintain glycemic control during pregnancy.2 Metformin crosses the placenta; although no fetal adverse effects have been found, no long-term studies of its safety during pregnancy have been reported.2

Sulfonylureas

Some studies support the use of sulfonylureas in pregnancy, but the FDA has not approved these drugs for use during pregnancy.3 Glipizide has not been studied in humans in terms of its potential teratogenic effects. Animal studies show a low risk of fetal harm from glipizide, but the drug can cause prolonged fetal hypoglycemia and is not recommended for use late in pregnancy. Glyburide has shown minimal risk of fetal hypoglycemia in human studies, as well as no teratogenicity.8 Women taking sulfonylureas who are contemplating or attempting pregnancy should consider changing to insulin in the preconception period. Other classes of oral antidiabetics are not well studied in pregnancy and are not recommended.3

Hypertension

Hypertension (HTN), common in patients with DM, increases the risk for CVD and microvascular disease.Chronic HTN in pregnancy increases the risk of poor pregnancy outcomes and maternal end-organ damage.1 DM increases the risks for pre-eclampsia and the development and/or progression of retinopathy and nephropathy, which may be exacerbated by HTN.The goal of hypertensive management before and during pregnancy is to optimize blood pressure (BP) control—target BP goals of 110-129/65-79 mmHg are reasonable—using medications with good safety profiles for mother and fetus.Unsafe antihypertensives should be avoided in women at risk for pregnancy and discontinued in those contemplating pregnancy.1,2

Antihypertensives contraindicated in pregnancy include angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, which have been linked to fetal renal dysplasia, oligohydramnios, and intrauterine growth restriction.2 Chronic diuretic use may decrease maternal plasma volume and inhibit uteroplacental circulation.2 Antihypertensives that are safe for use in pregnancy include labetalol, methyldopa, diltiazem, clonidine, and prazosin.2

Dyslipidemia

Dyslipidemia, another common co-morbidity in DM, contributes to CVD risk. Although many women with DM take antihyperlipidemics, most of these medications should not be used during pregnancy. Statins are contraindicated in pregnancy; other antihyperlipidemics, including ezetimibe, bile acid sequestrants, fibrates, and niacin, are not recommended because of insufficient data evaluating risk.9 Women using antihyperlipidemics should be counseled about fetal risks and discontinue these agents prior to conception.2 Omega-3 fatty acids are the only pharmacologic treatment for dyslipidemia known to be safe during pregnancy.9

Overweight/obesity

Overweight/obesity (OW/O) is associated with adverse maternal and fetal outcomes, including pre-eclampsia, macrosomia, and cesarean delivery, and has adverse effects on BP, lipid profile, and glycemic control. Diet and exercise are the cornerstones of weight management; women with DM and OW/O can benefit from referral to an RD. Women should strive to follow a healthful diet that includes monounsaturated fats, fruits, vegetables, and whole grains and limits refined sugar, and engage in ≥150 minutes of moderate-intensity exercise each week.Currently available medications for treatment of obesity are contraindicated in pregnancy; if medications are prescribed for weight loss, they must be discontinued before pregnancy is attempted.8 Women who attempt weight loss through bariatric surgery should delay conception for 12-18 months following surgery to minimize the adverse effects of postsurgical nutritional deficiencies.10

Nephropathy

Healthcare providers should assess patients’ renal function prior to conception and advise them that nephropathy may progress during pregnancy.2 HCPs and patients should aim to optimize control of risk factors for nephropathy, including elevated BP and elevated blood glucose.2

Retinopathy

Retinopathy may occur or progress during pregnancy.Women with DM who are contemplating pregnancy should be referred for a dilated retinal examination prior to conception and should undergo follow-up eye exams every trimester and as indicated during the first postpartum year.2 Optimization of blood glucose control may decrease the risk for progression of retinopathy.2

Conclusion

Nearly half of all pregnancies are unplanned.1 For women with DM, unplanned pregnancy carries a significant risk for poor maternal, fetal, and neonatal outcomes. HCPs should address reproductive life planning and preconception care components with all reproductive-aged patients with the potential to become pregnant. For those with DM, an additional focus on the unique preconception considerations to reduce risks related to DM and promote healthy pregnancy outcomes is important. Optimization of glycemic control; discontinuation of teratogenic medications; management of cardiovascular, renal, and ophthalmic risks; and patient education are essential components of preconception care that can reduce the risks for adverse maternal and fetal effects and optimize pregnancy outcomes.

Cynthia S. Watson and Janis R. Guilbeau 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

References

  1. Farahi N, Zolotor A. Recommendations for preconception counseling and care. Am Fam Physician. 2013;88(8):499-506.
  2. American Diabetes Association. Management of diabetes in pregnancy. Diabetes Care. 2016;39(suppl 1):S94-S98.
  3. American Academy of Clinical Endocrinologists. AACE Diabetes Resource Center. Management of Pregnancy Complicated by Diabetes.
  4. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. July 29, 2016.
  5. Charron-Prochownik D, Fischl AR, Choi J, et al. Mother-daughter dyadic approach for starting preconception counseling at puberty in girls with diabetes. Res J Womens Health. 2014;1.
  6. American Diabetes Association. Foundations of care and comprehensive medical evaluation. Diabetes Care. 2016;39(suppl 1):S23-S35.
  7. U.S. Preventive Services Task Force. Folic acid supplementation for the prevention of neural tube defects. U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183-189.
  8. Epocrates. Endocrine/metabolism drugs. 2016.
  9. Mukherjee M. Dyslipidemia in pregnancy. Am Coll Cardiology. 2014.
  10. Narayanan RP, Sayed AA. Pregnancy following bariatric surgery—medical complications and management. Obes Surg. 2016;26(10):2523-2529.

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.

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.

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.

PrEP for prevention: Practice update

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By Lorraine Byrnes, PhD, FNP-BC, PMHNP-BC

According to the Centers for Disease Control and Prevention (CDC), about 1.2 million persons are living with HIV in the United States, and about 20% of them are unaware of it.1 Lack of awareness of HIV status contributes to viral transmission. Healthcare providers (HCPs) play a vital role in the screening, diagnosis, and treatment of HIV infection, but they can also play an important role in HIV prevention. This article focuses on pre-exposure prophylaxis (PrEP), a safe and effective intervention that is rapidly becoming a major tool in HIV transmission prevention. The article also provides an overview of the assessment and management of patients prior to and during the use of PrEP.

The CDC estimates that 50,000 persons in the United States are newly infected with HIV every year.1 Most of the new cases involve men who have sex with men (MSM) (n = 30,689), but African-American women represent a disproportionate number of new infections (n = 5,300) when compared with white non-Hispanic women (n = 1,300) and Hispanic/Latina women (1,200).2

The birth rate among HIV-infected women has increased from 6,000-7,000 live births in 2000 to 8,700 live births in 2006, the last year reported.3 This increase in births may be related to the increased availability and use of antiretroviral medications, which significantly decrease mother-to-child transmission risk. Other factors are also in play. Study data suggest that women who are HIV positive and desire children, including those who disclose their seropositive status to their partners, may not be using condoms consistently.4,5 Little is known about birth rates in women who are HIV negative, desire children, and are in a relationship with an HIV-positive partner.

Pre exposure prophylaxis is the most recent intervention in the effort to fight the HIV epidemic. PrEP is a combination of two antiretrovirals, tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg, taken once daily. This treatment has been shown to reduce transmission risk by upwards of 92%.6 PrEP is available to adult men and women who are HIV negative but have an increased risk of exposure to HIV through sexual and/or injection drug use. PrEP is not approved for use in children or adolescents. Guidelines for PrEP were released in 2014 by the U.S. Public Health Service.<sup.6

Assessment

Health history
To identify and reduce their patients’ risk for contracting HIV infection, HCPs need to take a sexual history as part of primary care and specialty care services. Studies have shown that many HCPs do not ask about risky sexual behaviors and many patients do not disclose them.4,5,7 Assessment of patients’ sexual behaviors and their potential contribution to HIV risk should be part of every healthcare encounter. The 5 P’s of sexual health—partners, practices, protection from sexually transmitted infections (STIs), past history of STIs, and prevention of pregnancy—provide a framework to assess each patient.8

Many patients are not comfortable talking about their sexual practices, partners, and history. HCPs can facilitate this discussion by informing patients that they routinely take a sexual history so that they can provide appropriate sexual health care, and that all information provided is confidential. HCPs can begin by asking these questions, as recommended in the 2014 PrEP guidelines.6 In the past 6 months:

  • Have you had sex with men, women, or both?
  • How many men/women have you had sex with?
  • How many times did you have vaginal or anal sex when neither you nor your partner wore a condom?
  • How many of your sex partners were HIV-positive?
  • If you did have sex with HIV-positive partners, how many times did you have vaginal or anal sex without a condom?
  • Do you have sex with partners who do not know their HIV status?

Next, HCPs need to inquire about any past history of STIs, treatment, past or current symptoms, their partner(s)’ history of STIs, and whether they would like to be tested for HIV during this healthcare encounter. In addition, HCPs can ask patients if they have ever injected drugs not prescribed by their HCP. If the answer is yes, patients are asked whether they have shared injection or drug preparation equipment or been in a drug treatment program in the past 6 months.

If this assessment suggests that a given patient is at high risk for HIV infection, the HCP initiates a discussion about PrEP. Adult MSM who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative man are potential candidates if they have had anal sex with a male (receptive or insertive) without a condom and/or have had an STI diagnosed in the past 6 months. Adult men and women who are heterosexually or bisexually active who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative partner are potential candidates if they infrequently use condoms during sex with partner(s) of unknown HIV status who are at substantial risk for HIV infection. Any individual who is HIV negative and in an ongoing sexual relationship with an HIV-positive partner is a potential candidate. In addition, individuals who have used illicit injection drugs in the past 6 months that included sharing injection and drug preparation equipment or who have been in a drug treatment program in the past 6 months are potential candidates. If a patient found to be a potential candidate is interested in PrEP, then further evaluation is needed to determine whether this intervention is appropriate for him or her.

Physical examination and lab screening/testing
No specific physical examination is required prior to initiation of PrEP. However, HCPs should recognize and further investigate fever, rash, and cervical adenopathy as potential clinical signs of acute HIV infection. These findings are especially relevant if a patient reports having experienced viral infection symptoms such as fatigue, myalgia, headache, night sweats, and diarrhea in the prior 4 weeks.

Laboratory tests for prospective PrEP recipients include HIV testing, hepatitis B virus (HBV) screening, and renal function tests. HIV testing is done within 1 week of initiating PrEP. If the test result is positive, PrEP is not initiated because it does not provide adequate therapy for HIV; in addition, there is some concern about the development of drug resistance. If the test result is indeterminate, PrEP initiation is postponed until further testing determines HIV status.

Both TDF and FTC suppress replication of HBV as well as HIV, so the PrEP intervention may offer an additional benefit if a patient has active HBV infection. Reactivation of HBV infection may occur if PrEP is discontinued or taken inconsistently. If screening indicates that a patient is not infected by HBV or immune to it, HBV vaccination is recommended. Patients who have significantly reduced renal function should not take PrEP.

Pregnancy testing is done if indicated. Although data regarding the use of TDF/FTC in terms of fetal health and growth are limited, the FDA has approved PrEP use during pregnancy. No evidence exists of harm to fetuses exposed to TDF or FTC when used for treatment of HIV during pregnancy.6

Management

PrEP must be taken on a consistent basis for maximum prevention benefit. PrEP is safe and effective but may cause a loss of appetite, mild gastric upset, or mild headaches initially. HCPs need to counsel patients about these side effects and inform them about over-the-counter drugs that may lessen these effects. Patients are asked to contact their HCP if the side effects do not subside. PrEP reaches maximum intracellular concentrations in about 20 days; therefore, patients should be advised that effectiveness is not immediate.

All other medications that patients are taking should be reviewed. Drug interaction data are available for TDF, but not for FTC. TDF has no significant effect on oral contraceptive hormone levels. Serum concentrations of some drugs (e.g., acyclovir, valacyclovir, aminoglycosides) or of TDF may be increased when these agents are combined.6

Regardless of whether or not a patient decides to take PrEP, HCPs and patients need to discuss other ways to reduce HIV infection risk (e.g., limiting the number of sexual partners, always using a condom). For some individuals, multi-session behavioral counseling may be required. Women who have the potential to become pregnant should receive counseling and provision of contraception if they do not want to become pregnant, and pre-conception counseling if they are considering a pregnancy. Patients who report substance abuse should receive referrals for appropriate treatment.

Patients should receive information on the signs and symptoms of acute HIV infection and should be advised to contact their HCP if these occur. In addition, those patients who are taking PrEP need to know that they should not discontinue the regimen without first discussing it with their HCP.

Patients taking PrEP are seen for follow-up at least every 3 months. At these visits, HCPs need to assess them for side effects, medication adherence, and HIV risk behaviors, as well as for signs and symptoms of acute HIV infection. HIV testing is repeated at each follow-up visit. A pregnancy test is performed for women who could become pregnant, and STI tests are done as indicated. Renal function tests are conducted every 6 months.

These follow-up visits provide an important opportunity to reinforce the need for consistent medication use and to support HIV risk-reduction behaviors. Discussion about continuing PrEP should take into account personal preference, change in risk profile, and ability to adhere to the daily dosing regimen. PrEP must be discontinued if a patient’s HIV test result is positive or if renal function is significantly impaired.

Conclusion

PrEP is a safe and effective pharmacologic intervention for women and men at high risk for HIV infection. HCPs have the opportunity to improve the lives of their patients and provide preventive care in the fight against HIV.

Lorraine Byrnes is Associate Professor at Hunter Bellevue School of Nursing, Hunter College, City University of New York, in New York City. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Resources

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

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

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

4. Sanders LB. Sexual behaviors and practices of women living with HIV in relation to pregnancy. J Assoc Nurses AIDS Care. 2009;20(1):62-68.

5. Sullivan K, Voss J, Li D. Female disclosure of HIV-positive serostatus to sex partners: a two-city study. Womens Health. 2010;50(6):506-526.

6. Centers for Disease Control and Prevention. Pre-Exposure Prophylaxis (PrEP). 2015. cdc.gov/hiv/prevention/
research/prep

7. Bernstein KT, Liu KL, Begier EM, et al. Same sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches. Arch Intern Med. 2008;168(13):1458-1464.

8. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. cdc.gov/STD/treatment/
SexualHistory.pdf

Assessment, diagnosis, and management of headache

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By Janis R. Guilbeau, DNP, FNP-BC and Christy M. Lenahan, DNP, MSN, FNP-BC

 

shutterstock_271823513_CMYK

Healthcare providers caring for women can use advanced clinical skills in assessment and accurate diagnosis of headaches. Accurate diagnosis is imperative in providing effective management and making appropriate referrals. The overall goal is to make the correct diagnosis, adequately treat the headaches, and minimize the frequency and severity of headaches in the future.

About 45 million individuals in the United States complain of headaches to their healthcare provider (HCP), accounting for nearly 8 million clinical visits per year.1 The female preponderance of headaches emerges at puberty, with females, relative to males, having a 1.5-fold greater risk of headaches and 1.7-fold greater risk of migraine.2 The most common primary headaches are migraine, tension, cluster, and chronic daily headache.3 Secondary headaches are symptoms of diseases or conditions that can be relatively minor (e.g., sinusitis) or quite serious or even life threatening (e.g., meningitis, brain tumor, cerebral aneurysm, head trauma).3 HCPs must use keen skills to evaluate each woman’s symptoms, formulate a diagnosis, and devise a management plan.

Assessment

Health history

A complete history is key in making the diagnosis. Although symptoms of various types of headache may overlap, a detailed history helps the HCP determine whether a secondary cause needs to be further investigated or if the symptoms fit with one of the primary headache types. The HCP needs to ask the patient about the following3-5:

  • onset, location, frequency, duration, severity, and character (e.g., throbbing versus constant) of the headache(s);
  • existence of any aura or prodrome;
  • any association between the headaches and sleep patterns, emotional factors, or food or alcohol intake;
  • any associated symptoms with the headache;
  • precipitating and alleviating factors;
  • a family history of headache;
  • any changes in vision;
  • any history of trauma;
  • any relationship between the headaches and the menstrual cycle or a change in the method of birth control;
  • use of illicit drugs including cocaine and methamphetamine; and
  • current medications, including aspirin, nonster­oidal anti-inflammatory drugs (NSAIDs), anticoagulants, and glucocorticoids.

Answers to these questions will enable the HCP to rule out certain types of headaches.3-5

Red flags in the history require that further evaluation be done for secondary causes. Sudden onset of a severe, intractable headache may suggest an intracranial disorder such as subarachnoid hemorrhage or meningitis.3 Severe headache triggered by sexual intercourse, cough, or exertion may be caused by an intracranial mass or subarachnoid hemorrhage.5 New onset of headaches in persons older than 50, new onset of severe headaches during pregnancy or postpartum, or new headache types in patients with cancer or immunosuppression are of particular concern.3,5 Any headache described as the “worst headache ever” requires immediate attention.

Physical examination

Physical examination of a patient presenting with a chief complaint of headache includes a general survey, vital signs, focused assessment of the head and neck, and a full neurologic exam.5-7 The focused exam begins in a systematic manner starting with the scalp, which is assessed for swelling and tenderness. The temporal arteries are palpated. Nodularity, tenderness, and a diminished or absent pulse on one side are considered abnormal findings consistent with temporal arteritis.5,7,8

Next, the HCP assesses the temporomandibular joint for tenderness or crepitance,6,7 the eyes for lacrimation and conjunctival injection, and the periorbital area for eyelid swelling, ptosis, or miosis.5,6,9 Visual acuity, extra-ocular movements, visual fields, and pupillary size and response to light are checked for abnormalities and fundi are assessed with an ophthalmoscope for presence of spontaneous venous pulsations and/or papilledema.5-7 The nares are assessed for purulence, the sinuses palpated for tenderness, and the oropharynx examined for presence of purulence, erythema, and swelling.10 Assessment includes percussion of dentition for presence of tenderness.6 The HCP examines the patient’s neck utilizing flexion (unless contraindicated) to assess for discomfort and/or stiffness,6 and listens for bruits in the neck, which may suggest arteriovenous malformation.3 The cervical spine is palpated to assess for tenderness.6

Red flags in the physical examination include, but are not limited to, fever, weight loss, altered mental status, weakness, papilledema, focal neurologic deficits, proximal artery tenderness, and meningismus.6 All pertinent negative and positive physical exam findings, along with history findings, help the HCP further differentiate between primary and secondary headaches.

Diagnosis and treatment

Because of overlapping symptomatology among the different headache types, the diagnosis of a particular headache type can be challenging. In addition, the HCP must discern between a primary headache, which, although painful, is usually not harmful, and a secondary headache such as subarachnoid hemorrhage or transient ischemic attack, which could lead to a stroke.1Migraine

Migraines present as severe, disabling, unilateral headaches often described as pulsating in nature.11 Symptoms may worsen with routine physical activity. Sensitivity to light, sound, and smells is often present, as are nausea and stiff neck.11 Some migraineurs describe having prodromal symptoms (e.g., drowsiness, restlessness, decreased concentration, gastrointestinal upset) that may last for hours to days before the migraine.7 Twenty percent to 30% of migraineurs experience an aura. Aura consists of fully reversible visual, sensory, or speech disturbances that develop gradually before the headache and that last no longer than 60 minutes.7,11 Despite all these symptoms, neurologic examination findings in patients with migraine headache are negative or normal.

Migraines are 2-3 times more common in women than in men and vary in severity.11 In females, prevalence of migraines diminishes after age 50 or after menopause unless estrogen replacement therapy is used.11
Treatment for migraine is either abortive, halting an existing headache, or preventive, lessening the frequency and severity of the headaches. First-line abortive therapy for mild to moderate, non-disabling migraine includes simple analgesics, combination analgesics, and NSAIDs.7,12 Metoclopramide may be added for nausea relief and may promote absorption of oral pain medications.7 Abortive therapy for moderate to severe headaches and those not relieved by analgesics may include drugs that affect serotonin, including the triptans (oral, intranasal, subcutaneous), combination triptan/NSAIDs, ergotamine tartrate, dihydroergotamine, and acetaminophen-isometheptene-dichlor­alphen­a­zone.7,12,13 A weak opioid analgesic such as a butalbital compound or acetaminophen-codeine may be tried if the aforementioned agents are ineffective.12,13

Prevention includes elimination or reduction of identified triggers (e.g., aged cheeses, red wine, monosodium glutamate, artificial sweeteners, caffeine overuse or withdrawal, too much or too little sleep).7 Pharmacologic prophylaxis is considered when migraineurs have more than one headache per week.7,12,13 Drug classes that have proved useful in preventive therapy include beta blockers, calcium channel blockers (CCBs), antidepressants, anti-seizure medications, and some antihistamines.7,12,13Cluster headache

Cluster headaches usually occur at night and are severe and unilateral.14 Although cluster headaches have been found to be 6 times more prevalent in males than in females, more and more women—typically between ages 20 and 40—are being diagnosed with this condition.14,15 Cluster headaches are frequently misdiagnosed as migraine, sinusitis, or allergies.5 The patient may describe sharp, unilateral orbital, supraorbital, or temporal pain accompanied by autonomic symptoms on the affected side (e.g., teary eye, nasal congestion or runny nose, ptosis, eyelid swelling, conjunctival injection).1,7,9,14 Unlike migraineurs, who prefer to remain at rest in a dark room, patients with cluster headache tend to be restless.14

Episodes may last 15-180 minutes, and may occur once every other day to as often as 8 times daily.7,9,14 These headaches typically occur daily for several weeks, followed by a period of remission.7,9 Treatment entails alleviating pain at the onset of the attack and instituting preventive strategies such as smoking and alcohol cessation.16 Following onset of an acute attack, oxygen therapy and sumatriptan injection have been found to be the most effective treatment modalities.16 The CCB verapamil can be started at the beginning of a cluster headache, continued until the patient is headache-free for at least 7-14 days, and then slowly tapered and discontinued.7,9Tension headache

Tension headaches can be episodic (usually associated with a stressful event) or chronic (usually associated with muscular contraction in the neck and scalp).17 Definitive diagnosis includes two of these traits: pressing or tightening pain; occipitofrontal location; bilateral pain, with mild to moderate intensity; and lack of effect of physical activity.17 These head­aches are typically self-limiting and non-debilitating and have no associated symptoms. Physical exam findings are normal. Relief is generally achieved with acetaminophen or NSAIDs.7,12 Treatment modalities for chronic tension headache include lifestyle modifications such as regular exercise, stretching, stress management, relaxation techniques, and adequate sleep. Other treatments include use of hot or cold packs, ultrasound, improvement of posture, trigger point injections, and occipital nerve blocks.7,17Chronic daily headache

This type of headache occurs on 15 or more days per month for at least 3 months and is typically related to medication overuse, although it may represent chronic (transformed) migraine.12,18,19 Medication overuse headache results from taking acute headache medication for 2-3 days per week.12,18 Treatment for chronic daily headache includes preventive medications to decrease reliance on acute medications, and assistance with withdrawal symptoms such as nausea, vomiting, and restlessness.18 Transformed migraine is a constant (24-hour) headache with intermittent, superimposed migraine symptoms.19 As many as 80% of patients with transformed migraine have coexisting depression; treatment focuses on counseling and biofeedback in addition to medication needed to treat depression.19

“Choosing Wisely” initiative

With regard to headache assessment, diagnosis, and management, the American Headache Society endorses the “Choosing Wisely” initiative.20 The initiative lists five suggestions:

  • Avoid neuroimaging studies in patients with stable headaches that meet criteria for migraine.
  • When indicated, magnetic resonance imaging is preferred over computed tomography except in emergency settings when hemorrhage, acute stroke, or head trauma is suspected.
  • Do not recommend surgical deactivation of migraine trigger points outside of a clinical trial.
  • Do not prescribe opioid- or butalbital-containing medications as first-line treatment for recurrent headache disorders.
  • Do not prescribe frequent or long-term use of over-the-counter medications for headache.

Conclusion

Headaches are common occurrences in women; skilled HCPs are positioned to assess, diagnose, treat, and prevent headaches in these individuals. Familiarity with various types of headaches and their causes, appropriate treatment modalities, and preventive strategies can assist HCPs in management of women presenting with headache.

Janis R. Guilbeau and Christy M. Lenahan are Assistant Professors 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. Winland-Brown JE, Keller MB. Neurological problems. In: Dunphy LM, Winland-Brown JE, Porter BO, Thomas DJ. Primary Care: Art and Science of Advanced Practice Nursing. 4th ed. Philadelphia, PA: F.A. Davis; 2015:77-148.

2. International Association for the Study of Pain. Epidemiology of Headache. 2011. www.iasp-pain.org/files/
Content/ContentFolders/GlobalYearAgainstPain2/HeadacheFactSheets/1-Epidemiology.pdf

3. Bautista C, Grossman S. Somatosensory function, pain, and headache. In: Grossman SC, Porth CM. Porth’s Pathophysiology: Concepts of Altered Health States. 9th ed. Philadelphia, PA: Wolters Kluwer; 2014:422-451.

4. Bajwa ZH, Wootton RJ. Evaluation of headache in adults. UpToDate. December 10, 2014. www.upto
date.com/contents/evaluation-of-headache-in-adults

5. Hainer BL, Matheson EM. Approach to acute head­ache in adults. Am Fam Physician. 2013;87(10):682-687.

6. Silberstein SD. Approach to the patient with head­ache. Merck Manual. April 2014. www.merckmanuals
.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache

7. Hale N, Paauw DS. Diagnosis and treatment of headache in the ambulatory setting: a review of classic presentations and new considerations in diagnosis and management. Med Clin North Am. 2014;98(3):505-527.

8. Docken WP, Rosenbaum JT. Clinical manifestations of giant cell (temporal) arteritis. UpToDate. March 18, 2015. www.uptodate.com/contents/clinical-manifestations-of-giant-cell-temporal-arteritis

9. Weaver-Agostoni J. Cluster headache. Am Fam Physician. 2013;88(2):122-128.

10. Brook I. Chronic sinusitis clinical presentation. Medscape. April 7, 2014. http://emedicine.medscape.com/
article/232791-clinical

11. International Association for the Study of Pain. Migraine. 2011. www.iasp-pain.org/files/Content/
ContentFolders/GlobalYearAgainstPain2/HeadacheFactSheets/2-Migraine.pdf

12. Freitag FG, Schloemer F. Medical management of adult headache. Otolaryngol Clin North Am. 2014;
47(2):221-237.

13. Cunha JP. Migraine headache. Emedicine Health. March 16, 2015. www.emedicinehealth.com/migraine_
headache/article_em.htm

14. American Headache Society Committee on Headache Education. Cluster Headache and Other Medical Conditions. 2011. www.achenet.org/resources/cluster_headache_and_other_medical_conditions/

15. Cleveland Clinic Foundation. Diseases & Conditions: Cluster Headaches. 2014. http://my.clevelandclinic.org/
health/diseases_conditions/hic_Cluster_Headaches

16. Simon H. Headaches – cluster. University of Maryland Medical Center. September 18, 2013. http://umm.edu/
health/medical/reports/articles/headaches-cluster

17. Blanda M. Tension headache clinical presentation. Medscape. October 1, 2014. http://emedicine.medscape
.com/article/792384-clinical

18. Silberstein SD. American Headache Society. Medication Overuse Headache. www.americanheadache
society.org/assets/1/7/Stephen_Silberstein_-_Medication_Overuse_Headache.pdf

19. National Headache Foundation. Transformed Migraine. 2015. http://www.headaches.org/2007/10/25/
transformed-migraine-more-commonly-known-as-chronic-migraine/

20. Loder E, Weizenbaum E, Frishberg B, Silberstein S; American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.

Best practice recommendations for male sexual and reproductive healthcare

PDF 50

By Wendy D. Grube, PhD, CRNP

Healthcare providers (HCPs) working in the field of women’s sexual and reproductive healthcare (SRH) are accustomed to having a large body of clinical guidelines that establish the standard of care for women. With the advent of a national agenda to improve male SRH, it became critical to identify which services should be provided to which males and when—based on the best evidence available. A new publication from the Male Training Center (MTC) provides evidence-based and expert-informed recommendations for core clinical preventive care services for men of reproductive age.

Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice, a recent groundbreaking publication by the MTC, presents an expansive rubric under which male SRH services are defined and recommendations for best practice are offered.1 After conducting systematic reviews of the literature and examining current practice guidelines from professional organizations, the MTC developed these recommendations in response to the lack of systematized standards for SRH services for men. The complete recommendations and detailed supporting discussions can be found on the MTC website. This article is a brief summary of the recommended male SRH core services.

Health history

In addition to a customary health history, a comprehensive SRH history includes not only the five P’s (partners, practices, protection from sexually transmitted infections [STIs], past history of STIs, and prevention of pregnancy) but also the development of a reproductive life plan, which helps direct pregnancy preparation and/or identify male fertility concerns. Assessment for gonadal toxins and excessive heat exposure is recommended. Exploration of factors that may compromise sexual function or responsible sexual decision making (e.g., depression; alcohol, drug, or tobacco use) should occur. Probes for difficulty with sexual function (e.g., premature ejaculation, erectile dysfunction [ED]) and intimate partner/sexual violence are suggested as standard practice. Determination of immunization needs is based on risk: HPV vaccination for all males aged 11-26 years; hepatitis B vaccination for males younger than 19 and those with a risk for acquiring the disease from intravenous (IV) drug use or sexual exposure; and hepatitis A vaccination for males with exposure risks.

Physical examination

Core components of the physical exam include height, weight, body mass index, and blood pressure (BP). An external genital exam is recommended to determine that normal adolescent development has occurred, to identify genital problems such as hydrocele and varicocele, to detect signs of an STI, and to serve as part of a male infertility evaluation. During the exam, hair distribution and skin qualities are assessed, and inguinal nodes, the penis, and the scrotal contents are palpated both to confirm presence of the vas deferens and epididymis and to identify common structural anomalies or signs of infection. In males who engage in receptive anal sex, evaluation of the perianal area is recommended. In asymptomatic males, routine screening for testicular cancer and the teaching of testicular self-exam are not recommended. No evidence suggests that these practices result in improved health outcomes; in fact, they are considered potentially harmful. In addition, hernia screening is no longer recommended as part of the routine physical exam unless a clinical indication exists.

Laboratory screening/testing

Chlamydia
At-risk males younger than age 25 should be screened using urine-based nucleic-acid amplification tests (NAATs). Individuals at risk include men who have sex with men (MSM) and those who reside in a community with a high prevalence of chlamydia (e.g., correctional institution, military barracks). All men diagnosed with chlamydia are advised to be re-screened 3 months after treatment to assess for re-infection. Men who have had anal-receptive sex should be screened for rectal infection using an NAAT rectal swab. Screening for pharyngeal infection is not recommended.

Gonorrhea
Routine screening for gonorrhea is not recommended unless men are at risk for this infection by virtue of their being MSM, having multiple sex partners, or having sex associated with illicit drug use. MSM should be screened annually for urethral, anal, and/or pharyngeal infection depending on sites of exposure. MSM with multiple or anonymous partners should be screened every 3-6 months. Men diagnosed with gonorrhea should be re-screened 3 months after treatment to assess for re-infection.

Syphilis
Routine syphilis screening is recommended only among high-risk populations such as MSM, commercial sex workers, males exchanging sex for drugs, and individuals residing in correctional facilities or high-prevalence communities. Screening schedules are based on the degree of risky sexual behavior and may be as frequent as every 3-6 months.

HIV/AIDS
All males aged 13-64 years should be screened for HIV/AIDS, and those considered to be at high risk should be screened at least annually. In addition to engaging in the high-risk sexual behaviors discussed earlier, having sex partners with HIV/AIDS or who use IV drugs greatly increases men’s risk for acquiring HIV/AIDS. The MTC guidelines support the CDC recommendation that HIV/AIDS testing be on an “Opt Out” basis.2

Hepatitis C
One-time testing for hepatitis C is recommended for persons born between 1945 and 1965 because of the high disease prevalence among this population. Men considered at increased risk for hepatitis C because of sexual practices, known exposure, or IV drug use should undergo routine testing based on risk exposure.

Hepatitis B, herpes simplex
Routine screening for hepatitis B and herpes simplex among asymptomatic males is not recommended.

Other tests
In addition to screening for infections, the MTC guidelines recommend screening for diabetes in adult males with sustained BPs >135/80 mm/Hg. The MTC follows the recommendation from the U.S. Preventive Services Task Force to not screen routinely for prostate cancer using a prostate-specific antigen (PSA) test, but it acknowledges the alternative recommendations from the American Urological Association, American Cancer Society, and American College of Preventive Medicine, all of which advise various screening schedules using PSA tests and digital rectal exams based on age or risk factors. Other tests to be excluded from routine screening—based on recommendations from healthcare organizations serving males—include urinalysis and hemoglobin/
hematocrit. Insufficient evidence exists to support routine screening of males for trichomonas or HPV or to support anal cytologic screening.

Sexual and reproductive healthcare counseling

A substantial portion of the MTC recommendations focuses on core elements of SRH counseling. One of the most important core elements entails education about condom use. In particular, the counseling guidelines detail how to teach men to put on and remove condoms, choose the right type of condom, and avoid substances that might destroy the integrity of the latex and result in an increased risk for STI transmission. In addition, recommendations are made for behavioral counseling (through a series of visits) designed to reduce high-risk sex practices. HIV pre-exposure and post-exposure prophylaxis may be considered for individuals at high risk.

Counseling and support strategies for males struggling with sexuality concerns are outlined in the MTC guidelines, and include a sexuality assessment tool and a sample assessment approach. Elements of respect, safety, support, individuality, equity, acceptance, honesty/trust, and communication are explored in this framework. In addition, indications and warning signs of an unhealthy relationship are offered to assist men in identifying and addressing relationship problems.

Counseling regarding pregnancy planning or prevention is another core element of male SRH. A review of all contraceptive methods, for males and for females, should be provided, with attention to safety, efficacy, and correct and consistent use in a patient-centered reproductive life plan. Included in the discussion of contraceptive methods is prevention of STIs and pregnancy. Men who are planning a pregnancy with a partner should undergo pre-conception counseling. This counseling should include discussions about optimizing their partnership (to ensure that all pregnancies are desired) and about enhancing parenting practices (to ensure best outcomes for their children). Strategies to help men achieve optimal fertility should be offered as well.

For men seeking an infertility evaluation, the assessment/counseling process includes a problem-specific history and a physical exam if a pregnancy does not occur within a year of unprotected sexual intercourse—or sooner if the man is known to have bilateral cryptorchidism or suspected infertility potential or if his partner has infertility risks. However, any man, regardless of his present partner, should be able to seek information about his fertility status. Counseling and referral should be available for semen analysis or for medical evaluation if a possible endocrine or urinary disorder is suspected.

Acknowledging that male sexual dysfunction encompasses a common group of disorders that require multidisciplinary care, the MTC recommends specific resources that provide evaluation and treatment guidelines for ED, Peyronie’s disease, priapism, and problems related to libido, orgasm, and ejaculation. Of note, ED can be a sign of early cardiovascular disease (CVD); recommendations for assessment of cardiovascular status are provided along with suggestions for healthy lifestyle interventions that can favorably affect ED as well as CVD.

Conclusion

The MTC’s new document provides a comprehensive resource useful to HCPs who want to provide SRH for men that is evidence based and expert informed. This document provides a foundational framework upon which HCPs can build research to close knowledge gaps and move closer to reproductive healthcare equity for all.

Wendy D. Grube is a Practice Assistant Professor and Director of the Women’s Health Gender-Related Nurse Practitioner Program at the University of Pennsylvania School of Nursing in Philadelphia. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article. She participates on the Men’s Health Technical Panel.

References
1. Marcell AV and the Male Training Center for Family Planning and Reproductive Health. Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice. Philadelphia, PA: Male Training Center for Family Planning and Reproductive Health and Rockville, MD: Office of Population Affairs; 2014.

2. Centers for Disease Control and Prevention. 2010 STD Treatment Guidelines. Clinical Prevention Guidance. Updated January 28, 2011. www.cdc.gov/std/treatment/2010/
clinical.htm