Contraceptive and reproductive care in patients with systemic lupus erythematosus

The purpose of this article is to describe reproductive healthcare needs for patients with systemic lupus erythematosus (SLE), a condition that often affects females of reproductive age, and to describe a retrospective study conducted at Texas Children’s Hospital on contraceptive and reproductive care in female patients with SLE. Continue reading »

NPWH news & updates | June 2019

Message from the CEO

One of my favorite tasks as CEO of NPWH is to present two special awards during our annual conference. The first is the Fran Way Legacy Award, which we established in 2018. This award recognizes a women’s health nurse practitioner (WHNP) who has demonstrated a commitment to women’s health through practice, education, and advocacy. Last year, we honored Fran herself; you can read about Fran’s contribution to our profession here.

The second award is our longstanding Inspiration in Women’s Health Award, which recognizes outstanding WHNPs who animate and uplift us, who exemplify the WHNP role as innovative educators and researchers, and who have made contributions to policy work in women’s health and/or contributions to clinical practice in women’s health.

Both of these distinguished awards give us the opportunity to acknowledge extraordinary WHNPs. It will be my honor to present these awards to deserving WHNPs at this year’s 22nd Annual NPWH Premier Women’s Healthcare Conference, which will take place in Savannah, Georgia, on October 16-19.

On that note, this edition of Women’s Healthcare is accompanied by our Annual Conference Program Guide. Once again, our planning committee members have outdone themselves in creating content that is current, relevant, and evidence based, and that will enable conference attendees to provide up-to-date, high-quality healthcare to women. I encourage you to seize this opportunity to enhance your knowledge base and, just as important, to network with your colleagues.

I look forward to welcoming you in Savannah in October! Please join us!

– Gay Johnson Chief Executive Officer, NPWH

Editor-in-chief’s message

beth kelsey editor chiefDear Colleagues,

June is Men’s Health Awareness Month. Whether or not you provide direct care for men, you can play an important role in one aspect of men’s health: working to eliminate HPV-associated cancers. According to the CDC, about 15,800 men in the United States are diagnosed each year with HPV-associated cancers.1 Eighty percent of these men are found to have oropharyngeal cancer (base of tongue, tonsils, pharynx) and 20% are found to have penile, rectal, or anal cancer.

These cancers typically develop slowly over several years or even decades after HPV infection occurs. According to the CDC, with respect to HPV-associated cancers in men, the median age at diagnosis was 61 years for oropharyngeal cancer, 69 years for penile cancer, and 59 years for anal cancer.2 Most men with recently diagnosed HPV-associated cancers did not have the HPV vaccine (approved for use in males in 2009) available to them to prevent infection when they first became sexually active as adolescents or young adults.

Today we have an HPV vaccine approved for males and females that prevents infection by all seven of the high-risk HPV types associated with cancer, as well as the two low-risk types of HPV responsible for genital warts. Although HPV vaccination rates are improving, those in males continue to lag behind those in females: According to 2017 CDC data, 53.1% of girls aged 13-17 were up to date with the recommended HPV vaccination series, as compared with 44.3% of boys aged 13-17.3

Current recommendations for males include routine vaccination at age 11 or 12.4 Catch-up vaccination is recommended for males aged 13-21 who have not completed the vaccine series. In addition, vaccination is recommended through age 26 for males not adequately vaccinated previously who fall into any of these categories: men who have sex with men, individuals who are transgender, and individuals who have certain immunocompromising conditions.

A call for action: If you see adolescent and/or young adult males in your practice, ask them if they have completed the HPV vaccination series. If not, and when indicated, urge them to get vaccinated at that time. Because young males are not as likely as young females to seek regular reproductive/sexual healthcare, we must advocate for HPV vaccination for both males and females at every opportunity. When providing the vaccine to females, let them know why young males should get vaccinated too. When performing cervical cancer screening or discussing cervical cancer screening recommendations with female patients, let them know that the HPV vaccine that prevents cervical cancer also prevents several types of cancer in males. Offer your patients written information such as the CDC’s HPV and Men – Fact Sheet. With a concerted effort to get all preteen, adolescent, and young adult males HPV vaccinated, when these individuals reach age 40 and beyond, the cancer statistics for men should look much different than they do today.





Beth Kelsey, EdD, APRN, WHNP-BC, FAANP


1. Viens LJ, Henley SJ, Watson M, et al. Human papillo-mavirus-associated cancers – United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666.

2. CDC. HPV and Cancer. HPV-Associated Cancer Diagnosis by Age. Page last reviewed August 16, 2018. cdc.gov/cancer/hpv/statistics/age.htm

3. Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination coverage among adolescents ages 13-17 years – United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(33):909-917.

4. CDC. Vaccines and Preventable Diseases. HPV Vaccination Recommendations. Page last reviewed December 28, 2016. cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html

Improving prenatal health behaviors: Implementing a blended model of prenatal care

A key measure of the efficacy of prenatal care and childbirth education is whether or not they have a positive effect on health-promoting behaviors during and following pregnancy. The purpose of this study was to measure the performance of positive health behaviors prior to and following participation in a blended prenatal care (BPC) model (individual visits plus three group visits) versus traditional prenatal care (TPC) and to compare pregnancy outcomes between the BPC and TPC groups. 
Continue reading »

Editor-in-chief’s message

Dear Colleagues,

I hope the start of 2019 has been a good one for everyone. We have much to anticipate in the coming year with the journal and NPWH. For now, though, I want to take a look back at 2018, recognize the many individuals who helped us have an excellent year, and celebrate all we have accomplished for the journal.

I’ll start by thanking all the authors of articles published in the 2018 issues of the journal. They brought us high-quality, interesting, and clinically useful information for our everyday practice. The wide variety of content provides something for every reader. As special recognition, we asked readers to choose their Women’s Healthcare 2018 Favorite Articles. Congratulations to these winners:

Feature Articles

First place: The ABCDs of bacterial vaginosis: Abnormal flora, Bothersome symptoms, Chronicity, and the Differential diagnosis, by Alisa Pascale, DNP, WHNP-BC (December 2018)

Second place (tie):
Dense breasts: Cancer risk and supplemental imaging modalities, by Mary Ellen Egger, APN, WHNP, CBPN and Diana L. Lam, MD (March 2018)

Caring for women with disabilities during the perinatal period, by Lorraine Byrnes, PhD, FNP-BC, PMHNP-BC, CNM, FAANP; Mary Hickey, EdD, WHNP-BC, FNP; Jin Young Seo, PhD, WHNP-BC; and Lorie Goshin, PhD, RN (December 2018)

Department Articles

First Place: Policy & practice points: Cultivating your inner Wonder Woman: Policy advocacy, by Diana M. Drake, DNP, MSN, APRN, WHNP-BC (March 2018)

Second Place: Commentary: WHNPs in specialty programs: My experience in breast surgical oncology, by Caitlyn E. Hull, MS, APRN-CNP, WHNP-BC and Randee L. Masciola, DNP, APRN-CNP, WHNP-BC (September 2018)

I also extend a special thank-you to all the individuals who peer-reviewed manuscripts for us in 2018: 

We rely on their thoughtful and expert feedback to ensure that the articles we publish are the very best.

Our editorial advisory board (EAB) members continue to provide guidance on potential topics and format for the journal. They do this by reviewing feedback from readers on what they want to know more about, staying abreast of contemporary issues, and participating in a yearly meeting. Some of our EAB members also contribute by peer-reviewing manuscripts and submitting manuscripts of their own. I am pleased to welcome Lorraine Byrnes as our newest member of the board.

The HealthCom Media publishing team is outstanding. They bring together diverse talents that keep us moving forward and looking our best. Their commitment to publishing a journal we can be proud of is apparent in all they do. It continues to by my honor and delight to work in partnership with Dory Greene, our journal’s managing editor, as we share a passion in what we do. I appreciate beyond words her expertise, dedication, professionalism, and kindness.

Our Women’s Healthcare journal team includes editors, authors, peer reviewers, EAB members, publisher and publishing staff, and NPWH staff, board of directors (BOD), and CEO Gay Johnson. We all look forward to continuing to provide you with a variety of high-quality, interesting, and clinically relevant articles in 2019.

Beyond the journal, I want to recognize individuals who have participated on writing groups that create NPWH position statements. These individuals bring expertise and dedication to a process that takes time, discussion, and an ability to interact in a meaningful way to create a product that reflects the NPWH mission and values. In 2018, the NPWH BOD approved four new position statements:

Cervical Cancer Screening

Men with Breast Conditions: The Role of the WHNP Specializing in Breast Care

Male Sexual and Reproductive Health: The Role of WHNPs

Brain Health is Women’s Health

The writing group members for these position statements are:

Reviewers and individuals who provide feedback through public comment strengthen our position statements. I want to thank all who participated in this process.

We expect 2019 to be another busy year as NPWH continues to grow and provide the services and products we hear that our members want. We look forward to seeing you at NPWH events and hearing from you throughout the year!




WHNPs in specialty positions: Cultivating a new role in gynecologic oncology

Throughout my graduate education in nursing, I had no doubt that I ultimately wanted to focus my practice on women’s health. However, I did graduate with a fair amount of trepidation about the possibility that I had limited my options in the advanced practice arena, especially after I had chosen to narrow my focus to oncology. Over the next couple of years, I came to realize not only that my options as a women’s health nurse practitioner (WHNP) were more numerous than I had thought, but also that I would be able to help cultivate new roles within the profession as well. Continue reading »

Using simulation to practice IUD insertion and removal techniques

Statement of Retraction of Article

The article and video, “Using Simulation to Practice IUD Insertion and Removal Techniques,” by Aimee Chism Holland, DNP, WHNP-BC, FNP-C, FAANP, have been retracted by the editorial staff and on request of the author after concerns about accuracy were expressed by some readers.  The article and video should not be used or relied upon for IUD insertion and removal instruction.  The article and video are under review and may be revised and republished at a later date. 
Beth Kelsey, EdD, APRN, WHNP-BC, FAANP,
Editor-in-Chief, Women’s Healthcare: A Clinical Journal for NPs

Continue reading »

Men with breast conditions: The role of the WHNP specializing in breast care

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the role of the women’s health nurse practitioner (WHNP), as a member of a multidisciplinary breast care specialty team, in providing specialized breast care for women and men. Furthermore, NPWH supports the removal of any restrictions to the provision of male breast care that are based on the WHNP credential. Continue reading »

Editor-in-chief ’s message

Dear Colleagues,

The National Association of Nurse Practitioners in Women’s Health (NPWH) strives to continuously improve the accessibility and quality of healthcare for women. This improvement is accomplished by promoting innovation and excellence in continuing education and professional development; leadership in policy, practice, and research areas; and support and services for our members. Achieving all these goals is our organization’s vision. Continue reading »

Policy and preventive healthcare services: Women living longer, living well

By Diana M. Drake, DNP, MSN, APRN, WHNP-BC

From the perspective of women’s healthcare providers (HCPs) in the United States, one of the major shifts in their field over the past decade has been a female patient population that is growing older, with an increasing mix of midlife and senior-life patients. Continue reading »

NPWH 2016 Conference Abstracts

nurse practitioner womens healthcare journal new orleansThis issue of Women’s Healthcare: A Clinical Journal for NPs features abstracts presented at the 19th annual NPWH conference in New Orleans in October 2016. These abstracts include those of the podium presenters and that of the first-place poster award winner. My heartiest congratulations to all! Each year, the NPWH conference is enriched by these podium presentations and the poster sessions. Please take time to review the abstracts that provide state-of-the-science information about women’s health, and please consider submitting your work for 2018!

Lorraine Byrnes, PhD, CNM, FNP-BC, PMHNP-BC, FAANP
2016 NPWH Research Committee Chair Continue reading »

Laparoscopic vs. Robotic Surgery for Endometriosis

Outcomes can be equally good with either procedure

Contrary to the common expectation that robotic assistance can improve the outcomes of endometriosis surgery, a study found no evidence it is either superior or inferior to traditional laparoscopic technique.

“Both robotic and laparoscopic surgery improve quality of life and relieve pain when the procedures are done by experts in endometriosis,” says Tommaso Falcone, MD, Chairman, Ob/Gyn & Women’s Health Institute at Cleveland Clinic.

This conclusion is the result of a multicenter, randomized clinical trial comparing the use of traditional laparoscopic surgery with robot assisted surgery in women with endometriosis. The primary outcome was operative time. Secondary outcomes included perioperative complications and quality of life. Continue reading »

Scientists Seek People with Primary Progressive MS and Other Forms of MS to Study Gut Bacteria

Investigators at the University of California in San Francisco are recruiting people with MS for an international study of the gut microbiome – the population of bacteria in the gut – in MS. They are seeking people with primary progressive MS nationwide (there is no need for onsite visits), as well as people with any other type of MS who can make a one-time visit to San Francisco, New York, Boston or Pittsburgh. The overall purpose of these studies is to investigate the potential role of gut bacteria in MS.

Scientists Focus on Gut Flora for Future Treatments of Autoimmune Diseases

Continue reading »

Cervical Biopsy more efficient, less painful via new method

Physicians evaluate new device to test for cervical cancer. Comparison of Tissue Yield Using Frictional Fabric Brush Versus Sharp Curettage For Endocervical Curettage.

Women undergoing cervical biopsies might have lower odds of repeat tests with a rotating fabric brush than a sharp instrument because the soft device may capture more cells for analysis, a recent study suggests. Furthermore, biopsies with the softer tool may be less painful, researchers say. Cervical biopsies sometimes fail to collect enough cells from the cervix to accurately test for cancer, in which case another biopsy is needed. Continue reading »

Sexuality in the aging population: Q&A from a certified sex therapist

The author of the second part of this 2-part series on sexuality in the aging population is a Certified Clinical Specialist in Psychiatric/Mental Health Nursing and an AASECT-Certified Diplomate of  Sex Therapy. She shares her clinical expertise on  this topic in a Q&A format. Readers can access the first part of the series here.

1. What do you see as the biggest myths about sexuality in the over-50 population?

The first myth is that couples are no longer interested in sex after they reach the half-century mark. The second myth is that men lose the ability to have erections, and the third is that women do not enjoy sex after 50. Here are the facts. Although some couples do put sex on the back burner after childrearing ends, others find that with that empty nest comes the opportunity for more sexual playfulness and less worry about being discovered by others in the home. Men do experience changes in erectile function as they age, but, even into their 70s, only about a third of men regularly have difficulty getting and keeping erections. Many women find they become more adventuresome and finally have the time to discover their own sexual potential after age 50. The biggest risk to good sex in later life is boredom.

2. How does sexuality change for women during the postmenopausal years?

The body’s sexual signals change as women age. Whereas younger women become lubricated as one of the signs of sexual arousal, older women do not get as wet. If women have not learned to notice other arousal signs, they may think that they are not turned on. A lot depends on whether a woman has had a surgically induced menopause and whether she is able to take replacement estrogen. Without hormonal support, vaginal tissue becomes thin and dry, causing vaginal containment (of a penis, a finger, a tongue, a dildo, or the like) to be painful. To ameliorate the situation, many older women find they enjoy using lubricating oils such as coconut oil as a part of their sexual warmup. Some women may also need to use a vaginal moisturizer if penetration is uncomfortable.

3. Which techniques do you advise older couples to incorporate into their sexual repertoire?

I coined the phrase true oral sex to describe the absolute need for couples to communicate with their mouths and not just with their bodies. This practice is especially true for older couples, whether in long-term relationships or in newer ones. In addition, the sexual experience during later years requires a true hands-on approach. The body’s biological system is not going to be activated just by thoughts and hormones now—t must be physically coaxed. And both partners need to make sure that they are breathing—holding one’s breath is the biggest single reason most women at any age do not get sexually aroused.

4. How did your practice change after the FDA approved Viagra in the late 90s?

I had practiced for two decades before erectile dysfunction (ED) medications were approved by the FDA. I have found these agents to be a huge boost to what I could offer to men because they are actual treatments for the physical problems men experience. The downside was that although many men gained benefits from Viagra, their spouse or partner was not necessarily interested in resuming sexual activity. So, negotiations needed to take place—prompting an even greater need for true oral sex.

5. Is there an age when many women stop having sex?

Studies have shown that women stop having sex when they can no longer find interesting partners. For some women, this situation may occur when they are in their 50s and for others, this situation never occurs. Is there an age when women should stop having sex? Unless there are medical contraindications, a woman can have sex as long as she wants to do so.

6. What barriers prevent intercourse in the older couple?

Declining or compromised state of health of one or both partners is the greatest risk to good sexual health. However, even if one or both partners have minor or major health problems, many older couples find that, even without intercourse, they can enjoy many other sexual activities—what I call outercourse. Outercourse encompasses all sexual activities other than penis-invagina intercourse, including finger, tongue, and/or vibrator  stimulation of the clitoris, for instance, as well as cuddling and caressing of any and all body parts.

7. How can couples maintain their sexuality if intercourse (or vaginal penetration of any kind) is not an option?

Sexuality is a state of both feeling and being sexual. Couples who maintain their sexual vitality for a long time share traits of having fun, being open minded, and flirting and “dating” even if they are a long-time couple. Such couples take the time to touch and caress each other, even if not for sexual warm-up per se. Many couples find that after 20 minutes of non-sexual caressing, they begin to feel sexual yearnings. Couples who experiment with direct stimulation of a flaccid penis, with or without assistance of an ED medication, sometimes find that this “wakes up” the nerves and helps start an erection, which can then lead to some form of sexplay. Many couples do not have intercourse or even orgasm as a goal, as might have been the case earlier in their lives, but find great satisfaction in exploring other options.

8. Which resources do you recommend for older women seeking answers to their questions about sexual dysfunction?

These women should get the best help available regarding their state of physical and sexual health, including advice on hormone replacement, urinary incontinence, and pelvic floor evaluation. They should read age-related materials about sexuality. My book, Assisted Loving: The Journey through Sexuality and Aging, is written in question-and-answer format. The book addresses actual concerns expressed by my readers over the 6 years during which I wrote a column on the topic.

9. How do you counsel postmenopausal women who are entering into a new romantic relationship?

Most older women have had lots of life experiences and have developed common sense about keeping themselves safe, but romance can throw all that knowledge out the door. I suggest that these women move forward using their heads and their intuition—f something doesn’t feel quite right, don’t go there. If they are using an online dating service, for example, they should have several people they trust in the loop so they don’t take unnecessary chances. Until they are 100% sure of a partner’s sexual history, they should not trust that the potential mate does not have a sexually transmitted infection. If the partner is a male, they should insist that he use a condom. These women should also get checkups themselves and tell their healthcare provider that they are beginning a new sexual relationship. They should also be encouraged to enjoy the experience! =

Ginger T. Manley is a Certified Clinical Specialist in Psychiatric/Mental Health Nursing and an AASECTCertified Diplomate of Sex Therapy. She retired in 2015 from her faculty position as Associate in Psychiatry, Division of Addictive Medicine, at Vanderbilt Medical School in Nashville, Tennessee. Her website is  gingermanley.com. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


Message from the CEO

I am proud to say that, with this November 2015 issue, Women’s Healthcare: A Clinical Journal for NPs, is turning 2 years old! When we introduced the journal 2 years ago, we provided quarterly online issues. Now, as an added benefit, we provide our active NPWH members with both the electronic version and a complimentary print copy of each issue.

Since Women’s Healthcare began, we have added more departments such as On the case…, DNP projects: Spotlight on practice, Focus on sexual health, and Commentary. We have always offered one continuing education (CE) article per issue, along with two or three additional feature articles. Our goals for the future are to continue offering these articles and departments, to increase the number of issues per year, and to add more case studies, scientific studies, and clinical updates.

Our journal continues to grow, and is fast becoming a highly valuable asset to nurse practitioners (NPs) caring for women. The open rate – that is, the proportion of people on an email list who open (or view) a given email – for each issue of Women’s Healthcare is rising, and averages more than 30%. To put this statistic in perspective, the industry gold standard is an open rate of 20%. Even more stats support what our readers are discovering with respect to our journal’s content:

• 75% find the information in the journal “useful” to “very useful”;

• 83% engage in the journal’s CE articles;

• 58% utilize the journal’s “How to” and Case study articles;

• 54% find the journal’s research news useful; and

• 50% utilize the journal’s Clinical resources department.

NPWH takes great pride in providing a variety of tools that promote high-quality, evidence-based women’s healthcare. With regard to our 2-year-old journal, our goal moving forward is to ensure that all advanced practice nurses caring for women recognize Women’s Healthcare as the specialty go-to journal for expert women’s health content.

I want to mention a few of NPWH’s other accomplishments in 2015:

NPWH celebrated its 35th anniversary this year, a milestone marked at our 18th Annual NPWH PremierWomen’s Healthcare Conference in Salt Lake City, Utah, in October.

The 2nd Annual Women’s Sexual Health Course for NPs was a great success this year; we sold out of space! We are increasing the number of registrations next year to enable more NPs to participate. Save the Date: June 23-26, 2016.

We added a new component to our mobile app, a women’s cardiovascular health preventative screening tool, which we launched at our annual conference in October.

NPWH proudly welcomed our second class of Student Reporters to participate in our annual conference.

We partnered with Bedsider to provide grants to six clinical sites to measure and improve contraceptive practices for women aged 17-29.

Stay tuned for more CE opportunities, toolkits, and programs for NPs. Our main objective is to continue to provide more services and support for our members. We invite those of you who are not yet members to join NPWHA! And we thank all of you who supported our organization this year. All of us look forward to a wonderful 2016!

– Gay Johnson

Chief Executive Officer, NPWH



Editor-in-chief’s message

Dear Colleagues,

Are you looking for a challenging but rewarding opportunity to participate in enhancing advanced practice nursing (APN) knowledge? If the answer is yes, I hope you will consider becoming a peer reviewer for our journal. Here are some answers to frequently asked questions.

What is the role of a peer reviewer?

Peer reviewers are important consultants to journal editors and authors. Their major role may be content expert, practice expert, or research methodology expert, although one peer reviewer need not fill all these roles. We match the skills of a peer reviewer with the needs of a given manuscript. When a manuscript has a clinical focus, we try to choose reviewers with expertise in the content or practice area covered in the manuscript. When we receive a qualitative or quantitative research manuscript, we try to choose reviewers who have expertise in that research methodology.

Most important, we strive to identify and maintain a strong cadre of thoughtful and thorough reviewers who are willing to provide truthful and constructive critiques. Diversity among our peer reviewers is also important; we are looking for reviewers who vary in terms  of their role (academic or clinical practice), years of experience,  areas of expertise, and populations served.

What is in it for me?

APNs in the academic world reap the benefits of adding peer reviewer contributions to their CVs and promotion documents. Novice authors may find the process of doing peer reviews helpful in improving the quality of their own writing. Seasoned authors may enjoy fostering the professional growth of novice authors through constructive peer reviews that identify both the positive features of a manuscript and the areas that need improvement. All peer reviewers can take satisfaction in knowing that they are contributing to the APN profession by supporting the publication of high-quality, relevant, evidence-based articles that can help their colleagues provide the best possible care for their patients.

What happens when I receive a manuscript for review?

First, you will receive a request from us that informs you of the topic of the manuscript and our turnaround time (3-4 weeks). This information will help you decide whether you are interested and whether you have time to do the review. (If, after making the commitment, you find that you need a small extension, we are almost always able to grant it.) Next, if you accept our offer, we will send you the blinded manuscript with a peer reviewer evaluation form. The entire review process is completed electronically and takes about 4 hours.

The peer reviewer evaluation form includes a list of questions about the content and about your general impression regarding whether the manuscript merits publication in our journal. You can provide comments and suggestions on the evaluation form, but we encourage you to make them right on the manuscript.

We do not ask you to correct grammar or spelling errors;  in many, if not most, cases, we will have edited the  manuscript before we send it to you. We do ask that you  read the manuscript to determine whether the information is accurate, supported by evidence, relevant, and clearly presented, and to make suggestions for improvement. We also ask you to check the references for timeliness and appropriateness and to identify any important resources that might be missing. For research manuscripts, we ask for a thorough review of methodology.

How can I learn to do a good peer review?

At your request, Dory Greene, our managing editor, and I would be happy to provide feedback on your review. Even for novices, though, if your review is thoughtful, thorough, and truthful, it will be useful and very much appreciated.

How do I sign up to be a peer reviewer?

Click Here! I hope to hear from you soon!

Beth Kelsey, EdD, APRN, WHNP-BC


Formation of a peer review group for advanced practice nurses: Learning from and with colleagues

In 1996, Dr. Els Borst, former Minister of Health of the Netherlands, proposed that specially trained master’s-prepared nurses assume certain tasks of physicians in order to help meet the growing need for healthcare in the midst of a physician shortage. In light of the increased number of elderly and chronically ill patients today, this need is even more pressing.1  The consequence of Dr. Borst’s proposal was the inauguration of the first Master’s in Advanced Nursing Practice (MANP) program in Groningen, the Netherlands, at the Hanze University of Applied Sciences in 1997.

Since that time, the training and the work accountability of advanced practice nurses (APNs) in the Netherlands have been extended. A major change occurred in March 2009, when Dutch APNs were granted official registration numbers and legal title protection. Nurses can be registered as APNs only after earning a master’s degree from a certified university and undergoing training on the job at a certified healthcare institute with a certified medical and nursing trainer.

Dutch APNs can be registered in one of five nursing specialties: (1) acute care in somatic disorders, (2) intensive care in somatic disorders, (3) chronic care in somatic disorders, (4) preventive care in somatic disorders and (5) mental health. Like physicians, APNs must attend conferences offering staff development workshops and be actively employed for at least 24 hours a week. In 2014, more than 2,500 APNs were registered in the Netherlands.2

After initial registration, APNs must re-register every 5 years to maintain an active license. Since 2010, one of the requisites for re-registration has been participation in peer review (PR). Guidelines of the Dutch Nursing Specialty Registration Board (DNSRB) require APNs to participate in a PR group (PRG) for at least 40 hours per 5-year period.3 In addition, to ensure competence and continuous professional development, periodic self-appraisal and peer feedback must be in place for all levels of nursing.4 

Defining peer review

Peer review is a systematic process by which one assesses, monitors, and makes judgments about the quality of care provided to patients by others, as measured against established standards of practice. 5,6 Nursing PR is an evaluation of one’s professional nursing practice, including identification of opportunities to improve care, by persons with the appropriate expertise to perform the evaluation.7 Because they undergo PR, APNs are a group of healthcare providers (HCPs) whose personal competencies in various nursing specialties are compared— with those of other APNs and with objective criteria—with the aim of improving daily practice.3  PR, recognized as a measure of accountability and a means to evaluate and improve practice,4  enhances development of the APN profession and improves the quality of patient care.

Peer review has multiple benefits for APNs. It facilitates an open and safe learning environment. It provides APNs with an opportunity to reflect on questions and problems together. Because of the interactive setting, APNs invariably learn something new.8PR even offers APNs a break in an otherwise hectic workday. PR can help APNs evaluate the quality of care they have delivered, and gain insight into their greatest strengths and weaknesses as HCPs. With feedback and recommendations from the group, APNs can gain new knowledge and improve their skills.

Creating and working as a PRG

Because the APN profession is relatively new in the Netherlands, the nursing education department of the Erasmus Medical Center Rotterdam had no experience in starting or structuring a PRG. Five years ago, five pioneering APNs working on an internal medicine unit decided to create such a PRG. These APNs found several examples of PRGs in the literature and took the initiative in creating a framework, based on non-empirical research, that took into account the criteria requisites of the DNSRB.

To initiate an effective PRG, some basic steps are essential. The first step is to form a group of 3-5 APNs in the same specialty who have similar interests within their specialty. The next step is to elect a chair to serve a 1-year term. The chair then makes a yearly schedule so that members can plan to attend all PRG meetings. To meet the criterion of spending 40 hours in the PRG over 5 years, the group must meet for about 2 hours every 3 months.

At each meeting, members take turns serving as the contributor, who presents a case related to her work field. One week before the meeting, the contributor sends a recap of the case—along with corresponding literature, protocols, and guidelines—to PRG members so that they can read background material and analyze the case. Each case submitted for PR must have these elements:

• The patient’s presenting complaint, personal and family health history, and physical examination findings;

• An analysis of the case, with corresponding literature or guidelines to clarify or substantiate the diagnosis or the problem;

• A list of dilemmas that can occur or that did occur with the presented case, as well as learning points, and

• Learning objectives extracted from the presented case for discussion.

At the meeting, the contributor uses PowerPoint to present the case and then leads the discussion regarding dilemmas and learning goals. A member who is appointed secretary for each meeting takes notes and creates a report of the thoughts an views exchanged during the meeting. The report includes a summary of the case, the learning goals of the contributor, and feedback/recommendations from the group. After the meeting, the report is sent to the PRG members. Reports of PRG meetings are saved in a digital portfolio.

At the next PRG meeting, notes of the previous meeting are discussed. The chair asks the previous contributor whether she used feedback from the last PRG meeting and applied it to her practice. The process gives the contributor an opportunity to reflect on her own goals and improve the quality of her work.

Choosing the best method to present a case

Within the first year of the PRG’s existence, all five members had submitted a case. The group then met to determine the best format for presenting a case. The PRG considered three options: the testing method, the Balint method, and the research method. These methods were evaluated in terms of whether they enhanced the professionalism  the APN through the sharing of knowledge, expertise, and thoughts. The group was most satisfied with the testing method, which is particularly suitable for case study discussion and for evaluation of clinical guidelines and protocols. With this method, the group works together, sharing ideas and coming to an agreement on how practice can be improved. One downside of the testing method is that the personal learning goals of the APN are not included.

Gaining competencies

In the Netherlands, the focus of learning is to gain competencies. A framework used for the competency- based approach is that of the Canadian Medical Education Directives for Specialists (CanMEDS) (Figure).9 The CanMEDS framework describes seven different roles of an HCP: professional, communicator, collaborator, manager, health advocate, scholar, and, in the center, medical expert. APNs who have gained the first six competencies can become medical experts (the center of the honeycomb), but they cannot become medical experts if they fail to gain one of the six competencies surrounding the central competency. APNs need to enhance themselves in all seven competencies in order to become better HCPs.

Achieving the best practice

A combined framework using both the testing method and the CanMEDS framework was determined to be the best practice. This combined framework was deemed to be the best way to prepare a case for discussion and to give the PRG and the contributor the clearest insight into the question and learning issues provided by the case. The testing method is an ideal way to discuss problems or questions regarding certain procedures and guidelines within the safe confines of a group. In addition, each group member can impart information and share expertise via the group discussions, which can then be absorbed by the other members and translated into their own practices.


The PRG found that, over a 4-year period, a combined approach—the testing method and the CanMEDS framework—constituted the best practice for structuring a case for discussion and determining the contributor’s own learning issues. The DNSRB also recommends use of CanMEDS competencies in this regard. If the combined framework does not work well for a given PRG, it may be related to poor group dynamics, lack of a safe environment, or a tendency for members discussing a case to highlight their feelings rather than their own practice. Some PRG members indicated that they sometimes felt vulnerable. It take courage to learn from colleagues. According to Karas-Irwin and Hoffmann,4 a caring environment imbued with genuine respect enhances PRG interactions. By participating in a PRG, APNs in the Netherlands not only meet the needs and criteria of the DNSRB, but also enhance their professional skills and build their knowledge base.

Implications for APNs in the United States

Although there is no specific requirement to participate in PR as part of APN licensure in the United States, PR is recognized as an important component of practice and professional responsibility. 10,11 The opportunity to come together as a small group of APNs with similar clinical practices and interests on a regular basis to review challenging cases provides a collegial environment for learning from each other. Peer assessments can play an important role in enhancing quality of care for complex patients with multiple interrelated chronic conditions, especially as seen in the U.S. with its aging population and the increasing prevalence of obesity and its co-morbidities. =

Simone J. van der Linden is an APN in the Department of Hematology, Cancer Institute; Leni van Doorn is an APN in the Department of Medical Oncology, Cancer Institute; Judith P. van Eck is an APN in the Department of Medicine, Section of Endocrinology; Wanda Geilvoet is an APN in the Department of Medicine, Section of Endocrinology; and Greta Mulders is an APN in the Department of Hematology, all at Erasmus Medical Centre, Rotterdam, The Netherlands. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.


The authors thank L. Maas, RN, MS, Rotterdam University, Master’s in Advanced Nursing Practice Program, Rotterdam, the Netherlands.


  1. Statistics Netherlands. Dutch population expected to reach 17.5 million in 2038. cbs.nl/en-GB/menu/themas/bevolking/publicaties/artikelen/archief/2008/2008-085-pb.htm
  2. Dutch Nursing Association.  2013. venvnvs.nl/files/2014/09/Jaarverslag-VVN-VS-okt13-okt14-def.pdf
  3.  Dutch Nursing Specialty Registration Board. Intercollegiale Toetsing Verpleegkundig Specialisten. 2010. verpleegkundigspecialismen.nl/Portals/45/20100203%20Intercollegiale%20Toetsing%20Verpleegkundig%20Specialisten%20_3.pdf

  4. Karas-Irwin BS, Hoffmann RL. Facing the facts: in-person peer review. Nurs Manage. 2014;45(11):14-17.
  5.  Sherwood GD, Brown M, Fay V, Wardell D. Defining nurse practitioner scope of practice: expanding primary care services. Internet J Adv Nurs Pract. 1997;1(2). geide.org/uploads/6/4/8/8/6488798/definingscope.pdf

  6. Smith MA, Atherly AJ, Kane RL, Pacala JT. Peer review of the quality of care. Reliability and sources of variability for outcome and process assessments. JAMA. 1997;278(19):1573-1578.

  7.  Spiva LA, Jarrell N, Baio P. The power of nursing peer review. J Nurs Adm. 2014;44(11):586-590.

  8. de Haan E. Leren met Collega’s.  Uitgeverij Van Gorcum;2009.
  9.  Frank JR, Jabbour M, Fréchette D, et al. Report of the CanMEDS Phase IV Working Groups. Ottawa, Canada:The Royal College of Physicians and Surgeons of Canada;2005.
  10. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies. 2012. c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenciesfinal2012.pdf

  11. National Association of Nurse Practitioners in Women’s Health/Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.


Lung cancer screening: Low-dose computed tomography

In the United States this year, more than 200,000 individuals will be diagnosed with lung cancer and close to 160,000 individuals will die of lung cancer. Women represent half of both of these numbers. More than 50% of lung cancers will have distant metastasis at the time of diagnosis. The 5-year survival rate for these individuals is less than 5%, as compared with a 58% survival rate if cancer is detected while still localized to the lung.1,2 A screening program that can detect lung cancer at an early stage—when surgery can be curative—and that is designed to minimize harms associated with screening is highly desirable.

Findings from the National Lung Screening Trial (NLST) support the use of helical low-dose computed tomography (LDCT) for lung cancer screening in individuals at high risk for lung cancer.3 The NLST was an 8-year National Cancer Institute-funded randomized controlled trial conducted from 2002 through 2009 to compare the effects of the use of LDCT versus standard chest radiography on lung cancer mortality rates in high-risk individuals.3 Participants were adults aged 55-74 years who had a 30-pack-year smoking history and currently smoked or had quit within the previous 15 years. More than 50,000 participants were screened with LDCT or chest radiography annually for 3 years. Data were collected on lung cancer occurrences and lung cancer-related deaths through 2009. The data demonstrated a 20% reduction in mortality from lung cancer among participants screened with LDCT versus those screened with chest radiography.

The U.S. Preventive Services Task Force (USPSTF) used modeling based on the NLST data to assess the potential benefits and harms of screening with LDCT for varying populations.4 In 2013, the USPSTF issued a recommendation for annual screening for lung cancer using LDCT in adults aged 55-80 years who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years.4 The American Cancer Society and the American College of Chest Physicians issued similar lung cancer screening recommendations in 2013.5,6 The only variance from the USPSTF recommendations was an upper age limit of 74 years instead of 80.

LDCT uses much less radiation than does standard CT. With LDCT, the x-ray sources follow a helical or spiral path around the patient, taking less than 1 minute to scan the entire chest. Computers create multiple thinly-sliced 2-dimensional images of the lungs from the x-ray information. Further evaluation is needed if LDCT reveals a pulmonary nodule. Nodules with low probability of cancer may be followed with repeat LDCT scans over a period of time to watch for nodule growth. Higher-dose LDCT, positron emission tomography, and biopsies are used to evaluate nodules with moderate or high probability for cancer.7,8

The USPSTF has recommended standardization of LDCT screening and follow-up of abnormal findings, as well as development of a registry to collect data needed to enable continuous improvement in screening program quality over time.4 Several organizations have recommended that lung cancer screening and follow-up be conducted as part of a structured, high-volume, high-quality program involving a multidisciplinary team skilled in evaluation and treatment of lung cancer. Such programs would use eligibility criteria consistent with USPSTF recommendations, have American College of Radiology (ACR) certification in CT, and participate in the ACR data registry program.7 In addition, these programs would include use of smoking cessation strategies and informed and shared decision making with patients before initial screening.

Benefits of lung cancer screening can be maximized and harms minimized when healthcare provider (HCPs) do the following:

  • Limit screening to persons at high risk;
  • Discontinue screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or ability to have lung surgery;
  • Use healthcare facilities that have ACR certification in CT and a multidisciplinary team with access to clinical resources to provide diagnosis, follow-up treatment, and long-term patient management related to lung cancer screening; and
  • Avoid invasive follow-up procedures in patients with nodules identified as low probability. Instead, follow with repeat LDCT scans over a period of time to watch for nodule growth.7,8

The Patient Protection and Affordable Care Act requires most health insurance plans to cover preventive services with no deductible or co-payment for the patient if the USPSTF grades the recommendation as A (strongly recommended) or B (recommended).9 Both tobacco cessation (graded A) and lung cancer screening with LDCT (graded B) would qualify for insurance coverage at no additional cost.

Medicare covers annual lung cancer screening with LDCT for beneficiaries aged 55-77 years who are asymptomatic (no signs or symptoms of lung cancer), have at least a 30-pack-year smoking history, and currently smoke or have quit smoking within the past 15 years. HCPs must document an initial lung cancer screening counseling visit that includes the following:

  • Determination of eligibility for screening;
  • Shared decision making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false-positive rate, and total radiation exposure;
  • Counseling on the importance of annual lung cancer screening; and
  • Counseling on the importance of maintaining smoking abstinence if a former smoker and smoking cessation if a current smoker; and, if appropriate, providing information about smoking cessation interventions.10

In Talking With Your Patients about Screening for Lung Cancer, the USPSTF provides discussion points using three patient scenarios: patients who fit all screening criteria; patients who are outside the screening criteria; and patients who fit all screening criteria but have a significant co-morbid condition.11 The National Comprehensive Cancer Network provides a booklet, NCCN Guidelines for Patients®: Lung Cancer Screening that can facilitate informed and shared decision making about screening.12 The Association of Health Research and Quality’s Treating Tobacco Use and Dependence: 2008 Update is a good resource on smoking cessation for HCPs.13

Annual lung cancer screening with LDCT cannot prevent cancer but can reduce lung cancer mortality through earlier diagnosis in individuals at high risk based on age and smoking history. Such screening is recommended along with continued efforts to prevent smoking and exposure to other lung cancer risk factors and to assist individuals with smoking cessation.

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


1. National Cancer Institute. SEER Stat Fact Sheets: Lung and Bronchus Cancer. 2015. http://seer.cancer.gov/statfacts/html/lungb.html

2. American Cancer Society. Cancer Facts & Figures: 2015. www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2015/index

3. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.

4. U.S. Preventive Services Task Force. Lung Cancer: Screening. December 2013. www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/lung-cancer-screening

5. Wender R, Fontham ET, Barrera E Jr, et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107-117

6. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer; diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e78S-e92S. http://journal.publications.chestnet.org/article.aspx?articleid=1685837

7. Richards TB, White MC, Caraballo RS. Lung cancer screening with low-dose computed tomography for primary care providers. Prim Care. 2014;41(2):307-330.

8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening. 2015. www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf

9. HealthCare.gov. Preventive Health Services for Adults. https://www.healthcare.gov/preventive-care-benefits/adults/

10. Centers for Medicare & Medicaid Services. Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). February 5, 2015. www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

11. U.S. Preventive Services Task Force. Talking With Your Patients About Screening for Lung Cancer. Rockville, MD: USPSTF; 2013.

12. National Comprehensive Cancer Network. NCCN Guidelines for Patients: Lung Cancer Screening. 2015. www.nccn.org/patients/guidelines/lung_screening/index.html

13. Agency for Healthcare Research and Quality. Treating Tobacco Use and Dependence: 2008 Update. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

Strategies for collecting the family history to assess risk for inherited cancer

Collection of a patient’s family history (FH) is an important tool for establishing her risk levels for certain inherited cancers. Time constraints and other barriers challenge the ability of healthcare providers to collect a complete and detailed FH, which can result in inadequate risk assessment. The author presents strategies to improve FH collection and documentation and briefly reviews guidelines for assessing patterns of risk for inherited cancers within the history.

Key words: family history, inherited cancer, genetic testing, breast cancer

In clinical practice, a patient’s family history (FH) helps establish patterns of risk for hereditary disease and serves as a component of the general health history. Collection of an FH that reflects three or more generations (siblings, parents, grandparents) is recommended to assess a patient’s genetic risk for hereditary cancers. In many cases, FHs are limited to information about first-degree relatives; these histories are rarely updated to reflect newly discovered disease in family members.1 Lack of availability or inadequate review of the FH is a missed opportunity for risk stratification for hereditary cancers, referral for genetic testing, and provision of recommendations for early screening and risk reduction strategies if needed.

Healthcare providers (HCPs) should take a complete FH at each patient’s annual well-woman visit and be able to recognize patterns of risk for inherited cancers. A woman’s genetic predisposition to hereditary cancer will have implications for screening, disease prevention, and treatment options.2 The purpose of this article is to improve the quality of FH documentation by presenting strategies to streamline collection of FH information and to review guidelines for assessing patterns of risk for inherited cancers—specifically breast cancer, reproductive cancers, and colon cancer—within the history.

Inherited genetic mutations that increase cancer risk

Although generally recognized as a risk factor for breast cancer, a mutation of breast cancer gene 1 or 2 (BRCA 1/2) imparts substantial risk for the development of other cancers as well. A mutation in BRCA 1/2 disables the ability of the gene to affect cellular repair of damaged DNA, a condition particularly associated with breast, ovarian, prostate, and pancreatic cancers.3 The pattern of inheritance is autosomal-dominant; inheritance of the BRCA 1/2 mutation may arise from either the maternal or the paternal side of the family. Women who carry a mutation on BRCA 1/2 have a 40%-80% risk of developing breast cancer and a 11%-40% risk of developing ovarian cancer in their lifetime.4 Mutations on other genes (TP53, PTEN, STK11) have been linked to high risk for breast cancer in young women, but these mutations are less common.5

Lynch syndrome (hereditary nonpolyposis colon cancer [HNPCC]), another autosomal-dominant genetic condition, places individuals at high risk for cancer by inactivating the DNA repair function coded by MSH2, a DNA mismatch repair protein, or by the gene MLH1.6 Women with Lynch syndrome have lifetime risks of 40%-60% of developing endometrial cancer and of 4%-12% of developing ovarian cancer.7,8 Women and men with this genetic condition have an 80% lifetime risk of developing colon cancer.9

Importance and implications of the family history review

For young women with no personal history of cancer (unaffected women), an FH review is an opportunity to provide anticipatory guidance. When an FH may indicate an inherited cancer, testing for the suspected genetic mutation in the affected family member(s) is recommended. Once a particular genetic mutation is identified in the family member(s), other members can be offered early screening and specific testing for the mutation.5 Early awareness is important; women who test positive for a genetic mutation that imparts cancer risk should be counseled about early screening and consideration of preventive options.

For example, emerging data have associated the BRCA1 mutation with the development of cancers caused by the deleterious effect of estrogen metabolites on DNA synthesis. This link is noteworthy in that medications that decrease or halt estrogen production (e.g., luteinizing hormone-releasing agonists) could be offered as a preventive option against breast cancer for some women.10 Studies evaluating the effectiveness of aromatase inhibitors and selective estrogen receptor modulators for cancer prevention in these groups are under way. New evidence suggests that women with BRCA1 mutations who undergo oophorectomy before age 35 have decreased mortality rates from ovarian cancer (women who have BRCA2 mutations may be able to delay this surgery until their 40s).11 Oral contraceptive use and oophorectomy are recommended for prevention of HNPCC-related cancers.8

Of note, mutations in cancer predisposition genes other than BRCA1/2 and those that cause HNPCC can place women at high risk of developing breast cancer and/or reproductive cancers. Women who test negative for BRCA or HPNCC mutations but have a strong familial picture for cancer risk should begin screening early, and options for preventive treatment should still be considered.12

Family history collection methods

Many HCPs recognize the value of the FH but cite lack of time and limited patient knowledge of their own FH as major barriers to collection of an accurate FH.13 Several studies have established that a self-collected instrument is an effective and time-efficient method of collecting FH data and identifying risk for hereditary cancers.1,14,15 Individuals who self-collect may have access to family members with better recall for third- or fourth-degree relatives.14,15 Although initiatives to develop and improve access to self-collected and archived FHs are under way, adoption of this method has been slow.16,17

The Table lists some available FH tools. The Surgeon General’s Family History Initiative advocates use of an online tool, My Family Health Portrait (MFHP), which allows individuals to collect and upload accurate FH information. The MFHP facilitates creation of a table that can be populated online and downloaded for storage and periodic updating on a computer. The printed output can be shared with HCPs to help identify specific risk patterns within the family.16,18 Although few studies have been published on the efficacy of MFHP, evidence suggests that this tool is particularly useful as a means of recording FHs of breast and ovarian cancers.19,20Table


Family Healthware, developed by the CDC, is a Web-based tool that integrates familial risk assessment with generation of specific health screening recommendation messages based on risk.21 Although the results of a randomized trial conducted on 3283 primary care patients that compared the clinical usefulness of the Family Healthware tool versus general cancer prevention messages were equivocal,21 the authors suggested that better engagement with the clinician and integration with a health record and decision support might improve clinical outcomes and should be incorporated in future iterations of the tool. As this issue goes to press, the CDC website for Family Healthware indicates that the Web-based tool remains in testing but may be available for research purposes by contacting the CDC.22

Myriad Genetics created the Hereditary Cancer Quiz, a four-item online assessment that purports to identify flags for hereditary breast and ovarian cancer (HBOC) and HNPCC risks.23 Individuals whose answers trigger risk flags are invited to complete a detailed online Family History Tool (FHT). The FHT is similar to the MFHP in that individuals who complete the FHT can identify patterns showing risk for hereditary cancers within their family.24 The table and pedigree generated by the FHT can be shared with a specified HCP via encrypted email. The Web interface is intuitive, and results are both easy to understand and visually attractive. Individuals can choose to create a personal account maintained on the website or use the site via a guest account. The privacy statement for the website stipulates that individuals who create an account remain guard­ians of the data, meaning that account creators control all access. However, individuals using this site should read and review the privacy statement before setting up a personal account.25 Myriad Genetics makes no statements regarding the product’s efficacy or bias.

Paper-based instruments are an effective alternative if online access or privacy is a concern. Several such instruments are available. Hughes et al26 successfully deployed a self-administered paper-based FH instrument for patients in an internal medicine practice, resulting in 6% (51/567) being referred for additional services because of high risks suggested by the FH. A Family History Collection Form created by the National Coalition for Health Professional Education in Genetics is available for download and use.27 The download site includes supplementary instructions for completing and interpreting the collected data.

Barriers for providers and patients

According to HCPs, barriers to performing an FH review include a lack of familiarity with screening recommendations for inherited cancers and a lack of knowledge regarding which patients to refer to geneticists.13 Evidence suggests that low-risk, affluent women are over-referred for genetic counseling and genetic screening tests,28,29 whereas minorities are disproportionately under-referred for these same services.30 Over-referral for genetic testing of low- to average-risk women is associated with use of patient inquiry about FH as a determinant in the decision to refer for genetic screening.29 Barriers to routine collection of FH information also include low patient reading level and privacy concerns. Special efforts may need to be extended to women with low literacy. Some cultural groups may find “keeping it on paper” problematic.31 Protocols and education programs about protections provided by the Genetic Information Nondiscrimination Act will need to be developed and communicated broadly.

Recommendations for risk assessment and referral

In an FH, presence of any of these indicators is a red flag that warrants further investigation and possible referral to a genetics counselor32:

  •  Several family members with the same or related cancers
  • Early age of onset for cancer
  • Male breast cancer
  • Ashkenazi Jewish descent

The American College [now Congress] of Obstetricians and Gynecologists (ACOG) recommends genetic counseling and screening for unaffected women with a close relative who has been diagnosed with ovarian cancer or a BRCA1/2 mutation.33 In addition, women who have male relatives with breast cancer, multiple cases of breast cancer among close relatives, or close relatives diagnosed with breast cancer at an early age should be offered genetic screening.33 The most recent screening/genetics referral recommendations by the National Comprehensive Cancer Network are similar to those of ACOG, with an additional recommendation to offer genetic risk assessment for unaffected individuals who have more than one family member on the same side affected by any of these cancers: endometrial cancer, pancreatic cancer, aggressive prostate cancer, brain tumors, leukemia/lymphoma, thyroid cancer, or diffuse gastrointestinal cancer.34


Under the Affordable Care Act, coverage was extended for preventive health services, including genetic counseling and BRCA testing if a woman’s FH shows evidence of risk for deleterious mutations.35 Commencement of screening for cervical cancer is an opportune time to introduce the idea of FH data collection to young women. A few minutes could be used to discuss the benefits of FH awareness and to pre­sent options for data collection (online or paper tool). Women can choose to begin collecting FH data prior to their next scheduled annual visit, which will allow them and their families to discuss family members’ health histories and have adequate time to gather missing details. Interventions and screening should start early; beginning the process in a woman’s early 20s allows adequate time to collect information, determine risk, and, if necessary, refer for screening.


The information and resources provided in this article are intended to facilitate collection and interpretation of the FH during the annual well-woman visit. Hereditary patterns of disease are most readily identified by review of a comprehensive FH. As such, HCPs need to develop skills in collecting and interpreting FHs. Improved collection and documentation skills for HCPs may have a profound impact on decisions about further screening, disease prevention, and treatment options for inherited cancer.

Mary Elizabeth “Betsy” Guimond is Assistant Professor of Nursing at Robert Morris University in Pittsburgh, Pennsylvania. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Suggested reading
Cancer Genetics Risk Assessment and Counseling–for health professionals (PDQ®). Updated July 17, 2015. cancer.gov/about-cancer/causes-prevention/genetics/risk-assessment-pdq

1. van Altena AM, van Aarle S, Kiemeney LA, et al. Adequacy of family history taking in ovarian cancer patients: a population-based study. Fam Cancer. 2012;11(3):343-349.

2. Nilsson MP, Hartman L, Idvall I, et al. Long-term prognosis of early-onset breast cancer in a population-based cohort with a known BRCA1/2 mutation status. Breast Cancer Res Treatment. 2014;144(1):133-142.

3. Yoshida K, Miki Y. Role of BRCA1 and BRCA2 as regulators of DNA repair, transcription, and cell cycle in response to DNA damage. Cancer Science. 2004;95(11):866-871.

4. Petrucelli N, Daly MB, Feldman GL. BRCA1 and BRCA2 hereditary breast and ovarian cancer. GeneReviews®. 2013. ncbi.nlm.nih.gov/books/NBK1247/

5. Woodson AH, Profato JL, Muse KI, Litton JK. Breast cancer in the young: role of the geneticist. J Thorac Dis. 2013;(5 suppl 1):S19-S26.

6. Vasen HF. Clinical description of the Lynch syndrome [hereditary nonpolyposis colorectal cancer (HNPCC)]. Fam Cancer. 2005;4(3):219-225.

7. Auranen A, Joutsiniemi T. A systematic review of gynecological cancer surveillance in women belonging to hereditary nonpolyposis colorectal cancer (Lynch syndrome) families. Acta Obstet Gynecol Scand. 2011; 90(5):437-444.

8. Lu K, Daniels M. Endometrial and ovarian cancer in women with Lynch syndrome: update in screening and prevention. Fam Cancer. 2013; 12(2):273-277.

9. Kohlmann W, Gruber SB. Lynch syndrome. In: Pagon RA, Adam MP, Ardinger HH, et al, eds. GeneReviews®. Seattle, WA: University of Washington; 2014.

10. Savage KI, Matchett KB, Barros EM, et al. BRCA1 deficiency exacerbates estrogen-induced DNA damage and genomic instability. Cancer Res. 2014;74(10):2773-2784.

11. Finch APM, Lubinski J, Møller P, et al. Impact of oophorectomy on cancer incidence and mortality in women with a BRCA1 or BRCA2 mutation. J Clin Oncol. 2014;32(15):1547-1553.

12. Berliner J, Fay A, Cummings S, et al. NSGC practice guideline: risk assessment and genetic counseling for hereditary breast and ovarian cancer. J Genet Couns. 2013;22(2):155-163.

13. Wood ME, Stockdale A, Flynn BS. Interviews with primary care physicians regarding taking and interpreting the cancer family history. Fam Pract. 2008;25(5):334-340.

14. Vogel TJ, Stoops K, Bennett RL, et al. A self-administered family history questionnaire improves identification of women who warrant referral to genetic counseling for hereditary cancer risk. Gynecol Oncol. 2012;125(3):693-698.

15. Armel SR, McCuaig J, Finch A, et al. The effectiveness of family history questionnaires in cancer genetic counseling. J Genet Couns. 2009; 18(4):366-378.

16. Carmona RH, Wattendorf DJ. Personalizing prevention: the US Surgeon General’s family history initiative. Am Fam Physician. 2005;71(1):36-39.

17. Owens K, Marvin M, Gelehrter T, et al. Clinical use of the surgeon general’s “My Family Health Portrait” (MFHP) tool: opinions of future health care providers. J Genet Couns. 2011;20(5):510-525.

18. Flynn B, Wood M, Ashikaga T, et al. Primary care physicians’ use of family history for cancer risk assessment. BMC Fam Pract. 2010;11(1):45.

19. U.S. Surgeon General. My family health portrait. U.S. Department of Health & Human Services, Office of the Surgeon General; 2007.

20. Facio FM, Feero WG, Linn A, et al. Validation of My Family Health Portrait for six common heritable conditions. Genet Med. 2010;12(6):370-375.

21. Rubinstein WS, Acheson LS, O’Neill SM, et al. Clinical utility of family history for cancer screening and referral in primary care: a report from the Family Healthware Impact Trial. Genet Med. 2011;13(11):956-965.

22. Centers for Disease Control and Prevention. Public Health Genomics. Family History. Family History Collection Tools. Family healthware™. June 20, 2013. cdc.gov/genomics/famhistory/resources/tools.htm

23. Myriad Genetic Laboratories. Heriditary Cancer Quiz™. 2014. hereditarycancerquiz.com/

24. Myriad Genetic Laboratories. Family History Tool™. fht.myriad.com/app/#/get-started

25. Myriad Genetic Laboratories. Terms of Use/Privacy policy. fht.myriad.com/app/#/terms

26. Hughes KS, Roche C, Campbell CT, et al. Prevalence of family history of breast and ovarian cancer in a single primary care practice using a self-administered questionnaire. Breast J. 2003;9(1):19-25.

27. National Coalition for Health Professional Education in Genetics. The Jackson Laboratory. Family History Tool. 2014. nchpeg.org/index.php?option=com_content&view=article&id=61&Itemid=74.

28. White DB, Bonham VL, Jenkins J, et al. Too many referrals of low-risk women for BRCA1/2 genetic services by family physicians. Cancer Epidemiol Biomarkers Prev. 2008;17(11): 2980-2986.

29. Bellcross CA, Kolor K, Goddard KA, et al. Awareness and utilization of BRCA1/2 testing among U.S. primary care physicians. Am J Prev Med. 2011;40(1):61-66.

30. Trivers KF, Baldwin LM, Miller JW, et al. Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians: a vignette-based study. Cancer. 2011; 117(23):5334-5343.

31. Thompson T, Seo J, Griffith J, et al. “You don’t have to keep everything on paper”: African American women’s use of family health history tools. J Community Genet. 2013;4(2):251-261.

32. National Coalition for Health Professional Education in Genetics. The Jackson Laboratory. Interpreting the Family History. 2014. nchpeg.org/index.php?option=com_content&view=article&id=170&Itemid=64

33. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 103: Hereditary breast and ovarian cancer syndrome. Obstet Gynecol. 2009;113(4):957-966.

34. Daly MB, Pilarski R, Axilbund JE, et al. Genetic/familial high-risk assessment: breast and ovarian, version 1.2014. J Natl Compr Canc Netw. 2014; 12(9):1326-1338.

35. Centers for Medicare & Medicaid Services. Affordable Care Act Implementation FAQs – Set 12. cms.gov/CCIIO/

From practice to policy: The WHNP as advocate

As most of our readers know, the National Association of Nurse Practitioners in Women’s Health (NPWH) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) released the 7th edition of the Women’s Health Nurse Practitioner: Guidelines for Practice and Education in December 2014. Many women’s health nurse practitioners (WHNPs) use this document to outline their clinical competencies, and faculty use it as a framework in developing WHNP program curricula. But the guidelines go beyond describing clinical practice components and educational requirements; they also include policy and advocacy competencies. In particular, the guidelines enumerate participating in legislative/policy-making activities that influence women’s health and serving as “a consultant and trusted source of information on women’s health for healthcare systems and policy-makers” as key WHNP leadership competencies.1

As core WHNP competencies, policy and advocacy align well with NPWH’s mission and values. NPWH’s mission is to “ensure the provision of quality primary and specialty healthcare to women of all ages by women’s health and women’s health-focused nurse practitioners.” This mission includes protecting and promoting a woman’s right to make her own choices regarding her health within the context of her personal, religious, cultural, and family beliefs. As a professional membership organization, NPWH strives to continuously improve access and quality of healthcare for women through excellence and innovation in continuing education and professional development; to demonstrate leadership in policy, practice, and research; and to provide support and services for our members. These policy-related values are key to achieving our mission:

  • To advocate for healthcare policies that support women and advanced practice registered nurses (APRNs) who care for them; and,
  • To collaborate with strategic partners to enhance the effectiveness and timeliness of our efforts in the policy arena.2

How do these competencies affect clinical practice?

So, what does all of this mean in the real world of clinical practice? As most of our readers witness every day, policy decisions related to everything from reimbursement for healthcare service delivery to state-based APRN scope of practice regulations to decisions regarding availability of services, medications, or new technologies can affect women’s health—and the realization of NPWH’s mission. The following discussion provides just a few examples.

The Patient Protection and Affordable Care Act seeks to increase access to affordable health insurance, with the ultimate goal of increasing access to healthcare. One way that it does this is by providing a mechanism for federally supported Medicaid expansion to cover most low-income adults (i.e., those earning up to 138% of the federal poverty level). Yet, to date, approximately 20 states have not expanded Medicaid to this level of coverage.3 Most states provide Medicaid coverage during pregnancy; however, in non–Medicaid-expansion states, this coverage stops shortly after delivery. Although coverage of prenatal care facilitates a favorable pregnancy outcome, lack of coverage for care needed before and between pregnancies can have devastating effects on women and their children.

Consider the reproductive-aged woman with type 1 diabetes mellitus (T1DM). Diabetes in pregnancy can adversely affect both maternal and infant outcomes. Women with T1DM have higher rates of maternal mortality and morbidity, including increased rates of pre-eclampsia and cesarean section. Likewise, maternal T1DM increases the risks for fetal and neonatal loss, congenital anomalies, macrosomia, and a host of other neonatal complications. A patient with T1DM who qualifies for Medicaid during pregnancy but loses coverage soon after delivery will not have access to care for her chronic disease prior to her next pregnancy. This gap in care can allow her T1DM to spiral out of control, contributing to increased maternal and infant health problems or even death during subsequent pregnancies.4

In June 2015, the House Labor, Health and Human Services (LHHS) Subcommittee marked up its fiscal year 2016 spending bill, which contained a complete elimination of Title X. The following week, the Senate released a funding bill proposing $257.8 million for Title X, a decrease from the prior year’s $286.5 million budget.5 By the time this article goes to press, we should know how the Title X program fares in the 2016 budget. It is estimated that publicly funded healthcare providers, such as those funded through Title X, met an estimated 42% of the need for publicly supported contraceptive services and supplies in 2013.6 Cuts to, or elimination of, the Title X program would effectively bar many of these women from accessing similar services in the future. In the case of the patient with T1DM discussed earlier who has already lost access to care for her chronic disease, she will also lose family planning services, which may contribute to a shortened pregnancy interval and may increase the potential for a poor pregnancy outcome. Furthermore, because Title X clinics are staffed primarily by NPs, cuts to Title X could decrease women’s access to quality care by WHNPs and other NPs who provide family planning services.

Professional competencies plus organizational values in action

Although many of our readers in clinical practice may have little time to “participate in legislative and policy-making activities that influence women’s health” in the traditional sense, they are our greatest asset in terms of bringing women’s stories to the forefront. NPWH staff keep our fingers on the pulses of policy-makers with power to make decisions about how, where, and from whom each woman can access care that is “within the context of her personal, religious, cultural, and family beliefs,” but our organization’s members provide the stories that give life to the policy. It is through our organization’s members that we at NPWH learn about the challenges that women face in accessing woman-centric care to meet their needs, as well as the barriers faced by WHNPs in attempting to provide that care.


In keeping with the NPWH/AWHONN guidelines, WHNPs possess the leadership competencies to serve as trusted sources of information on women’s health. As NPWH Policy Director, I invite all of our readers to collaborate with NPWH as “strategic partners to enhance the effectiveness and timeliness of our efforts in the policy arena.” Please contact me at skendig@npwh.org to share your stories about policy issues affecting your practice and your patient population at the local, state, or national level. In this way, we can work together to become a collective voice for the women we serve in moving the policy needle to a place that supports women’s full access to the care that they need delivered by the providers they choose.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri-St. Louis; a consultant at Health Policy Advantage, LLC, in St. Louis, Missouri; and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH).


  1. National Association of Nurse Practitioners in Women’s Health/Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.
  2. NPWH. Mission, Vision, and Values. Mission. 2015. https://www.npwh.org/pages/about
  3. Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions. July 20, 2015. http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
  4. Negrato CA, Mattar R, Gomes MB. Adverse pregnancy outcomes in women with diabetes. Diabetol Metab Syndr. 2012;4(1):41.
  5. National Family Planning & Reproductive Health Association. Title X: Budget & Appropriations. http://www.nationalfamilyplanning.org/title-x_budget-appropriations
  6. Frost JJ, Frohwirth L, Zolna MR. Contraceptive Needs and Services, 2013 Update. Washington, DC: Guttmacher Institute; July 2015. www.guttmacher.org/pubs/win/contraceptive-needs-2013.pdf

Lung cancer screening*

Tests are used to screen for different types of cancer.

Some screening tests are used because they have been shown to be helpful both in finding cancers early and in decreasing the chance of dying from these cancers. Other tests are used because they have been shown to find cancer in certain people; however, it has not been proven in clinical trials that use of these tests will decrease the risk of dying from cancer.

Scientists study screening tests to find those with the fewest risks and most benefits. Cancer screening trials also are meant to show whether early detection (finding cancer before it causes symptoms) decreases a person’s chance of dying from the disease. For some types of cancer, finding and treating the disease at an early stage may result in a better chance of recovery. Clinical trials that study cancer screening methods are taking place in many parts of the country. Information about ongoing clinical trials is available from the National Cancer Institute website.

Three screening tests have been studied to see if they decrease the risk of dying from lung cancer.

Low-dose spiral CT scan (LDCT scan): A procedure that uses low-dose radiation to make a series of very detailed pictures of areas inside the body. It uses an x-ray machine that scans the body in a spiral path. The pictures are made by a computer linked to the x-ray machine. This procedure is also called a low-dose helical CT scan.

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Sputum cytology: Sputum cytology is a procedure in which a sample of sputum (mucus that is coughed up from the lungs) is viewed under a microscope to check for cancer cells.

Screening with low-dose spiral CT scans has been shown to decrease the risk of dying from lung cancer in heavy smokers.

The National Lung Screening Trial studied people aged 55 years to 74 years who had smoked at least 1 pack of cigarettes per day for 30 years or more. Heavy smokers who had quit smoking within the past 15 years were also studied. The trial used chest x-rays or LDCT scans to check for signs of lung cancer.

The scientists found that LDCT scans were better than chest x-rays at finding early-stage lung cancer.  Screening with LDCT also decreased the risk of dying from lung cancer in current and former heavy smokers. A Guide is available for patients and healthcare providers to learn more about the benefits and harms of LDCT screening for lung cancer.

Screening with chest x-rays and/or sputum cytology does not decrease the risk of dying from lung cancer.

Chest x-ray and sputum cytology are two screening  tests that have been used to check for signs of lung cancer. Screening with chest x-ray, sputum cytology,  or both of these tests does not decrease the risk of dying from lung cancer.

  • National Cancer Institute. Updated April 27, 2015. Readers are invited to photocopy Patient education pages in the journal and distribute them to their patients.




Female sexual dysfunction: Why is it so difficult to treat?

Many healthcare providers avoid addressing and treating sexual problems in women for a multitude of reasons, including the paucity of FDA-approved medications for female sexual dysfunction (FSD), concern about the additional time required during the patient visit, and confusion over billing and coding, leading to challenges regarding reimbursement. In this column, I describe the common barriers and misconceptions that impede successful evaluation and treatment of FSD.

Over recent years, multiple studies have demonstrated the high prevalence of sexual complaints in women. In fact, more women than men report problems with sexual functioning, including problems related to libido, arousal, orgasm, and pain. In the National Health and Social Life Survey, 43% of women reported one or more sexual problems, compared with 31% of men.1 Nearly 10 years later, the PRESIDE study demonstrated a 44% prevalence of female sexual dysfunction (FSD) in the United States.2 Despite these compelling statistics, research regarding treatments for sexual dysfunction and marketing for products designed to improve sexual function have been primarily geared toward men, not women. Although the focus may finally be shifting to women, why is FSD still so difficult to treat?

#1: Few FDA-approved treatments for FSD

In 1998, the FDA approved sildenafil (Viagra®) as the first medication for the treatment of erectile dysfunction (ED) in men, initiating a new kind of sexual revolution. Men with ED who had previously been rendered virtually abstinent were now able to resume satisfying sexual activity. Since that time, 27 medications have been approved by the FDA for the direct or indirect enhancement of sexual functioning in men. Until 2 months ago, the total number of FDA-approved medications for the treatment of low sexual desire in women was zero. But on August 18, 2015, the FDA made history by approving flibanserin (Addyi™), the first-ever medication for the treatment of hypoactive sexual desire disorder in women.3

#2: Too time consuming to address

One of the biggest complaints that I hear from healthcare providers (HCPs) regarding addressing their female patients’ sexual concerns is that it takes too much time in an already busy clinic setting. I recommend the use of any of the following validated questionnaires, which can facilitate discussions about this sensitive and complicated topic.

  • Sexual Function Questionnaire4
  • Female Sexual Function Index5
  • Female Sexual Distress Scale-Revised6
  • Decreased Sexual Desire Screener7
  • Hypoactive Sexual Desire Disorder Screener8
  • Abbreviated Sexual Function Questionnaire9
  • Sexual Quality of Life-Female10

#3: Not a profitable specialty

Although billing based on time spent face-to-face with a patient is not typically a lucrative method for running a practice, HCPs do have ways to enhance reimbursement when treating female patients with sexual complaints. For instance, offering services such as colposcopy, vulvovaginal biopsy, biothesiometry, perineometry, and trigger-point injections can provide a major increase in revenue when utilizing procedural modifiers. Even minor tests such as urinalysis, wet preps, and vaginal pH analysis can add profit to a patient encounter. When applicable, providing urogynecologic services such as urodynamics, tibial nerve stimulation and pessary placement/maintenance can further boost clinic revenue.

#4: Prevalence versus “distress”

Although nearly half of all surveyed women in the two aforementioned studies reported sexual complaints,1,2 only 12% reported experiencing distress related to their sexual problems.2 In order for a woman to meet criteria for an FSD diagnosis, she needs to be bothered by her condition. If she does not experience such distress, then treatment is unnecessary and unlikely to prove beneficial. HCPs need not create a diagnosis where none exists. At the same time, FSD is a true entity that deserves attention when warranted.

#5: Multifactorial etiology of FSD

Many factors affect female sexual functioning, including overall health, medication use, stress, pregnancy, menopause, drug and alcohol abuse, mental health, relationship status, and socioeconomic status. Existence of all these contributing factors necessitates that history taking in women with FSD be thorough. Although this list is not exhaustive, relevant health conditions for which to screen in women reporting sexual complaints include depression, diabetes, thyroid disease, hyperprolactinemia, cardiovascular disease, neurologic disease, androgen insufficiency, and estrogen deficiency.11 The Table lists commonly prescribed medication classes that can increase
FSD risk.11


#6: Lack of provider training

In 2010, the Journal of Sexual Medicine published proceedings from the International Consultation in Sexual Medicine, which included this quote: Current sexual health education for undergraduate and practicing physicians is inadequate to meet the advancing science and technology and increasing patient demand for high-quality sexual health care.12 That being said, many academic programs for prospective physicians, nurse practitioners, and physician assistants are beginning to incorporate more sexual health training into their curricula, which will arm HCPs with the knowledge and confidence needed
to manage patients’ sexual problems or refer them to another provider when appropriate.

#7: Social stigma and patient unwillingness to discuss sensitive topics

In a study presented in 2010, Parish et al13 evaluated 75 videotaped patient–provider interactions regarding distressing low desire (DLD). HCPs underestimated the prevalence of distress in 82% of women who described themselves as very distressed with respect to their low desire. In this same study, 69% of women minimized their distress during the encounter with the provider but then acknowledged their distress after the visit. Although the impact of DLD was not addressed in any of the 75 interactions, after the visit, 95% of the patients reported that DLD affected their relationship and 98% reported that it affected their partners.


Considering the high prevalence of FSD, and the likelihood that it is distressing to at least a sizable minority of women who have it, HCPs must aim to identify it and treat it—despite the barriers that still exist. Addressing patients’ concerns in a holistic manner, establishing rapport, and providing a nonjudgmental environment for discussion about sensitive topics is the best method to facilitate success in this patient population.

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

1. Laumann, EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;

2. Shifren, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970-978.

3. FDA News Release. FDA Approves First Treatment for Sexual Desire Disorder. August 18, 2015. fda.gov/News

4. Quirk FH, Heiman JR, Rosen RC, et al. Development of a sexual function questionnaire for clinical trials of female sexual dysfunction. J Womens Health Gend Based Med. 2002;11(3):277-289.

5. Quirk F, Haughie S, Symonds T. The use of the sexual function questionnaire as a screening tool for women with sexual dysfunction. J Sex Med. 2005;2(4):469-477.

6. Derogatis L, Clayton A, Lewis-D’Agostino D, et al. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5(2):357-364

7. Clayton AH, Goldfischer ER, Goldstein I, et al. Validation of the decreased sexual desire screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6(3):730-738.

8. Leiblum S, Symonds T, Moore J, et al. A methodology study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2006;3(3):455-464.

9. Williams K, Abraham L, Symonds T. Psychometric validation of an abbreviated version of the sexual function questionnaire (ASFQ). Value in Health. 2010;13(7):A381.

10. Symonds T, Boolell M, Quirk F. Development of a questionnaire on sexual quality of life in women. J Sex Marital Ther. 2005;31(5):385-397.

11. Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urol Clin North Am. 2007;34(4):497-506.

12. Parish SJ, Rubio-Aurioles E. Education in sexual medicine: proceedings from the international consultation in sexual
medicine, 2009. J Sex Med. 2010;7(10):3305-3314.

13. Parish SJ, Hahn SR, Kingsberg SA, et al. Doctor-patient communication about desire with women who have distressing low desire in primary care and general OB/GYN practice. Presented at: The International Society for the Study of Women’s Sexual Health; 2010; St. Petersburg, Florida.

Reproductive life plans among Spanish-speaking Hispanic women in the U.S.

Pregnancy and pre-conception care (PCC) are major concerns for reproductive-aged women. Although researchers are beginning to find an association between women’s intendedness of pregnancy and their reproductive health-related behaviors, little is known about this topic with respect to Hispanic women in the United States who speak only Spanish. The authors report findings from interviews with 263 members of this population to ascertain their thoughts regarding reproductive life plans and two other topics of interest—PCC and the danger of oral contraceptive use versus pregnancy.

Key words: reproductive life plan, Hispanic women, intendedness of pregnancy, pre-conception care

The ability to choose whether and when to bear children is a fundamental aspect of reproductive health. Yet for more than a decade, about one-half of all pregnancies in the United States have been unintended.1 This statistic represents an average; the proportion of unintended pregnancies varies substantially by demographic group. For example, when compared with non-Hispanic white women, Hispanic women have higher rates of unintended pregnancy, unintended births, and abortions and lower rates of contraception use.2 Rates of unintended pregnancy are substantially increased among poor and low-income women and decreased among higher-income women.2 Poor women are more likely than other women to have unprotected intercourse, and when they do use contraception, they report markedly higher rates of method failure.3,4

Although the reasons are not fully understood and are likely complex, ethnicity, race, culture, and
socioeconomic status all affect decision making about pregnancy and contraceptive use. These factors, alone or in combination, can facilitate or compromise a woman’s ability to formulate a reproductive life plan (RLP) and to meet her RLP goals. These factors can also affect a woman’s knowledge and decisions about pursuing pre-conception care (PCC).


Between 2000 and 2010, the Hispanic population in this country grew by 43% and now comprises 16% of the total U.S. population.5 Compared with non-Hispanic women, Hispanic women have higher rates of unintended pregnancy and lower rates of contraception use. The growing Hispanic population in the U.S. means that healthcare providers (HCPs) will see more and more Hispanic women in their practices and need to know how to help these women make informed decisions about RLPs, use effective contraception when pregnancy is not desired, and obtain PCC to optimize pregnancy outcomes.

Several studies have sought to provide insight into the factors that influence Hispanic women’s decisions about and effective use of contraception. These factors include knowledge about contraception, level of acculturation, attitudes toward planning a pregnancy and toward unintended pregnancy, and attitudes and biases of their HCPs.1,6-8 However, these studies have not focused on Hispanic women who speak only Spanish, or on factors that might influence their RLPs and related decision making about contraceptive use and PCC.

The State of California provides comprehensive family planning and reproductive health services to low-income residents through Family Planning, Access, Care, and Treatment (Family PACT), a federally funded program. In 2010, Family PACT provided services to 1.8 million women and men.9

A sizable proportion of Family PACT clients are Hispanic women who speak only Spanish because they are recent immigrants to this country. This study was conducted with a sample of Spanish-speaking Hispanic women seen at a Family PACT clinic for contraceptive care to explore various aspects of the participants’ RLPs. This study was the first to use CDC guidelines on RLPs and PCC10 as a basis to explore these practices in female members of this ethnic group.

Purpose of study

With the ultimate goal of optimizing women’s health and knowledge before conceiving, the investigators designed a structured interview to determine whether a convenience sample of reproductive-aged, Spanish-speaking women seeking care in a family planning clinic had formulated RLPs. Definitions used by the American College [now Congress] of Obstetricians and Gynecologists (ACOG)11 and in the CDC guidelines for RLPs and PCC10 provided the basis for the interview questions posed in this study.

  • A reproductive life plan is defined as a strategy based on a woman’s values and resources to achieve a set of goals about having children, including whether to get pregnant, when to get pregnant, and how many children to have in her lifetime.10 The RLP includes a strategy for effective contraceptive use and options if pregnancy is not desired at all.
  • Core pre-conception care involves assessment of a woman’s undiagnosed, untreated, or poorly controlled health conditions; immunization history; medication use; nutritional concerns; genetic risks; substance use; and occupational or environmental exposures prior to conception.11

The investigators sought to answer three questions: (1) Do these women have RLPs? (2) Do they think that women should plan and prepare for pregnancy? and (3) How do they compare the health risks posed by use of birth control pills versus those posed by pregnancy?

Methods and materials

Approval to conduct this study was obtained from the John F. Wolfe Human Subjects Committee and the Research Committee of the Los Angeles Biomedical Research Institute. A 3- to 5-minute interview tool was developed and piloted with 25 potentially eligible women to determine understandability in Spanish and to correct questions that might be confusing. Questions about personal information and RLPs had single answers, and those about pregnancy planning and preparation were open ended (Box).

Neither the term reproductive life plan nor the abbreviation RLP was used when interviewing study participants. Instead, the investigators asked participants how many children they wanted to have and when they wanted to have them. Provision of answers to these questions was considered evidence that a woman had envisioned some form of an RLP for herself. With regard to the question about risks posed by oral contraceptive (OC) use versus pregnancy, the investigators chose to use the term birth control pill as a proxy not only for OCs but for all hormonal contraceptives because they believed that participants would be most familiar with this term.

Interviews were conducted from January 2013 through November 2013 by one of the authors whose first language is Spanish (PX). Prospective participants were approached in the waiting area of the Women’s Health Care Clinic at Harbor UCLA, which provides all types of birth control products to low-income women for free. Women were eligible for the study if they were non-pregnant, Spanish speaking, at least 18 years of age but premenopausal, and at risk for pregnancy. Exclusion criteria were prior hysterectomy or tubal sterilization and lack of ability to give consent. An explanation of the study—including any risks or benefits, assurances of confidentiality, and an option to withdraw at any time without consequences—was read to prospective participants in Spanish. Because the project was an interview with no personal identifiers and no interventions, the Institutional Review Boards approved a waiver of informed consent signature. If a woman gave verbal consent to participate, she was taken to an adjacent private area for the interview. The interviewer used a standard script to ensure uniformity of interview administration and to enable all the data to be merged.

Demographic information was solicited to characterize the study sample. Questions were read aloud and participants’ answers documented verbatim. Participants who did not mention any medical measures in their answer to the question of whether a woman should plan and prepare herself for pregnancy were asked a follow-up question about anything they thought a woman should do medically to plan and prepare for a pregnancy. Medical measures, as described in the CDC guidelines, entail pre-conception screening for health conditions and practices associated with adverse pregnancy outcomes (e.g., obesity, hypertension, smoking).10 The intent of the guidelines is to identify and modify risks before conception occurs. If a participant did not mention any of these medical measures or others, she was asked, Is there any reason for a woman to see a healthcare provider before getting pregnant?

Three investigators placed the participants’ answers to the question about the content of PCC into one of five categories: social, personal, financial, psychological, or medical. Of note, although social, financial, and psychological planning are parts of PCC, this study was designed, at least in part, to find out whether women would include medical measures as part of PCC. If the participants responded with answers that fell into more than one category, each category was tallied. The three investigators had 100% agreement on all category assignments.


A total of 265 women whose primary spoken language was Spanish were approached to participate in the survey. No woman declined, but 2 were excluded because they were surgically infertile; therefore, data for this study were derived from 263 women.

Mean age of the sample was 34 years (range, 18-50 years). Among 263 participants, 4 (1.5%) were younger than 20, 54 (20.5%) were aged 20-25, 42 (15.9%) were aged 26-30, 48 (18.2%) were aged 31-35, and 115 (43.7%) were older than 35. Mean duration of formal education was 10 years (range, 0-18 years). Parity ranged from 0 to 7 births (mode, 2). The time that each woman took to respond to the question about her age was used as the comparator for the speed with which she answered questions about her RLP. Answers to questions were classified as “rapid” if a woman’s response time was at least as fast as when she answered the question about her age, “delayed” if they were more slowly provided, or “unsure” if a woman was unable to provide an answer.

Reproductive life plan

A total of 239 (91%) of the participants said that they knew how many children they wanted to have in their lifetime; among this group, nearly half wanted at least 3 children. A total of 226 women (85.9%) answered this question rapidly, 35 (13.3%) delayed their answers, and 2 (0.8%) were unsure. The 122 women who said that they wanted more children were asked how soon they wanted to become pregnant. Their responses and the speed/assurance of their responses (rapid, delayed, unsure) appear in Table 1.

Table 1

Birth control methods used by these participants were grouped by tiers of efficacy as defined by first-year failure rates in typical use.12Tier I methods include implants, intrauterine devices, and abstinence. Tier 2 methods include pills, patches, vaginal rings, and injections. Tier 3 methods include barrier methods and behavioral methods. Fewer than 20% of women who wanted to delay pregnancy for at least 3 years reported use of tier I methods (Table 2).

Table 2

Pre-conception care

A total of 252 participants (95.8%) said that a woman should plan and prepare for pregnancy. But when asked how a woman should prepare, only 10.7% provided answers that fell into the category of medical care. More than half of the answers related to financial preparation (26.4%) or mental preparation (26.7%). The remainder of the answers pertained to social preparation (6.3%) or other concerns (13.3%). Even when asked Do you think that there is anything the woman should do to prepare medically for pregnancy? only 2% of the women who had not initially spoken of the need for any medical preparation mentioned PCC at this second opportunity.

Hazards of OC use versus pregnancy

In the last section of the interview, 188 (71.5%) of the participants said that birth control pills were at least as hazardous to a women’s health as pregnancy, whereas only 56 (21.3%) knew that pregnancy was more dangerous than taking birth control pills. Nineteen subjects (7.2%) reported that they did not know which situation was more hazardous.


Results of this study suggest that these traditional Hispanic women tended to prize relatively larger families—as compared with the average number of children in U.S. families (~2.4, depending on various definitions of a family by the 2010 Census Bureau).13 Most participants appeared certain about the number of children they wanted and how soon they wanted their next pregnancy. Nevertheless, fewer than one-fifth of those who wanted to delay their next pregnancy for 3 or more years were using a Tier 1 contraceptive method. About one-third were using the least effective Tier 3 methods.

Hispanic women, relative to their non-Hispanic counterparts, know less about reproduction and contraception use, which may partly account for their significantly lower rates of contraceptive use.3,4 Although the findings regarding the use of less effective contraceptive methods by Hispanic women are consistent with other existing research, the purported causes demonstrate that pregnancy planning and contraceptive decision making go beyond simple knowledge. A recent study conducted in Texas, another state with a large Hispanic population, related Hispanic women’s use of less effective contraceptive methods or inconsistent use of methods to their ambivalence about pregnancy.6 In this study, as many as one-third of participants who claimed they wanted no more children still said they would feel very happy or somewhat happy about becoming pregnant in the next 3 months.6 Another study on contraceptive use among young Hispanic women conducted in southeast Texas showed that women low in acculturation (defined by the language portion of the Short Acculturation Scale for Hispanics), compared with women high in acculturation, were more likely to use no contraception or cyclic contraception rather than Tier 1 methods.7 A study by the National Latina Institute for Reproductive Health showed that a large majority of Hispanic women do not use contraception consistently because of economic barriers and deeply rooted cultural and religious influences.2

When asked whether a woman should plan and prepare herself for pregnancy, nearly 96% of the participants responded in the affirmative. However, when asked how a woman should do so, fewer than 11% mentioned anything related to medical aspects of planning and preparation even when prompted. More than 89% gave answers related to psychological, financial, or social planning and preparation. Monitoring a woman’s pre-conception health was not mentioned. Based on these women’s responses, this study population seemed relatively unfamiliar with the importance of medical care prior to becoming pregnant to identify, intervene with, and monitor pre-conception risk to improve pregnancy outcomes. No other studies looking specifically at Hispanic women’s knowledge or attitudes related to PCC were found.

When asked whether they thought birth control pills or pregnancy was more hazardous to a woman’s health, more than 70% of participants chose the former—even though pregnancy is far more dangerous than use of any of the hormonal contraceptives.14 These women, like most U.S. wom­en, believe that pregnancy is a natural process that could not possibly be riskier to their health than hormonal contraceptive use. In fact, a study of English-speaking, reproductive-aged women’s knowledge of the health risks of pregnancy versus those risk of OC use showed the same misconceptions.14 Even the more highly educated, affluent women in this study considered OC use more hazardous than pregnancy.

Study limitations

Generalizability of these study findings is limited. The data were derived from an interview of Hispanic women, many of whom were recent immigrants to the U.S., at a single clinic for low-income women. The results do not represent women in general or Spanish-speaking Hispanic women. Another concern is that more than half (53.6%) of these participants had completed their families and wanted no more pregnancies. However, this subgroup provided the investigators with important insights into the mismatch between their pregnancy plans and their selection of less effective contraceptive methods.

Practice implications

This survey revealed three important points. First, HCPs need to be aware that many Spanish-speaking women may not have clearly defined their fertility goals. Rather than asking a woman whether she plans to get pregnant in the next year, HCPs should ask, How would you feel if you were to get pregnant in the next year? Her answer may reveal her commitment or ambivalence regarding pregnancy prevention, which is important to know when prescribing a user-dependent birth control method. For women seeking contraception who are ambivalent about pregnancy prevention, HCPs may want to plan for follow-up to address any concerns that might arise during early use of the method.15

Second, HCPs need to directly address women’s concerns about contraceptive safety.7,12 HCPs should assess each woman’s contraceptive experiences and preferences. This assessment may help uncover misconceptions, fears, or the influences of others on her contraceptive decision making.15 Use of less effective contraceptive methods (i.e., those in Tier 3) may reflect her concerns about the safety of using more effective methods (i.e., those in Tiers 1 and 2). Every time HCPs prescribe a particular method, a patient should be informed that this method is safer for her than pregnancy.

Third, to address a Spanish-speaking, reproductive-aged woman’s lack of familiarity with the importance of PCC, HCPs should routinely remind her that, if and when she wants to get pregnant, she should return to have her health status evaluated and to learn what she can do to improve the outcome of the intended pregnancy. Every family planning visit provides an opportunity for pre-conception counseling on healthy lifestyle behaviors and pre-pregnancy management of risk factors and medical conditions that influence pregnancy outcomes.


Lack of pregnancy planning and inconsistency between stated pregnancy plans and effective contraceptive use are common among U.S. women.16 The findings of this study reflect the need to continue to expand HCPs’ understanding of the causes for this inconsistency in both the general population and in specific populations.

Pamela E. Xandre is Assistant Professor at the School of Nursing, California State University, Long Beach. Salma Shabaik is a physician at Family Practice in Long Beach, California. Anita L. Nelson is Professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine, University of California at Los Angeles. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006; 38(2):90-96.

2. Ranjit N, Bankole A, Darroch JE, Singh S. Contraceptive failure in the first two years of use: differences across socioeconomic subgroups. Fam Plann Perspect. 2001;33(1):19-27.

3. Sangi-Haghpeykar H, Ali N, Posner S, Poindexter AN. Disparities in contraceptive knowledge, attitudes, and use in Hispanic and non-Hispanic whites. Contraception. 2006;74(2): 125-132.

4. Schwarz EB, Smith R, Steinauer J, et al. Measuring the effects of unintended pregnancy on women’s quality of life. Contraception. 2008;78(3): 204-210.

5. Humes KR, Jones NA, Ramirez RR. Overview of race and Hispanic origin, 2010. Census Briefs. March 2011. census.gov/prod/cen2010/briefs/c2010br-02.pdf

6. Aiken AR, Potter JE. Are Latina women ambivalent about pregnancies they are trying to prevent? Evidence from the Border Contraceptive Access Study. Perspect Sex Reprod Health. 2013;45(4):196-203.

7. Roncancio AM, Ward KK, Berenson AB. The use of effective contraception among young Hispanic women: the role of acculturation. J Pediatr Adolesc Gynecol. 2012;25(1):35-38.

8. Rocca CH, Harper CH. Do racial and ethnic differences in contraceptive attitudes and knowledge explain disparities in method use. Perspect Sex Reprod Health. 2012;44(3):150-158.

9. California Department of Healthcare Services. Fact Sheet on Family PACT: An Overview. Updated January 2012. familypact.org/Providers/Fact-sheets/2-2012_FamPACT_FS_Overview_2-15ADA.pdf

10. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR Preconception Work Group and the Select Panel on Preconception Care. Morbid Mortal Weekly Rep. 2006;55(RR-06):1-23.

11. American College of Obstetricians and Gynecologists. ACOG Committee Opinion number 313, September 2005. The importance of pre-conception care in the continuum of women’s health care. Obstet Gynecol. 2005;106(3):665-666.

12. Wysocki S. The state of hormonal contraception today: enhancing clinician/patient communications. Am J Obstet Gynecol. 2011;205(4 suppl):S18-S20.

13. United States Census Bureau. America’s Families and Living Arrangements: 2010. census.gov/

14. Nelson AL, Rezvan A. A pilot study of women’s knowledge of pregnancy health risks: implications for contraception. Contraception. 2012;85(1):78-82.

15. Gavin L, Moskosky S, Carter M, et al; Centers for Disease Control and Prevention. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep. 2014;63(RR-04):1-54.

16. Morgan SP, Rackin H. The correspondence between fertility intentions and behavior in the United States. Popul Dev Rev. 2010;36(1):91-118.

Not your mother’s WHNP guidelines

In the past, and even continuing into the present day, low-income women and children have encountered barriers in accessing healthcare. Fifty years ago, to help overcome these barriers, Loretta Ford, RN, and Henry Silver, MD, created the first nurse practitioner (NP) program at the University of Colorado; it was there, in 1965, that the NP role first emerged. This certificate education program, which built on the knowledge and skills of the public health nurse, prepared pediatric NPs (PNPs) to work in collaboration with physicians to care for underserved low-income pediatric populations.1

Inspired by the success of the PNP role, innovative nurses and physicians expanded the registered nurse role to include provision of care to underserved pregnant women. The evolution of the obstetric/gynecologic (OB/GYN) nurse’s role from maternity care to women’s healthcare throughout the lifespan, in what would become an advanced practice role, drove the need for uniform standards for education and practice.

To serve this need, the first guidelines, Obstetric-Gynecologic Women’s Health Nurse Practitioner: Role Definition, Role Description, and Guidelines for Educational Development, were published in 1979. These guidelines, updated in 1984 and 1990, remained in effect until 1996. Reflecting the spirit of cooperation inherent in women’s healthcare, the National Association of Nurse Practitioners in Women’s Health (NPWH) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) collaborated to develop and publish Women’s Health Nurse Practitioner: Guidelines for Practice and Education (hereafter called the Guidelines) in 1996. This 4th edition and two subsequent editions have delineated the emerging skills and competencies necessary for WHNPs to meet women’s healthcare needs.

The 7th edition of the Guidelines

The evolving national healthcare scene, the changing policies/guidelines affecting NP education and practice, and multiple emerging population health concerns have driven the need for periodic comprehensive reviews and revisions of the Guidelines. The 7th edition of the Guidelines provides a clarification of the WHNP role, without expanding the role.1 This edition articulates and differentiates the women’s health population focus by:

• Strengthening language regarding the WHNP’s role in primary care, and;
• Describing key areas of specialty practice consistent with WHNP education and identified competencies, including high-risk pregnancy, infertility, urogynecology, gynecologic oncology, menopause, and gynecologic office-based procedures.

The revision process for the Guidelines

In April 2013, a joint NPWH/AWHONN task force of WHNPs, with equal representation from the two associations, was convened to revise the Guidelines under the leadership of a chairperson with dual NPWH/AWHONN membership. Task force members were selected for their knowledge and experience in women’s health, nursing education, and clinical practice. In addition, the National Certification Corporation (NCC), the only nationally recognized certifying body for WHNPs, was invited to name a representative to participate on the task force.

Over the course of 18 months, the task force took steps to ensure that the updated document would reflect not only current WHNP practice but also the an­ticipated WHNP role of the future. First, the task force reviewed key documents guiding NP practice and education, as well as women’s healthcare, to ensure alignment. Upon completion of the draft document, key WHNP stakeholders were asked to review the document and provide comments to strengthen it. Following this review, NPs in other population foci, along with representatives from the American Association of Nurse Practitioners, the Gerontological Advanced Practice Nurses Association, the National Association of Pediatric Nurse Practitioners, and the National Organization of Nurse Practitioner Faculties (NONPF), participated in a second review. The second review hinged on these questions:

• Do these Guidelines align with key NP guidance documents regarding NP practice and education?
• When, and for what services, would you refer to a WHNP?
• Is the reason that you would refer to a WHNP adequately reflected in the Guidelines document?

All comments were reviewed by the task force and incorporated into the document.

During development of the Guidelines, all NCC-certified WHNPs were invited to complete a survey regarding their current practice, including work setting, skills utilized in practice, content learned in WHNP programs, and content and skill building in the workplace. Survey results indicated that approximately 82% of WHNPs practice in primary care settings, including OB/GYN and family practice offices, family planning clinics, governmental health departments, college health departments, sexually transmitted disease clinics, and prenatal care clinics.2 The other respondents reported working in specialty and sub­specialty practices such as gynecologic oncology, urogynecology, infertility, and maternal–fetal medicine. The survey results, combined with input from non-WHNP colleagues, underscored the broad reach of WHNP practice.

Revisions include alignment with Licensure, Accreditation, Certification & Education (LACE), NONPF NP Core Competencies, American Association of Colleges of Nursing MSN and DNP Essentials, other NP population focus guidelines, and the Institute of Medicine’s (IOM’s) The Future of Nursing: Leading Change, Advancing Health, as well as key documents pertaining to women’s health.

Key differences from prior editions

The 7th edition of the Guidelines represents a comprehensive view of WHNP practice today, emphasizing a lifespan approach to care extending from menarche through senescence. Written within the framework of the LACE consensus model for advanced practice nursing and consistent with the IOM’s groundbreaking report on the future of nursing, the Guidelines, compared with earlier editions, reflect a broader description of WHNP assessment, diagnostic, and treatment activities within the context of general competencies, gynecology, male sexual and reproductive healthcare (SRH), nongynecologic primary care, and obstetrics. WHNP education concepts reflect the practice competencies necessary to partner with women to meet their healthcare needs. The Guidelines elaborate on the WHNP role in male SRH, take a gender-focused approach to women’s health concerns, and recognize WHNPs’ expertise in performing selected office-based procedures. In further clarifying the components of WHNP practice, the Guidelines reflect WHNPs’ expertise and value as care providers, leaders, and consultants in the areas of women’s health and male SRH.


The writing team and reviewers for the Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition spent countless hours bringing this final document to fruition. Guideline development and publication by NPWH and AWHONN included a review of interdisciplinary documents and input from family NP, adult-gerontology NP, PNP, and faculty colleagues in addition to a team of WHNPs. This multifaceted approach exemplifies the collaborative nature of women’s healthcare providers as partners with their female patients in promoting health, preventing disease, and optimizing health outcomes.

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

1. National Association of Nurse Practitioners in Women’s Health/ Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.

2. Kelsey B and the National Association of Nurse Practitioners in Women’s Health. NPWH Women’s Health NP Role and Competencies Survey. 2013. Unpublished data.

Message from the CEO

Another year has begun, and we are meeting it head on with enthusiasm and energy! This month, February, is American Heart Month. NPWH is proud to be a partner with the Million Hearts® campaign and to promote the Spread the Word campaign, and we are already hard at work developing the cardiovascular portion of our Well Woman Visit mobile app. We recognize the importance of providing more information about women’s heart health and distributing valuable tools to clinicians and their patients. In the spirit of women’s heart health this month, I ask you to please read Editor-in-Chief Beth Kelsey’s message and Suzanne Shugg’s article, and to please take a look at the tip sheet on antihypertensive medication adherence in our Clinical resources department.

I want to share with you some exciting experiences from our 17th Annual Premier Women’s Healthcare Conference, which was held this past October. For starters, we launched a new Student Reporter Program, which was a huge success! We chose 10 students from around the country to participate in this program based on their interest and on recommendations from their faculty (Figure 1). Through an educational grant from Pfizer, we were able to provide transportation to and from the conference and cover registration fees and meals for the duration of the conference.

In return, the students met with NPWH board members and staff, networked with NP colleagues, attended all sessions, assisted as runners, offered assistance in the hands-on workshops, promoted the conference through social media, and recorded their daily experiences. An outbriefing with the students revealed that their experience was unmatched by any they had ever had before. Here is what some of the student participants had to say:

“Participating in the inaugural student reporter cohort for NPWH was a humbling and rewarding experience, one I will never forget. I was able to learn  about new and evolving research from experts in various fields; network with nurse practitioners, physicians, and researchers from across the country; and gain exposure to products and services I will utilize in the future. The conference exposed me to the breadth of information available through NPWH that will inform my current studies, as well as my future practice.”

“Before the conference, I was having second thoughts about finishing school. I was not certain that I wanted to become a NP, but then I attended this conference, which gave me the inspiration and motivation I needed. Since the conference, I find myself excited about school again and I am driven to learn as much as I can so that I can apply it to my practice. This experience has changed my life. I don’t think I would have continued my education in this direction if I had not attended this conference, and I would not have been able to attend without being selected as a Student Reporter.”

“I am thrilled to be graduating in May, and I am so excited to begin my career as a nurse practitioner. I have always had a passion for learning. The NPWH conference was my first experience attending a conference dedicated solely to women’s health issues. It was empowering to be surrounded by a group of other NPs and experts in this field. I have already had the opportunity to apply information I learned at the conference to real-life settings. Thank you so much for contributing to my education and for supporting my passion for women’s health.”

As you can see from the students’ comments, our Student Reporter Program provided a great opportunity for WHNP students. We hope to continue this program in 2015.

At the October 2014 conference, we were able to recognize NPs who are an inspiration to others by providing our 7th annual Inspiration in Women’s Health Awards. These awards were made possible by a generous grant from Teva Women’s Health. This year’s first-place winner is Diane Todd Pace, PhD, FNP-BC, NCMP, FAANP, a Clinical Associate Professor at the Loewenberg School of Nursing at the University of Memphis in Memphis, Tennessee (Figure 2A). Diane is the first NP to serve as President of The North American Menopause Society (NAMS).

We also honored three runners-up. Kayla E. Castañeda, RN, MSN, WHNP-BC, AOCNP, is a Faculty Associate in the Department of Obstetrics and Gynecology at the Paul L. Foster School of Medicine at Texas Tech University in El Paso (Figure 2B). She is also a women’s health and oncology nurse practitioner at Texas Tech University Health Sciences Center in El Paso. Kayla has piloted a cancer group for her patients that supports them through the course of their treatment. Paula Newman-Skomski, MSN, FNP-BC, ARNP, SANE-A, a nurse practitioner/forensic nurse examiner at Providence Intervention Center for Assault and Abuse in Everett, Washington, is the founder of Peoria Home, which will be a residential recovery program for woman exploited through sex trafficking and prostitution (Figure 2B). Susan Moskosky, MS, WHNP-BC, is the Acting Director of the Office of Population Affairs (OPA), U.S. Department of Health and Human Services (Figure 2C). Under Susan’s leadership, the OPA worked jointly with the CDC to develop the Quality Family Planning Recommendations, the first federal evidence-based recommendations for highquality family planning services delivery.

We at NPWH are looking forward to another exciting year. As always, are working to provide you with top-notch education and resources that support best practices and evidence-based care for women.

– Gay Johnson

Chief Executive Officer, NPWH


Billable coding for female sexual dysfunction disorders*

Billable coding for general medical diagnoses and procedures is a complicated process. Within a subspecialty such as female sexual health, which lacks a clear consensus regarding diagnostic coding for sexual dysfunctions, the process can be even more challenging and frustrating. As such, some women’s healthcare providers do not even treat patients with sexual dysfunction in their practices. The purpose of this very first article in the “Focus on sexual health” department is to shed light on the billable coding process for female sexual dysfunction disorders in order to clarify, if not simplify, this process.

DSM-5 categories

The World Health Organization’s International Classification of Diseases (ICD) is utilized in the United States for diagnostic coding for most diseases and other health problems. However, female sexual dysfunction (FSD) diagnoses were developed through the American Psychiatric Association and are listed in the Diagnostic and Statistical Manual (DSM). A text revision of the fourth edition, the DSM-IV-TR,1 published in 2000, included five categories of FSD: hypoactive sexual desire disorder (HSDD), female sexual arousal disorder, female orgasmic disorder, dyspareunia, and vaginismus. With release of the fifth edition, the DSM-5,2 desire and arousal disorders were merged into one unified diagnostic category—female sexual interest/arousal disorder—and vaginismus and dyspareunia were merged into genito-pelvic pain/penetration disorder (Table 1).1,2 A subcategory of HSDD, sexual aversion disorder, was removed.2

According to the DSM-5, in order to meet diagnostic criteria, a person must experience the FSD condition 75%-100% of the time for at least 6 months.2 In addition, the condition must result in significant distress. The disorder must not better be explained by a nonsexual mental disorder, a consequence of severe relationship distress such as domestic violence, or other significant stressors. Also, a new severity scale, which designates a condition as mild, moderate, or severe, was added to allow for more diagnostic specificity.

Current and future ICD diagnostic codes

With regard to the complicated matter of translating these definitions into billable coding, women’s healthcare providers must consider the landscape of the ninth edition, clinical modification, of the ICD (ICD-9-CM).3 Diagnostic codes are categorized into chapters of different body systems, symptoms, and conditions. One of the chapters is mental and behavioral disorders, which coincides with DSM definitions. This chap­ter includes the FSD diagnostic codes. When billing for patient care specific to FSD diagnoses, providers will find that these disorders are typically covered through a separate division of a patient’s healthcare plan or that they are not covered at all. To overcome this challenge, providers can find codes in other areas of the ICD-9-CM that cover symptoms of FSD such as low libido and dyspareunia (Table 2).3

To complicate matters further, the tenth edition of the ICD (ICD-10) is slated to be released in October 2015. Whereas previous revisions to the ICD were fairly easy to follow, ICD-10 coding will not resemble the familiar ICD-9 terrain at all. To begin, the first character of each code is a letter of the alphabet, not a number.4 F codes will cover mental, behavioral, and neuro­developmental disorders. Other chapters of relevance to women’s healthcare providers are E codes for endocrine, nutritional, and metabolic diseases; L codes for diseases of the skin and subcutaneous tissue; M codes for diseases of the musculo­skeletal system and connective tissue; N codes for diseases of the genitourinary system; and R codes for symptoms, signs, and abnormal clinical and laboratory findings.4Table 3 compares ICD-9-CM and ICD-10 codes related to FSD (with the latter codes still subject to change) and Table 4 lists additional codes that may apply to female sexual complaints.

CPT codes

Table 5 lists Current Procedural Terminology® (CPT) codes for procedures commonly performed in a sexual health practice. In many cases, though, time spent with female patients reporting sexual complaints can surpass that spent performing hands-on examinations and procedures. In these circumstances, providers should bill based on time spent, assuming that more than 50% of the time spent with the patient was face to face and for counseling. If a procedure is performed on the same day as an evaluation and management visit for a separately identifiable complaint, providers should use modifier 25 so that each element can be billed at 100%.


Although navigating the complicated billable coding process for FSD can be confusing and frustrating, treatment for these conditions is frequently reimbursable. General understanding of ICD and DSM terms and codes is critical to smart billable coding. If uncertain about a particular situation, women’s healthcare providers should consult with a billing and coding specialist.

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA; 2000.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC; APA; 2013.

3. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) Professional Edition. USA: Elsevier/American Medical Association; 2013.

4. ICD-10-CM: The Complete Official Draft Code Set. USA: American Medical Association; 2014.

Improving medication adherence among patients with hypertension: A tip sheet for healthcare providers

Medication adherence is critical to successful hypertension control for many patients. However, only 51% of Americans treated for hypertension follow their healthcare providers’ (HCPs’) advice when it comes to their long-term medication therapy.

Adherence matters. High adherence to antihypertensive medication is associated with higher odds of blood pressure control, whereas non-adherence to  cardioprotective medications increases a patient’s risk of death from 50% to 80%.

As an HCP, you can empower your patients to take their medications as prescribed. Effective two-way communication is critical; in fact, it doubles the odds of your patients taking their medications properly. Try to understand your patients’ barriers and address them as honestly as you can to build trust.

The SIMPLE method

Use the SIMPLE method to help improve medication adherence among your patients.

Simplify the regimen

Encourage patients to use adherence tools such as day-of-the-week pill boxes or mobile apps.

Work to match the action of taking medication with a patient’s daily routine (e.g., mealtime or bedtime, with other medications they already take properly).

Impart knowledge

Write down prescription instructions clearly, and reinforce them verbally.

Provide websites for additional reading and information— find suggestions at the Million Hearts® website.

Modify patients’ beliefs and behavior

Provide positive reinforcement when patients take their medication successfully, and offer incentives if possible.

Talk to patients to understand and address their concerns or fears.

Provide communication and trust

Allow patients to speak freely. Time is of the essence, but research shows that most patients will talk no longer than 2 minutes when given the opportunity.

Use plain language when speaking with patients. Ask, “Did you take all of your pills?” instead of using the word “adherence.”

Ask for patients’ input when discussing recommendations and making decisions.

Remind patients to contact your office with any questions.

Leave the bias

Understand the predictors of non-adherence and address them as needed with patients.

Ask patients specific questions about attitudes, beliefs, and cultural norms related to taking medications.

Evaluate adherence

Ask patients simply and directly if they are sticking to their drug regimen.

Use a medication adherence scale—most are available online:

  • Morisky-8 (MMAS-8)
  • Morisky-4 (MMAS-4 or Medication Adherence Questionnaire)
  • Medication Possession Ratio (MPR)
  • Proportion of Days Covered (PDC)

Additional materials to help your patients control hypertension are available at the Million Hearts® website. =

The information in the article is courtesy of the Million Hearts Initiative at www.millionhearts.hhs.gov


Practical strategies for the diagnosis and management of binge eating disorder

Binge eating disorder (BED), now included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),1 is defined as follows:

  • Recurrent and persistent episodes of binge eating
  • Binge eating episodes that are associated with three (or more) of the following:
    • Eating much more rapidly than normal
    • Eating until feeling uncomfortably full
    • Eating large amounts of food when not feeling physically hungry
    • Eating alone because of being embarrassed by how much one is eating
    • Feeling disgusted with oneself, depressed, or very guilty after overeating
  • Marked distress regarding binge eating
  • Absence of regular compensatory behaviors (such as purging)

Particularly common among females (See Cases 1, 2, and 3) and associated with obesity, BED poses physical, psychological, and social challenges that decrease health-
related quality of life (HRQOL) and increase disease burden.


The etiology of BED is multifactorial and complex. Although associated with hedonic hunger, BED is linked less to pleasure and more to an attempt to suppress negative feelings through bingeing without purging.2 Motivation to binge likely also arises from homeostatic hunger.

Risk factors

Risk factors for BED include genetics, female gender, Caucasian ethnicity, weight concern, negative body image, childhood problems, low self-esteem and self-efficacy, low family cohesion, psychiatric morbidity, and stressful events.3,4 In addition, a community-based case–control study demonstrated that patients with BED, versus controls, were significantly more likely to report sexual abuse and repeated severe physical abuse. The typical overweight person with BED is overly concerned with body shape and weight. BED is most likely to occur in young women of high socioeconomic status in industrialized countries, but it is not limited to this population (See Cases 1, 2, and 3).

Binge-eating disorder in children and adolescents

In children and adolescents, early identification and treatment of BED is vital (See Case 1). Loss of control over eating is associated with modifiable lifestyle factors. Often considered temporary, BED is actually a long-term chronic condition often associated with co-morbid obesity. Childhood factors that increase risk for BED include obesity, self-criticism, poor self-esteem, body dissatisfaction, and emotional abuse.5 In female adolescents and young adult women, BED is associated with pre-existing depressive symptoms and an increased risk for developing mood disorders.6

Specific goals of treatment for children and adolescents include treatment of underlying depression or anxiety, improvement of self-esteem, normalization of eating patterns, promotion of physical activity, and implementation of family therapy to address family dysfunction and engage family members in supporting the patient’s recovery. BED treatment outcomes can be optimized through early detection and referral to eating disorder specialists; incorporating a multidisciplinary treatment team to address the physical, psychological, nutritional, and spiritual aspects of BED; and combining cognitive behavioral therapy (CBT), a self-help program, and, when appropriate, pharmacotherapy.

Co-morbid psychiatric disorders

Co-morbid anxiety, mood, and disruptive behavior disorders are common in patients with BED, as are obsessive-compulsive disorder, post-traumatic stress disorder, and substance abuse. Co-morbid obesity increases psychopathology, emotional eating, concerns about weight and body shape,7 and perhaps a desire for bari­atric surgery.8 Obesity and BED are common in patients with bipolar disorder. In patients with personality disorders, alexithy­mia (a personality construct characterized by the subclinical inability to identify and describe emotions in the self) correlates more highly with BED than with other eating disorders.9

A case–control study showed that patients with BED, compared with controls, reported a significantly greater number of adverse life events during the year prior to symptom onset, suggesting that the accumulation of stressful events can trigger the disorder.10 Even after weight loss and CBT, patients with BED experienced higher morning basal cortisol levels than did a control group without BED.

Effects of disordered eating patterns on reproductive health

Disordered adolescent eating patterns affect one’s development, with implications for reproductive function. Behaviors associated with risk-taking and self-harm frequently co-exist with eating disorders and increase risks for unplanned pregnancy and sexually transmitted infections. Obesity is strongly associated with conditions that adversely affect reproductive function.

In anovulatory overweight or obese women, sustained gradual weight loss will regulate menstrual cycles and increase the chance of spontaneous ovulation and conception.11Lifestyle modification has been shown to improve reproductive function.

Effects of binge eating disorder on pregnancy

Pre-pregnancy and pregnancy dietary patterns of women with BED may influence pregnancy outcomes. Many obstetricians do not query patients about weight control or disordered eating during pregnancy, and many patients do not seek treatment. Studies evaluating maternal and fetal outcomes in women with eating disorders are limited.

Women with BED during pregnancy are considered high risk. BED treatment during pregnancy is important for long-term management and reduction of harmful behaviors such as smoking; in fact, treatment during pregnancy is particularly likely to produce long-lasting results.

Pregnant patients with BED need frequent prenatal visits to discuss problems related to both nutrition and BED. Healthcare providers (HCPs) should do the following:

• Empower women to discuss weight and body-image concerns during pregnancy;
• Educate patients that uneven weight gain patterns may occur in pregnancy;
• Inform patients that controlling BED during pregnancy reduces the risk for a large-for-gestational-age newborn;
• Provide or refer for dietary support and meal planning;
• Assess and/or refer for management of psychiatric co-morbidities;
• Provide a routine postpartum visit at 1-2 weeks to monitor for relapse or exacerbation of BED; and
• Provide nutritional and dietary counseling for breastfeeding mothers and for the first 6-12 months postpartum.12

Co-morbid physical disorders

Binge eating disorder is associated with multiple physical co-morbidities, with decreased HRQOL and physical and psychosocial functioning.13 A large majority of individuals with BED receive medical treatment for co-morbidities, particularly obesity-related conditions such as type 2 diabetes mellitus (DM). Weight loss in patients with type 2 DM and BED who control their eating habits is similar to that in persons who have never experienced BED. BED may precede bariatric surgery and/or re-emerge post-surgery.

Screening and diagnosis

Assessment for eating disorders, including BED, should be part of a routine health evaluation. HCPs can use an assessment tool or pose a simple screening question in a matter-of-fact, nonjudgmental, empathetic manner to facilitate open conversation: Do you have thoughts, feelings, or behaviors regarding eating, weight, or body image that occupy most of your time or that make you feel out of control? (See Cases 1, 2, and 3.) The SCOFF Questionnaire can be useful. Practical strategies for screening and diagnosis implemented by the authors include the following:
• Use an eating disorder screening question at routine visits as patients age from childhood through the older adult years;
• Engage patients in a conversation about possible BED;
• Maintain accurate chronological weight records;
• Be familiar with DSM-5 diagnostic criteria;
• Obtain a 24-hour written food intake and feelings journal for
7 consecutive days (including weekends) and review the journals with patients;
• Assess for underlying depression or anxiety; initiate medication if indicated;
• Use physical, nutritional, and psychological findings to incentivize patients to engage in treatment;
• Avoid references to calories, weight, and dieting that may exacerbate feelings of shame or excessive focus on food;
• Advocate an approach for treatment of BED and obesity that does not center on the need for dieting but, instead, emphasizes the importance of specialized psychological, medical, and nutritional care;
• Be familiar with eating disorder specialists in your geographic area and be able to implement the referral process; and
• Confirm that patients follow through with BED treatment.

Binge-eating disorder subtypes may manifest in difficult-to-treat food addictions, which are common in patients with co-existing histories of addictive personality or substance abuse disorder. A marker of substance dependence includes consumption of high-fat/high-sugar foods.14 A food addiction symptom count (using criteria similar to those for substance abuse disorder in the DSM-5) should be obtained for these patients.15 Emotions associated with binge eating may be experienced differently by individuals from specific ethnic, racial, and cultural groups.


The American Psychiatric Association has established levels of care guidelines for patients with eating disorders, who can be difficult to treat. Many patients with BED experience shame, embarrassment, self-disgust, depression, and guilt as a result of their eating disorder. They tend to eat secretly or alone and may hide binge foods. Patients may deny that they have an eating disorder and may be reluctant to discuss BED with their HCP. Many patients who use binge eating to deal with difficult life situations are reluctant to eliminate this behavior and do not fully commit to a treatment program. Others welcome interventions that may improve HRQOL.

Nonpharmacologic approaches
Cognitive behavioral therapy, considered a first-line therapy for BED, and interpersonal psychotherapy are effective in patients with BED (See Cases 1, 2, and 3). Other nondrug approaches usually entail a combination of a lifetime nutritional plan, assertiveness training, improved stress management, and moderate exercise to increase lean muscle mass.

No agent is FDA-approved for the treatment of BED. An application for an indication for lisdexamfetamine dimesylate as a treatment for BED likely will be filed soon with the FDA. Multiple pharmacologic agents have demonstrated benefits at varying dosages in trials conducted between 2005 and 2010.

Antidepressants address common mood-related co-morbidities. Of note, many patients with BED consume tryptophan-containing carbohydrates that synthesize serotonin. When these patients’ serotonin levels are low, cravings commence. Antidepressants that inhibit reuptake of serotonin can help decrease compulsive/binge eating. In many patients with co-morbid depression (or if CBT is unavailable), selective serotonin reuptake inhibitors (SSRIs) can decrease bingeing (and purging) by 50%, although some patients may not respond to treatment or may relapse with SSRI dis­continua­tion.16 Bupropion has beneficial effects on weight and does not have SSRI side effects. Bupropion dosages of 300-450 mg/day have been shown to be effective.17Psychostimulants
Agents used to treat attention defi­cit hyper­activity disorder (ADHD) affect dopamine/norepinephrine systems associated with both the etiology of BED and eating behavior/reward behavior. An epide­miologic relationship between BED and ADHD has been noted in adolescents18 and adults.19 An association has also been reported between bulimia nervosa (BN) and ADHD; a small study of patients with co-morbid BN and ADHD showed the efficacy of psycho­stim­­ulant medication. An ongoing study is comparing methyl­phen­i­date with CBT in the treat­ment of BED.20Pharmacotherapy during pregnancy
Few studies have evaluated the use of psychotropic agents during pregnancy other than a large cohort evaluation of SSRIs. Additional data may guide decision making regarding the use of agents such as bupropion, methylphenidate, memantine, naltrexone, sodium oxybate, topiramate, and zonisamide in pregnant women.


Binge-eating disorder is a complex, multifactorial condition that requires a comprehensive and integrated course of treatment. Nurse practitioners and other advanced practice HCPs caring for women are positioned to play important roles in patient assessment and management.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013.

2. Witt AA, Lowe MR. Hedonic hunger and binge eating among women with eating disorders. Int J Eating Disord. 2014;47(3):273-280.

3. Jacobi C, Hayward C, de Zwaan M, et al. Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychol Bull. 2004;130(1):19-65.

4. Jacobi C, Paul T, de Zwaan M, et al. Specificity of self-concept disturbances in eating disorders. Int J Eat Disord. 2004;35(2):204-210.

5. Dunkley DM, Mashib RM, Grilo CM. Childhood maltreatment, depressive symptoms, and body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. Int J Eat Disord. 2010;43(3):274-281.

6. Skinner HH, Haines J, Austin SB, Field AE. A prospective study of overeating, binge eating and depressive symptoms among adolescent and young adult women. J Adolesc Health. 2012;50(5):478-483.

7. Vancampfort D, Vanderlinden J, De Hert M, et al. A systematic review on physical therapy interventions for patients with binge eating disorder. Disabil Rehabil. 2013;35

8. Bulik CM, Sullivan PF, Kendler KS. Medical and psychiatric morbidity in obese women with and without binge eating. Int J Eat Disord. 2002; 32(1):72-78.

9. Wheeler K, Gruner P, Boulton M. Exploring alexithymia, depression and binge eating in self-reported eating disorders in women. Perspect Psych Care. 2005;41(3):114-123.

10. Pike KM, Wilfley D, Hilbert A, et al. Antecedent life events of binge-eating disorder. Psychiatry Res. 2006;142(1):19-29.

11. Pandey S, Pandey S, Maheshware A, Bhattacharya S. The impact of female obesity on the outcome of fertility treatment. J Hum Reprod Sci. 2010;3(2):62-67.

12. Harris AA. Practical advice for caring for women with eating disorders during the perinatal period. J Midwifery Womens Health. 2010;55 (6):579-586.

13. Rieger E, Wilfley DE, Stein RI, et al. Comparison of quality of life in obese individuals with and without binge eating disorders. Int J Eat Disord. 2005;37(3):234-240.

14. Cooper R. Could your patient have an eating disorder? Nurs Womens Health. 2013;17(4):317-324.

15. Gearhardt AN, Corbin WR, Brownell KD. Preliminary validation of the Yale food addiction scale. Appetite. 2009;52(2):430-436.

16. Mehler PS, Anderson AE. Eating Disorders: A Guide to Medical Care and Complications. 2nd ed. Baltimore, MD: John Hopkins University Press; 2010.

17. Stahl SM, Pradko JF, Haight BR, et al. A review of the neuropharmacology of bupropion, a dual norepinephrine and dopamine reuptake inhibitor. Prim Care Companion J Clin Psychiatry. 2004;6(4):159-166.

18. Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723.

19. Hudson J, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.

20. Quilty LC, Kaplan A. Center for Addiction and Mental Health, Toronto, Ontario, Canada. Methylpheni­date versus cognitive behavior therapy in overweight or obese adult females. ClinicalTrials.gov. 2014.

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

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.

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.

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.

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.


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.

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/

Depression among women of childbearing age*

More than just feeling sad or down or having the blues, many women like yourself, in your late teens to early 50s, can develop a mental illness called depression. Yes, depression is an illness, not a sign of weakness, and it is treatable. If you think you might have depression, see your healthcare provider (HCP) to find out, and to get the treatment you need.

What is depression?

Many women, including pregnant women and women who have recently given birth, experience depression. Just like other illnesses, depression has symptoms, including:

  • A low or sad mood
  • Loss of interest in fun activities
  • Changes in eating, sleep, and energy
  • Problems in thinking, concentrating, and making decisions
  • Feelings of worthlessness, shame, or guilt
  • Thoughts that life is not worth living

When many of these symptoms occur together and last for more than 1-2 weeks at a time, this is depression. According to a national survey, about 11% of non-pregnant women of childbearing age experienced major depression in the previous year.1

What is postpartum depression?

Postpartum depression is depression that occurs after having a baby. Symptoms of postpartum depression are similar to those of depression, but they also include:

  • Trouble sleeping when your baby sleeps (more than the lack of sleep new moms usually get)
  • Feeling numb or disconnected from your baby
  • Having scary or negative thoughts about the baby, like thinking someone will take your baby away or hurt your baby
  • Worrying that you will hurt the baby
  • Feeling guilty about not being a good mom, or ashamed that you cannot care for your baby

According to the same national survey, 8%-19% of women who gave birth within the past year reported having frequent postpartum depression symptoms.

I just had a baby. Why am I having such a hard time now?

Being a mom is hard! For some women, the journey to becoming a mom is hard too. You may have heard of postpartum depression, but many women don’t know that depression can occur during pregnancy (it’s called perinatal depression) or with other events, such as losing a baby or having trouble getting pregnant. According to the same national survey mentioned above, about 8% of women who were pregnant during the past year experienced depression during their pregnancy.1

Did you know that the following experiences may put some women, including you, at higher risk for depression than others?

  • Having a hard time getting pregnant: Depression affects many women who experience infertility.
  • Having twins or triplets: Mothers of multiples, compared with women who give birth to just one baby, have a greater risk of developing depression.
  • Losing a baby: Women who experience miscarriage (losing a baby early in pregnancy), stillbirth (losing a baby late in pregnancy), or death of a newborn are more likely to experience depression.
  • Having a baby as a teen: Teen moms are more likely than older moms to have postpartum depression.
  • Having premature labor and delivery: These mothers have a significantly higher risk for depression.
  • Having a baby who is different: A mother’s risk for depression increases if the baby has a birth defect or disability.
  • Pregnancy and birth complications: Some studies have shown an increased risk for depression among women who experienced complications and hospitalization during pregnancy or an emergency C-section.
  • Having a baby who is sick or in the hospital: Women with sick or hospitalized babies may be at increased risk for depression, as well as stress and anxiety.
  • Having a healthy pregnancy and childbirth: Women having a difficult pregnancy or childbirth are not the only ones who experience depression. Depression can also occur among women with a healthy pregnancy and healthy birth.

That sounds like me. But how do I know if what I’m experiencing is depression? What should I do?

Depression is common. If you are worried about the way you have been feeling, you need to tell your HCP about your concerns. Answering these questions may help you determine whether what you are experiencing is depression. During the past 2 weeks, how often have you felt…

Little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
Down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day

If you answered “more than half the days” or “nearly every day” to either question, you may be depressed and should seek help from an HCP. Your HCP can help figure out whether you have depression or not, and she or he can help find the best treatment for you.

If I don’t do anything about my depression, will it eventually go away on its own?

The depression may eventually go away without help. It could also get worse instead of better. There are effective treatments for depression that may include medication or talking with a trained therapist. The best way to deal with depression is to see an HCP or a counselor. The earlier you seek help, the better you may do.

1. Ko JY, Farr SL, Dietz PM, Robbins CL. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009. J Womens Health (Larchmt). 2012;21(8):830-836.

2. Davé S, Petersen I, Sherr L, Nazareth I. Incidence of maternal and paternal depression in primary care: a cohort study using a primary care database. Arch Pediatr Adolesc Med. 2010;164(11):1038-1044.

Content source: Centers for Disease Control and Prevention, Division of Reproductive Health, National Center for Chronic Disease Prevention, and Health Promotion. http://www.cdc.gov/reproductivehealth/Depression/

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

Women’s health: More than an annual event*

As I write this column in mid-May, we are  week past Mother’s Day, and Women’s Health Week has just ended. During the 5th month of the year, healthcare providers (HCPs) and healthcare consumers are bombarded with messaging focused on the importance of women’s health. But then these messages go virtually silent until October—Breast Cancer Awareness Month. During the 10th month of the year, media attention will be drawn to breast cancer, the most frequently diagnosed cancer among women. By the end of October, the women’s health voice will once again be stilled until new messaging emerges during February, designated as American Heart Month, when we are encouraged to wear red to symbolize our solidarity in the fight against cardiovascular disease, the No. 1 cause of premature death among women. And so it goes.

On an individual level, as each woman makes her yearly appointment to see her HCP, she also tends to think of her health as an “annual event.” Most women perceive of this annual visit as the time to be screened for breast and cervical cancers and to address their family planning needs, menopausal symptoms, and/or other gynecologic health problems and concerns. But for HCPs who care for female patients, as well as for the patients themselves, women’s health is more than just an annual event.

Reproductive and maternal–child health

National and global statistics underscore the importance of women’s health status in affecting birth outcomes. The United States ranks 31st out of 178 countries on Save the Children’s Mothers’ Index.1 This ranking is based on a composite of five indicators related to maternal well-being: risk of maternal death, under 5-mortality rate (the probability per 1,000 live births that a newborn will die before reaching his or her 5th birthday), expected number of years of formal schooling, gross national income per capita, and women’s participation in national government.

Although the U.S. has placed in the top 10 on the Mothers’ Index as recently as 2006, next to Cyprus, our country has fallen farthest from the top. Of the 30 countries now ahead of the U.S. on this index, all but the Republic of Korea have a higher percentage of seats held by women in national government. When women have a voice in policy, issues important to women and children are more likely to emerge as national priorities.1 Worldwide, prematurity is the leading cause of newborn death (birth to 4 weeks) and the second leading cause of death in children younger than 5 years. The U.S. ranks 37th of 165 countries in the number of deaths due to prematurity, placing 6th among the top 10 countries responsible for 60% of the world’s premature births.1,2

The burden of perinatal morbidity and mortality extends to mothers as well. Since 1990, maternal mortality in this country has nearly doubled. Of approximately 4 million U.S. women each year who give birth, about 52,000 experience severe complications and 500-600 die of these complications. Of these maternal deaths, approximately one-half are preventable. Leading causes of these maternal deaths include thromboemboli, obstetric hemorrhage, and severe hypertension or preeclampsia.3,4

Of the 6.6 million pregnancies that occur in the U.S. each year, 3.4 million (51%) are unintended, occurring disproportionately in non-Hispanic black women, unmarried women, and women with less education and financial stability.5,6 Intendedness of pregnancy and birth spacing of approximately 2 years are linked to improved pregnancy outcomes. Care before, during, and between pregnancies—including reproductive life planning, optimization of nutrition and exercise, folic acid supplementation, screening for and management of chronic diseases, immunizations, management of infectious diseases, and attention to psychological and behavioral health—contributes to more favorable maternal and child outcomes.2

Sexual/gynecologic health

Sexually transmitted infections (STIs), when untreated, can increase the risk for contracting other STIs, including HIV infection, and lead to other reproductive health problems such as cervical cancer and infertility. STI rates are highest among individuals younger than 25 years, with more than 70% of gonorrhea and chlamydia cases occurring in women in this age group. Gynecologic problems are among the most common health-related complaints for reproductive-aged women. Of the top 10 sites of cancer occurrence in the U.S. population, 3 are woman specific. Lung and bronchial cancers are the leading cause of cancer death among women aged 34-85 years, but breast cancer is more commonly diagnosed and ranks as the second leading cause of cancer death. Recommended screenings can help detect infections that compromise reproductive health, as well as breast, cervical, colorectal, and other cancers, at earlier, more treatable stages.7

Women’s health across the lifespan

Both male and female life expectancies have increased over the years, with women now living approximately 4.8 years longer than men. However, female mortality rates have increased in more than 40% of U.S. counties, as compared with an increase in male mortality in only 3.4% of U.S. counties.7 Although women’s longevity outpaces that of men in all age groups, the most impoverished 40% of women, relative to the previous generation of women, are seeing life expectancy decline.8

While women live longer than men, they are not necessarily healthier.9Women are more likely than men to report activity limitations, with 70% of women older than 65 years reporting such limitations. The most commonly reported causes of activity limitations include back and neck problems, arthritis, depression, anxiety or emotional health problems, bone injuries, and weight problems. Overall, heart disease, cancer, and stroke are the leading causes of death in women, followed by chronic lower respiratory disease and Alzheimer’s disease. Overweight and obesity are key contributors to increased risk for chronic disease, including hypertension, type 2 diabetes mellitus, cardiovascular disease, liver disease, arthritis, cancer, and reproductive health disorders. In addition to chronic disease, women experience higher rates of mental illness than do men,10 with suicide recognized as one of the top 10 causes of death in women aged 18-64 years. Physical, behavioral, and mental health problems affecting women require recognition of gender-related differences in symptoms, diagnostic considerations, and treatment decisions.

More than one-third of women have experienced physical violence at the hands of an intimate partner, and 20% of homicides are directly related to intimate partner violence (IPV). IPV, the most common cause of violence-related deaths among 40- to 44-year-olds, is associated with long-term effects on physical, emotional, and sexual health.11 Despite increased attention on the effects of violence against women in their homes, their communities, within the military, and on college campuses, effective screening for such violence remains uneven in healthcare settings. Major HCP organizations, including the National Association of Nurse Practitioners in Women’s Health (NPWH), support universal screening for IPV and other forms of violence against women.

Importance of the well-woman visit

Although the snapshot of women’s health presented in this column may be somewhat disturbing, we can take this opportunity to sharpen our focus and improve the picture now. The well-woman visit (WWV) is designed to make a difference by helping patients identify their personal health risks, access healthcare appropriate to their own needs, and receive support in achieving their goal to be as healthy as possible. The WWV gives women a chance to partner with their HCP in order to do the following:

Access recommended health screenings and assessments;

Recognize and address emerging personal and/or family risk factors that may have direct impact on their present and future health status;

Attend to physical, emotional, behavioral, and environmental factors that affect health and well-being; and

Identify personal health goals and the strategies to achieve these goals.

These key components of the WWV directly address the many factors affecting women’s reproductive, gynecologic, and sexual health; maternal–child health outcomes; and overall health status from menarche through older adulthood. Under the Affordable Care Act, basic women’s preventive healthcare is covered with no cost-sharing (e.g., copayments, co-insurance, deductible costs) to the woman. The well-woman preventive care visit is defined as occurring “annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care….”12 In general, the WWV occurs once a year, although the U.S. Department of Health and Human Services recognizes that, depending on a woman’s health status, health needs, and other risk factors, several visits may be needed within a year to obtain all necessary recommended preventive services.12 The Table lists examples of the types of services that are available as part of the WWV without co-pays, co-insurance, or deductible costs to the woman.12,13


A woman’s physical and emotional health is influenced by biologic, psychosocial, behavioral, and environmental factors. In addition, the impact of gender differences on the manifestations of chronic disease and mental illness cannot be overlooked. Although events such as Mother’s Day, Women’s Health Week, Breast Cancer Awareness Month, American Heart Month, and other awareness campaigns serve to remind us of the importance of attention to women’s health, they cannot be the sole driver of our focus. Like the components of the WWV, women’s health is addressed and improved in a variety of steps, over time. In order to improve women’s health, regardless of life stage, women’s issues must be a key consideration in every policy decision—education, economics, and, of course, healthcare. In crafting policy related specifically to women’s health issues, one must consider how such policies…

Affect the overall health status of women;

Affect women’s access to and acquisition of high-quality primary and specialty healthcare through the life span—care that is delivered by women’s health-focused HCPs within the context of their patients’ personal, religious, cultural, and family beliefs14; and

Leverage the expertise of multiple types of gender-focused HCPs, including OB/GYN physicians, women’s health nurse practitioners, certified nurse-midwives and certified midwives, women’s health and perinatal clinical nurse specialists, and other HCPs working in women’s health by convening more comprehensive task forces, commissions, and other panels assembled to inform policy. =

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri-St. Louis, a consultant at Health Policy Advantage, LLC, in St. Louis, Missouri, and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH). She can be reached at 314-629-2372 or at sue@healthpolicyadvantage.com.


  1. Save the Children. State of the World’s Mothers 2014. Westport, CT: Save the Children; 2014.

2. Partnership for Maternal, Newborn & Child Health. Born Too Soon: The Global Action Report on Preterm Birth. Geneva, Switzerland: World Health Organization; 2012.

3. UNFPA. Trends in Maternal Mortality:1990-2010. Geneva, Switzerland: WHO; 2012.

4. The National Maternal Health Initiative. The Burden of Maternal Mortality and Morbidity in the United States.

Rockville, MD: HRSA Maternal Child Health Bureau; 2014.

5. Mosher WD, Jones J, Abma JC. Intended and unintended births in the United States: 1982-2010. Natl Health Stat Rep. 2013;24(55):1-28.

6. Guttmacher Institute. Unintended Pregnancy in the United States. December 2013. www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

7. U.S. Department of Health and Human Services. Health Resources and Services Administration. HRSA Maternal Child Health Bureau. Women’s Health USA 2013. http://mchb.hrsa.gov/whusa13/dl/pdf/hs.pdf

8. Bosworth BP, Burke K. Differential Mortality and Retirement Benefits in the Health and Retirement Study. April 8, 2014. www.brookings.edu/research/papers/2014/04/differential-mortality-retirement-benefits-bosworth

9. Kaiser Family Foundation. The role of Medicaid and Medicare in women’s health care. JAMA. 2013;309(19):1984. http://jama.jamanetwork.com/article.aspx?articleid=1687586

10. Substance Abuse and Mental Health Services Administration. Results From the 2010 Survey on Drug Use and Health: Mental Health Findings. 2011. www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm

11. Office of the Assistant Secretary for Planning and Evaluation. Screening for Domestic Violence in Health Care Settings. Washington, DC: USDHSS; 2013.

12. U.S. Department of Health and Human Services. Health Resources and Services Administration. Women’s Preventive Services Guidelines. www.hrsa.gov/womensguidelines/

13. Institute of Medicine. Clinical Services for Women: Closing the Gaps. Washington, DC: National Academies Press; 2011.

14. National Association of Nurse Practitioners in Women’s Health (NPWH). Mission Statement. 2014. www.npwh.org/i4a/pages/index.cfm?pageid=3333


Human papillomavirus (HPV)*

As parents, you do everything you can to protect your children’s health for now and for the future. Today, there is strong weapon to prevent several types of cancer in our kids: the HPV vaccine.

HPV and cancer

HPV is short for human papillomavirus, a common virus. In the United States each year, there are about 17,000 women and 9,000 men affected by HPV-related cancers. Many of these cancers could be prevented with vaccination. In both women and men, HPV can cause anal cancer and mouth/ throat (oropharyngeal) cancer. It can also cause cancers of the cervix, vulva, and vagina in women; and cancer of the penis in men.

For women, screening is available to detect most cases of cervical cancer with a Pap smear. Unfortunately, there is no routine screening for other HPV-related cancers for women or men, and these cancers can cause pain, suffering, or even death. That is why a vaccine that prevents most of these types of cancers is so important.

More about HPV

HPV is a virus passed from one person to another during skin-to-skin sexual contact, including vaginal, oral, and anal sex. HPV is most common in people in their late teens and early 20s. Almost all sexually active people will get HPV at some time in their lives, though most will never even know it. Most of the time, the body naturally fights off HPV, before HPV causes any health problems. But in some cases, the body does not fight off HPV, and HPV can cause health problems, like cancer and genital warts. Genital warts are not a life-threatening disease, but they can cause emotional stress, and their treatment can be very uncomfortable. About 1 in 100 sexually active adults in the United States has genital warts at any given time.

HPV vaccination is recommended for pre-teen girls and boys at age 11 or 12 years

HPV vaccine is also recommended for girls aged 13 through 26 years and for boys aged 13 through 21 years who have not yet been vaccinated. So if your son or daughter hasn’t started or finished the HPV vaccine series—it’s not too late! Talk to his or her healthcare provider (HCP) about getting the series for your child now. Two vaccines—Cervarix and Gardasil—are available to prevent the HPV types that cause most cervical cancers and anal cancers. One of the HPV vaccines, Gardasil, also prevents vulvar and vaginal cancers in women and genital warts in both women and men. Only Gardasil has been tested and licensed for use in males. Both vaccines are given in a series of 3 shots over 6 months. The best way to remember to get your child all three shots is to make an appointment for the second and third shot before you leave the HCP’s office after the first shot.

Is the HPV vaccine safe?

Yes. Both HPV vaccines were studied in tens of thousands of people around the world. More than 57 million doses have been distributed to date, and there have been no serious safety concerns. Vaccine safety continues to be monitored by the CDC and the FDA. These studies continue to show that HPV vaccines are safe.

The most common side effects reported are mild. They include pain where the shot was given (usually the arm), fever, dizziness, and nausea.

You may have heard that some kids faint when they get vaccinated. Fainting is common with preteens and teens for many health-related procedures, not just the HPV shot. Be sure that your child eats something before going to get the vaccine. It’s a good idea to have your child sit or lie  down while getting any vaccine, and for 15 minutes afterwards, to prevent fainting and any injuries that could happen from fainting.

The HPV vaccine can safely be given at the same time as the other recommended vaccines, including the Tdap, meningococcal, and influenza vaccines. Learn more about all of the recommended pre-teen vaccines at www.cdc.gov/vaccines/teens.

Help paying for vaccines

The Vaccines for Children (VFC) program provides vaccines for children aged 18 years or younger who  are under-insured, not insured, Medicaid-eligible, or American Indian/Alaska Native. Learn more about the VFC program at www.cdc.gov/Features/VFCprogram/.

Whether you have insurance, or your child is VFC-eligible, some HCPs’ offices may also charge a fee to give the vaccines.

For more information about the vaccinesrecommended for pre-teens and teens:800-CDC-INFO (800-232-4636) http://www.cdc.gov/vaccines/teens


Effective communication regarding advanced care planning and end-of-life care options

Advanced care planning is a process used by patients, caregivers, and healthcare providers (HCPs) to establish goals for end-of-life (EOL) care.1 Patients who receive EOL care that is inconsistent with their wishes are likely to be dissatisfied with this care and consume large amounts of healthcare resources.2 Studies have shown that many EOL care discussions are ineffective because of poor patient–HCP communication and the patient’s lack of sufficient understanding of EOL care options.1 This article provides an overview of the consequences of poor communication and a guideline for nurse practitioners regarding the best evidence-based practices for discussing EOL care options most effectively with patients.

Key words: advanced care planning, end-of-life care, cardiopulmonary resuscitation, advance directive

The U.S. Census Bureau reports that by 2030, 72 million Americans will be aged 65 years or older; these individuals will represent 20% of the pop­ula­tion.3 As a result, one might reasonably expect that more and more healthcare providers (HCPs), patients, and caregivers would be focusing their attention on advanced care planning (ACP) and end-of-life (EOL) care options. However, current research indicates that conversations about ACP and EOL care options are infrequent and that many HCPs lack sufficient training and/or experience to effectively communicate with patients about these topics.4

Many HCPs report difficulty in initiating EOL care discussions,1 and many patients report that their HCPs display discomfort during these discussions.4 Patients want their HCPs to be honest with them.5 Most older persons are well prepared for the event of death (i.e., they have prepared a will), but not for the dying process (i.e., they have not completed ACP).4 Ineffective communication about EOL care options may lead to an overestimation of cardiopulmonary resuscitation (CPR) survival rates, decreased satisfaction among caregivers, and, ultimately, a dying experience that goes against the patient’s wishes.

Consequences of ineffective communication

Inaccurate or inadequate information—Most HCPs use verbal descriptions to discuss ACP and EOL care, including terms such as cardiopulmonary resuscitation or CPR, intubation, and mechanical ventilation. These terms may be difficult for some patients to conceptualize.1 Poor understanding about ACP and EOL care may prompt some patients to seek information elsewhere—for example, on television or on the Internet. As a consequence, some patients may make ACP and EOL decisions based on inaccurate information.6 Even if HCPs do engage in a conversation about ACP with their patients, these conversations may not take place early enough or often enough.4

According to the Pew Research Internet Project, 30% of adults aged 65+ and 54% of those aged 50-64 have looked online for health information in the past year (vs. 67% of adults aged 30-49 and 72% of adults aged 18-29).7 Other studies have shown that up to 92% of persons older than 62 years get health information from TV.6 In a classic study evaluating the influence of the media on healthcare decisions, investigators reviewed 97 episodes of medical TV dramas.8 In these episodes, 75% of “patients” undergoing CPR were successfully resuscitated. This fictional survival rate is a stark contrast to reality. The overall survival rate of intra-hospital CPR is only about 15% but can be as low as 0%-1% in seniors with terminal stages of cancer.8 The media’s misinformation leads people to base decisions on inaccurate information. If HCPs have better communication skills and timing, patients will no longer need to rely on the media as a main source of health information.

Overestimation of CPR outcomes—When patients do not receive accurate information about CPR, they tend to overestimate rates of survival and retention of good neurologic function related to its performance. Most in-hospital patients with full code status orders cannot identify the three steps of intra-hospital CPR: defibrillation, chest compressions, and intubation with mechanical ventilation.9 If patients are considered a full code, they are designated to receive
all three of these components. Among 100 patients in a medical intensive care unit who were surveyed, only 4 could identify all three components of CPR.9 Patients were also asked about the overall likelihoods of surviving CPR and retaining good neurologic function following CPR. They predicted an overall survival rate without loss of good neurologic function to be 71.8% (range, 10%-100%), even though the actual survival rate of in-hospital CPR is only 15%. The likelihood of leaving the hospital after CPR with good neurologic function is 14%.

In this study by Gehlbach et al,9 the higher the patients predicted the survival rate of CPR to be, the greater the likelihood that they would prefer to receive CPR. When patients were informed about actual survival rates and potential consequen­ces of CPR, several were less interested in receiving CPR. After the interviews, patients’ health records were assessed for documentation of code status. Ninety-eight of the 100 patients had documentation of code status in their chart. Of these, 16 discrepancies were found between code status preference expressed during the interview and the code status order in the chart; 10 of the 16 cases preferred less treatment and 6 preferred more.

Patients’ inadequate knowledge of CPR and its possible outcomes leads to an excessively
favorable view of potential outcomes. Few HCPs discuss success rates of CPR,9 an oversight that may lead to discrepancies between patients’ wishes and actual code status orders. When patients are fully informed about CPR and its potential outcomes, they are less likely to prefer it. This same correlation has been noted among non-hospitalized patients. If HCPs educate their patients and are mindful of their learning preferences and needs, code status discrepancies might be avoided.

Decreased satisfaction among caregivers—Many caregivers indicate that HCPs are not forthcoming enough with regard to the reality of a patient’s prognosis, and that the timing of the EOL care discussion is often not early enough.10 Caregivers ask that HCPs stop worrying about “failing” to cure patients’ incurable diseases and, instead, provide them with accurate and timely information so that they can prepare emotionally and physically for tending to patients’ EOL care needs (e.g., saying their goodbyes, preparing for funeral arrangements).10,11

How to improve communication

Because communication with patients and their caregivers regarding ACP and EOL care is often ineffective, HCPs need to hone their communication skills.12 Although many passive strategies are being implemented in undergraduate programs, interactive approaches such as workshops for HCPs and videos for patients have proved to be more useful.

Workshops for HCPs—Participating in workshops that focus on communication skills may improve ACP and EOL care. In an illustrative study, a total of 115 medical oncology fellows participated in a workshop entitled Oncotalk that emphasized communication skills practice.13 The fellows were evaluated pre- and post-retreat with respect to their skills in conveying bad news to simulated cancer patients and transitioning these patients from curative to palliative care. Overall, the fellows gained 10 new communication skills, including the ability to remain silent for 10 seconds after delivering bad news and the ability to use empathetic statements. For example, after receiving bad news, the patient was cued to ask, “Is there any hope for a cure?” Prior to the retreat, fellows responded by immediately offering new anticancer therapies, even if those therapies had no chance of working. After the retreat, fellows had learned how to express regret that no cure was available and wishing that there were a cure. Although this workshop was limited to oncology fellows, the authors of this article believe that the findings can be generalized to all patient populations for whom HCPs’ communication skills are needed to address bad news. However, additional studies are needed to confirm this belief.

Videos for patients—Verbal descriptions of complex health interventions may be difficult for patients to conceptualize. Use of videos can improve patients’ understanding of potential health situations, increase their preference for comfort measures when nearing the end of life, and decrease their uncertainty regarding EOL care decisions.1 In a recent study, 50 patients with malignant glioma were randomized to either a verbal narrative of EOL care options (control) or a video after the same verbal narrative (intervention).1 The 6-minute video depicted three levels of medical care: life-prolonging care (CPR, ventilation), basic care (hospitalization, no CPR), and comfort care (symptom relief). To depict these three respective levels of care, the video presented images of a patient on a ventilator and a simulated code, a patient receiving antibiotics through a peripheral intravenous line and oxygen via a nasal cannula, and a patient at home receiving pain medication and assistance from a nurse’s aide.

After the interventions, the two groups were asked which level of care they would prefer when they were near the end of life (Figure 1). Among the controls, 25.9% preferred life-prolonging care, 51.9% preferred basic care, and 22.2% preferred comfort measures. Among the intervention group, none preferred life-prolonging care, 4.4% preferred basic care, 91.3% preferred comfort measures, and 4.4% were uncertain. Intervention group participants reported feeling very comfortable viewing the video, and they recommended that the video be shown to other patients with cancer. Results of this study verified that when patients have a better understanding of healthcare options, they are more likely to choose less aggressive treatment. At the bottom of this page, readers can click on an example of the type of video on ACP that patients can view in the waiting room or the examination room.

Appropriate timing and setting

Fewer than 20% of patients with an impaired capacity for decision making have completed advance directives—the written portion of ACP. Many patients initially discuss ACP with an HCP during a hospital admission for an acute episode. Research suggests that anxiety related to hospitalization hinders patients’ ability to make complex health-related decisions such as completing advance directives.4 In addition, patients feel uneasy when discussing ACP with HCPs (e.g., a hospitalist) other than their primary care practitioner (PCP).4

Initiating ACP discussions during well-patient visits with patients’ PCP is preferable.4 Just as PCPs rely on milestones to initiate certain conversations in the pediatric population, PCPs can designate milestones that trigger the need for ACP discussions with adults—for example, when they reach a certain age or when they receive a diagnosis of a potentially life-threatening disease. Because patients may become incapacitated at any time and without warning, PCPs should have open and ongoing communication with patients about their EOL care wishes. These well-timed conversations might help patients avoid a dying experience that goes against their wishes.

Recognizing and responding to patients’ emotional concerns

Patients may readily discuss their ACP concerns with their HCP, but it is often the HCP who is responsible for initiating this conversation. Communication techniques such as using open-ended questions, allowing adequate time for patients to speak, and showing empathy encourage patients to express their concerns. In addition, patients give cues that they have concerns about EOL care; for example, they may describe themselves as unsure or fearful. HCPs need to recognize these cues and understand that these patients may need more information and/or emotional support.5

Proposed guidelines

Based on the evidence presented, the authors suggest that HCPs seek out workshops focused on improving ACP and EOL communication with patients. Workshops have been shown to enhance HCPs’ communication skills. In addition, HCPs should assess each patient’s learning needs; patients may respond preferentially to audio-visual aids, repetition, or written information. EOL care discussions can occur during patients’ annual visits beginning in adulthood or with the diagnosis of a potentially life-ending disease. These conversations can be revisited at regular intervals to ensure continuing understanding of patients’ wishes. By using appropriate communication tools, HCPs can improve patient and family satisfaction, increase the public’s general knowledge regarding ACP and EOL care options, and decrease the potential for unwanted dying experiences.


Evidence to date suggests that communication among patients, caregivers, and HCPs regarding ACP and EOL care options is inadequate. Many patients do not comprehend the language used when EOL care is described and they do not know the facts about CPR. However, once they learn about the steps involved in CPR and about possible complications resulting from this intervention, many individuals will choose to abstain from extreme resuscitative measures.

Nurse practitioners’ holistic approach to patient care, along with their eagerness to learning new communication skills, makes them ideal HCPs to lead discussions about ACP and EOL care with patients. Participating in workshops has been shown to improve communication with patients regarding ACP and EOL care. Using videos to enhance discussions with patients has also been shown to be beneficial. Utilizing empathetic communication techniques, asking open-ended questions, and giving patients adequate time to speak also promote effective communication regarding ACP and EOL care (Figure 2).

Lori Abney, Amanda Burks, and Whitney Pitman are family nurse practitioners (FNPs) in Louisville, Kentucky. Jaclyn Taylor is an FNP in Hilton Head Island, South Carolina. Nancy Kern is an assistant professor at Spalding University School of Nursing in Louisville, Kentucky. Lois Obert is a market educator for Take Care Health Systems. Ann Lyons is a professor and coordinator of the MSN nurse practitioner program at Spalding University School of Nursing in Louisville, Kentucky.


1. El-Jawahri A, Podgurski LM, Eichler AF, et al. Use of video to facilitate end-of-life discussions with patients with cancer: a randomized controlled trial. J Clin Oncol. 2010;

2. Heyland DK, Frank C, Groll D, et al. Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members. Chest. 2006;130(2):419-428.

3. United States Census Bureau. 2012 National Population Projections. Summary Tables. http://www.census.gov/population/projections/files/summary/NP2012-T2.xls

4. Malcomson H, Bisbee S. Perspectives of healthy elders on advance care planning. J Am Acad Nurse Pract. 2009;21(1):18-23.

5. Back AL, Anderson WG, Bunch L, et al. Communication about cancer near the end of life. Cancer. 2008;113(7 suppl):1897-1910.

6. Cadogan MP. CPR decision making and older adults: clinical implications. J Gerontol Nurs. 2010;36(12): 10-15.

7. Pew Research Internet Project. Health Fact Sheet. 2014. http://www.pewinternet.org/fact-sheets/health-fact-sheet/

8. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. N Engl J Med. 1996;334 (24):1578-1582.

9. Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, et al. Code status orders and goals of care in the medical ICU. Chest. 2011;139(4): 802-809.

10. Cherlin E, Fried T, Prigerson HG, et al. Communication between physicians and family caregivers about care at the end of life: when do discussions occur and what is said. J Palliat Med. 2005;8(6): 1176-1185.

11. Csikai EL. Bereaved hospice caregivers’ perceptions of the end-of-life care communication process and the involvement of health care professionals. J Palliat Med. 2006; 9(6):1300-1309.

12. Hales BM, Hawryluck L. An interactive educational workshop to improve end of life communication skills. J Contin Educ Health Prof. 2008;28(4):241-255.

13. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167

Expanding the NP role in the cervical cancer prevention triad: Screening, diagnosis, and treatment

Great strides  have been made in reducing the incidence of invasive cervical cancer in the United States. As of 2010, 24 states had achieved the Healthy People 2020 goal of reducing the incidence of this disease to 7.1 per 100,000 women.2 In 2010, 83% of U.S. women underwent the recommended cervical cancer screening.2 

Although these achievements merit celebration, new strategies are needed to reach women who remain at risk. Approximately half of cervical cancers occur in women who have never been screened.1 Many of these women are poor, reside in rural areas, and lack access to primary care providers.3Since 1991, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has provided free services to more than 4.5 million women, diagnosing more than 3,400 invasive cervical cancers.4 Women eligible for this program—about 10% of U.S. women—live at or below 250% of the federal poverty level. However, the NBCCEDP reaches only 8.2% of eligible women, and certain populations of women still suffer from a higher incidence of cervical cancer despite these efforts.

Barriers to cervical cancer screening and treatment are complex, and comprise psychosocial, socioeconomic, and cultural factors.5,6 Healthcare providers (HCPs) must understand the circumstances contributing to patients’ health beliefs and behaviors, and try to foster a constructive therapeutic partnership emphasizing empowerment, agency, and informed decision-making. These principles guide advanced practice nurses (APNs) as they provide screening, diagnostic services (colposcopy and cervical biopsy), and treatment (cryotherapy and the loop electrosurgical excision procedure [LEEP]) for precancerous cervical lesions.

Increased APN involvement may be a reasonable approach for reducing the incidence of cervical cancer in the United States. Although nurse practitioners (NPs) have gained acceptance as providers of cervical cancer screening, these HCPs are capable of playing a more prominent role by participating in the entire cervical cancer prevention triad: screening, diagnosis, and treatment. Now is the time to re-examine the NP role in this regard.

Frontline primary care providers

Nurse practitioners are ideal clinicians to provide full cervical cancer prevention services. With 89% of NPs prepared in primary care and 75% actively providing primary care nationwide, NPs are the most rapidly growing population of the primary care workforce.7 By contrast, according to Naylor and Kurtzman,8 primary care medical residency programs decreased by 3% from 1995 through 2006 (over this same period, primary care programs for NPs increased by 61%). In addition, compared with primary care physicians, NPs are more likely to work in rural areas and with underserved populations.9

Evidence indicates that NPs provide quality care at a lower cost than their physician colleagues.10 An extensive literature review showed that NPs  provide equal or better quality care at a lower cost compared with other practitioners providing the  same services. 10 NPs are consistently cost efficient  across diverse practice settings, including managed  care organizations, nurse-managed centers,  health management organizations, on-site NP  practices, and acute care settings.11

Competency and current state of nursing practice

Screening—NPs are the main providers of primary care in family planning clinics and they perform  the majority of primary care services, including  cervical cancer screening, in these clinics.12  Cervical cancer screening is a well-accepted aspect of NP scope of practice.13

Diagnosis—Less well established is the NP role in providing follow-up care to women with abnormal Pap test findings, even though NPs are in a pivotal position to do so. Research indicates that they can perform colposcopy and diagnostic procedures as competently as their physician colleagues. A 2012 study conducted by Kilic et al14 to compare physician and NP accuracy in recognizing cervical dysplasia during colposcopy showed that these two groups of HCPs were similarly capable. Studies conducted in the United Kingdom and New Zealand reached similar conclusions.15-17

In the United States, APNs who complete training courses and demonstrate competency in colposcopy  through programs such as the American Society for Colposcopy and Cervical Pathology  (ASCCP) Comprehensive Colposcopy Education and Mentorship Program may perform colposcopy  in their clinical practice, pending permission of  the state and medical facility. At the time of this  article’s publication, nearly 500 individuals will have completed the ASCCP Mentorship since its inception, and almost 90% of enrollees are advanced  practice clinicians (nurse-midwives, NPs,or physician assistants).18

Treatment for precancerous lesions—Since the  1980s, NPs have been performing cryotherapy as  part of cervical cancer prevention programs. 19 The ASCCP  also provides training  in LEEP to NPs  who can incorporate  this skill into their  practice, depending  on institutional policies. 20 No state regulations prevent NPs  from performing treatment of precancerous cervical lesions, although states may require extra documentation and education demonstrating competency.18 Further research is necessary to ascertain NP efficacy at cryotherapy and LEEP when compared with physicians.

Benefits of nursing practice and the cervical cancer prevention triad

More innovative and thoughtful approaches incorporating an in-depth understanding of women’s cultures and communities are needed to decrease the incidence of cervical cancer in the United States. This understanding, in and of itself, is an essential aspect of nursing practice. Furthermore, health education, cultural competency, and collaboration of care are key areas of competency for NPs.21 Collaboration of care emphasizes therapeutic partnerships that empower women with the information and agency to make informed decisions  regarding their health.21

Considering the intimate nature of pelvic examinations, HCPs must provide psychosocial support  and ample consultation time to establish a rapport with each patient and maximize her comfort level. In a 2010 study of cervical cancer screeningpractices of women in Appalachian West Virginia, Grube22 found the patient–HCP relationship to be  integral to a woman’s decision to pursue screening.  Time dedicated to building a bond with a patient helps HCPs understand each woman’s unique circumstances and determine a realistic follow-up plan. Research indicates that patients who see an NP not only have longer consultations, but also benefit from the NP’s distinctly applicable skill set to provide respectful, patient-centered care.8

Changing nursing practice: Formalize and normalize the APN role in cervical cancer  prevention

Enabling more NPs to provide the full triad of cervical cancer prevention services may not only be  cost effective and ensure greater access to care for women everywhere but may also address barriers to reaching unscreened and under-screened women and those lost to follow-up. To achieve this goal, the APN role in diagnosis and treatment of cervical cancer needs to be formalized through inclusion of relevant skills in the standard APN curriculum. In the current state of colposcopy education, an APN is advised to wait for 2 years after graduation before entering a short-study colposcopy program, which lacks both a standardized clinical component and a mechanism for determining safe practice upon completion. No data were found supporting the need for 2 years of clinical practice before undertaking colposcopy training, and positioning this education after graduation from a formal  APN program might decrease the likelihood of enrollment. Placing colposcopy skill training on a continuing education (CE) level suggests that this service or skill is not fundamental to practice. Of note, though, courses on intrauterine contraception and endometrial biopsy that were initially offered as CE sessions have now become solidly integrated into basic graduate curricula, resulting in more widespread student comfort in clinical skills.

In a similar type of evolution, creation of a semester- long course in colposcopy and management modalities could ensure that APNs receive detailed classroom instruction, participate in simulation labs, and complete a clinical preceptorship that would enable them to integrate didactic knowledge and develop their skills. If colposcopy education were part of a standard curriculum, students might be more likely to acquire education loans and expert clinicians might be more likely to link with university programs and serve as clinical preceptors. Examinations and clinical evaluations would serve as a means to assess successful completion of such a program.

Support from professional organizations is needed to normalize these skills as part of the NP scope of practice and facilitate acceptance of NPs providing services, especially in low-resource settings. Elimination of cervical cancer is an ambitious goal, but one that can be realized. A key way to  make progress toward reaching this goal is by capacitating NPs in the cervical cancer prevention  triad to help ensure that women nationwide have access to comprehensive, high-quality, and compassionate care. =

Keri E. Zug is a WHNP Candidate and Wendy D.  Grube is Practice Assistant Professor and Director, Women’s Health/Gender Related Nurse Practitioner Program, both at the University of Pennsylvania School of Nursing in Philadelphia. The authors state that they have no financial interest in or other relationship with any commercial product named in this article.


1. The Oncology Policy Resource Center. Women in Government. 2010 State Report on Cervical Cancer Prevention. 2010. www.womeningovernment.org/oncology/hpv/state_report/2010

2. Henley SJ, Singh S, King J, et al. Invasive cancer incidence—United States, 2010. MMWR Morb Mortal Wkly Rep. 2014;63(12):253-259. www.cdc.gov/mmwr/preview/mmwrhtml/mm6312a1.htm

3. Schulz M, Cukr P, Ludwick R. Developing a community based screening program: commitment to the underserved. J Am Acad Nurse Pract. 1999;11(6):249-252.

4. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Updated March 7, 2014. www.cdc.gov/

5. Hatcher J, Studts CR, Dignan MB, et al. Predictors of cervical cancer screening for rarely or never screened rural Appalachian women. J Health Care Poor Underserved. 2011;22(1):176-193.

6. Ackerson K, Gretebeck K. Factors influencing cancer screening practices of underserved women. J Am Acad Nurse Pract. 2007;19(11):591-601.

7. American Association of Nurse Practitioners. Nurse Practitioners in Primary Care. Updated 2013. www.aanp.org/

8. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Aff. 2010;(29)5:893-899.

9. Hooker, RS, Berlin, LE. Trends in the supply of physician assistants and nurse practitioners in the United States. Health Aff. 2002;21(5):174-181.

10. Bauer JC. Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. J Am Acad Nurse Pract. 2010;22(4):228-231.

11. American Association of Nurse Practitioners. Nurse Practitioner Cost Effectiveness. 2013. www.aanp.org/images/documents/publications/costeffectiveness.pdf

12. Wysocki S. Nurse Practitioners and Women’s Health Care. January 7, 2009. www.npwh.org/files/public/Transition%20Team.pdf

13. Brown S, Grimes, D. A meta-analysis of nurse practitioners and nurse midwives in primary care. Nurs Res. 1995;44(6):332-339.

14. Kilic G, England J, Borahay M, et al. Accuracy of physician and nurse practitioner colposcopy to effect improved surveillance of cervical cancer. Eur J Gynaecol Oncol. 2012;33(2):183-186.

15. Hartz L. Quality of care by nurse practitioners delivering colposcopy services. J Am Acad Nurse Pract. 1995; 7(1):23-27.

16. McPherson G, Horsburgh M, Tracy C. A clinical audit of a nurse colposcopist. Colposcopy: cytology: histology correlation. Nurs Prax N Z. 2005;21(3):13-23.

17. Jolley S. Quality in colposcopy. Nurs Stand. 2004; 18(23):39-44.

18. Huff, B. Can advanced practice clinicians perform loop electrosurgical excision procedures and cryotherapy? J Low Genit Tract Disease. 2005;9(3):143-144.

19. Blumenthal PD. Treatment with cryotherapy by midlevel clinicians in low-resource settings. Int J Gynecol Obstet. 2003;83(3 suppl):3. Abstract.

20. American Society for Colposcopy and Cervical Pathology. Loop Electrosurgical Excision Procedure. Updated 2014. http://www.asccp.org/Education/Meetings-and-Courses/Loop-Electrosurgical-Excision-Procedure-LEEP

21. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women’s Health. April 2002. www.aacn.nche.edu/education-resources/npcompetencies.pdf

22. Grube W. Talk and backtalk: negotiating cervical cancer screening among Appalachian women in West Virginia [dissertation]. Philadelphia, PA: University of Pennsylvania; 2010.

Assessment and management of patients with obesity

Obesity is a disease, not a condition resulting from ill-advised behavioral choices. 1 After all, obesity meets the essential criteria of a disease: It has characteristic signs or symptoms; it manifests as an impairment in the normal functioning of some aspect of the body; and it results in harm or morbidity. As such, healthcare providers (HCPs) need to identify obesity in their patients, assess each patient’s risk for obesity-related complications, begin the weight-loss discussion in a thoughtful and constructive manner, and institute an individualized management plan.

Definitions and prevalence

Obesity can be defined as a body mass index (BMI) ?30 kg/m2 or it can be suggested by a waist circumference (WC) >35 inches (in women).2 But obesity is more than just a calculation or a measurement; it is a primary disease entity that can lead to cardiometabolic, biomechanical, and other complications (Figure 1).3,4CNER_Figure 1













Here is a number that matters: Almost 80 million U.S. adults—almost 35% of the adult population in this country—meet criteria for obesity,5 with certain geographic areas and certain ethnic groups overrepresented. Prevalence of obesity is higher in southern states and some Midwestern states than in other parts of the country,6 as illustrated by this CDC map. Non-Hispanic blacks have the highest age-adjusted rate of obesity (47.8%), followed by Hispanics (42.5%), non-Hispanic whites (32.6%), and non-Hispanic Asians (10.8%).5 Although overall obesity prevalence is similar in women and men at any given age, women have a higher prevalence of class II obesity (BMI, 35.0-39.9) and class III obesity (BMI ?40).7

Risk assessment

Given the high prevalence of obesity, HCPs will likely encounter many patients in their practices who are candidates for weight management. In each case in which obesity is identified, the first step needed is to assess the patient’s risk for obesity-related complications. This assessment includes calculating BMI, measuring WC, and screening for the presence of cardiovascular disease (CVD) risk factors and co-morbidities.8 Compared with body weight alone, BMI is a better, albeit indirect, measure of adiposity, which is associated with a host of cardiometabolic abnormalities. WC, an indicator of abdominal adiposity, should be measured in patients with a BMI ?35 (the WC cutoff of >35 inches in women adds little predictive value in those with a BMI >35), including those who are overweight (BMI, 25-29.9). Women whose WC exceeds 35 inches are at increased risk for developing hypertension (HTN), type 2 diabetes mellitus (T2DM), and CVD.

Therefore, HCPs need to check patients’ blood pressure (BP) to assess for HTN and order a fasting blood glucose (FBG) test, and even a 2-hour oral glucose tolerance test and HbA1c in high-risk individuals, to assess for T2DM and pre-diabetes.9 The metabolic syndrome, which increases risk for T2DM, CVD, and stroke, is identified in women by the presence of at least three of these five risk factors: WC >35 inches, triglycerides ?150 mg/dL, high-density lipo­protein cholesterol (HDL-C) <50 mg/dL, BP ?130/85 mm Hg, and FBG ?100 mg/dL.10

Some obesity-associated diseases and risk factors place patients in a very-high-risk category for subsequent mortality.8 Patients with obesity and co-morbid coronary heart disease (CHD), other atherosclerotic diseases, T2DM, metabolic syndrome, pre-diabetes, or sleep apnea require aggressive modification of risk factors in addition to clinical management of the co-morbid disease. Furthermore, obesity has an aggravating effect on CVD risk factors such as cigarette smoking, HTN, high concentration of low-density lipoprotein cholesterol, low concentration of HDL-C, impaired FBG, family history of premature CHD, and age ?55 years (in women). HCPs need to identify these risk factors to determine the intensity of the clinical intervention that a patient requires.
Obesity takes a toll not just in terms of its effect on CVD risk, but also on cancer risk. The Cancer Research UK study showed that women with obesity had a 25% risk of developing a weight-related cancer—including cancer
of the bowel, gallbladder, uterus, kidney, pancreas, or esophagus, as well as post-menopausal breast cancer—in their lifetime.11 Cancer risk in these women was 40% higher than that in their slimmer counterparts.

Initiating the conversation

Either a patient or an HCP can initiate the conversation regarding the need to lose weight. The situation is generally easier to handle when a patient expresses a desire to lose weight. She has already acknowledged existence of the disease—that is, the obesity—and is seeking treatment for it on her own. However, in many cases, the HCP must broach the topic, usually after a patient has come in for a routine visit and the findings from her history, physical examination, and laboratory tests indicate that steps must be taken to lower her risk for experiencing obesity-related complications—or to treat the complications that already exist.

To avoid discomfiting a patient in this situation, a panel of nurse practitioners convened by the American Nurse Practitioner Foundation (ANPF) recommends that the HCP show her objective data reflecting her disease and her risk for future complications—with an emphasis that obesity is a health problem—and then assess her motivation and readiness for change.7 In this context, the HCP and the patient need to synchronize their expectations and goals for weight loss therapy. HCPs now have reliable tools to help patients lose 5%-10% of their body weight. This weight loss may not produce the desired cosmetic outcome but will no doubt result in clinical benefits. The emphasis is on improving the health of the patient.

To inspire a patient with obesity to want to lose weight and to commit to follow a weight-loss treatment plan, the HCP can help her identify at least one compelling reason to lose weight.7 Common patient-centered reasons include (1) decreasing the risk of having a complicated pregnancy; (2) being able to play with children or grandchildren; (3) walking without becoming short of breath; (4) preventing other chronic diseases such as T2DM; and (5) improving existing weight-related complications such as sleep apnea or T2DM. Of note, some patients may not be aware of the health risks posed by obesity and will be motivated to lose weight once educated about the risks.

Approach to management

Once a patient with obesity is motivated and ready to lose weight, the HCP needs to work with her to devise a management plan. Both of them should agree on the goals of weight-loss therapy and on the purpose of long-term therapy. A realistic initial goal for many patients is a loss of 5% of body weight in 3 months. Three major management options—lifestyle modification, pharmacotherapy, and bariatric surgery—can bring about weight loss and reduce obesity-related morbidity and mortality.1 This article focuses on the first two options.

Lifestyle modification

A comprehensive weight-loss program starts with lifestyle modification comprised of dietary changes, increased activity, and behavioral control.12

Dietary changes

With regard to energy intake, the ANPF recommends a reduction of 500-1,000 kcal/day, which can be accomplished by limiting portion size, reducing fat and sugar intake, and using commercial weight-loss meal replacements.7 The patient can follow one of many diets shown to be safe and effective; examples are a low-carbohydrate diet,13 a low-fat diet,14 a Mediterranean diet,15 a low-glycemic-load diet,16 and a portion-controlled diet.17

Practical dietary tips include avoiding skipping meals and consuming small meals and between-meal snacks every 3-4 hours. With regard to food intake, moderation is the watchword. With regard to fluid intake, however, drinking eight 8-oz glasses of water a day is crucial unless contraindicated (e.g., in patients with renal failure).

Choice of a particular diet is less important than making a commitment and adhering to the diet,18 although following a regimen tailored for a co-morbidity makes sense. Because compliance is the key to success, the diet plan should accommodate the patient’s personal and cultural preferences. Regardless of the diet chosen, patients should monitor their caloric intake via a food diary and weigh themselves at least once a week.19

Increased activity

Choice of a particular activity (e.g., walking, swimming) depends on a patient’s preference and access to, say, a pool, as well as her current weight and health status. An assessment of mobility, cardiovascular (CV) status, and perhaps pulmonary function is needed before a patient embarks on a new exercise program.20 The goal is to increase energy expenditure.20 Exercising for ?150 minutes/week can lead to modest weight loss and help prevent weight regain; doubling this amount will promote more robust weight loss.21 As with food intake, patients should record their daily physical activity.

Exercise not only facilitates weight loss but also improves CV health by reducing BP, lipid levels, and visceral fat. These reductions are linked to improved glucose tolerance and insulin sensitivity in persons without diabetes and improved glycemic control in patients with T2DM.12 Enhanced physical fitness may even lessen obesity-related mortality. Of note, patients with obesity must modify their diet and increase physical activity in order to lose weight and reduce their risk for obesity-related complications. Another note: In addition to traditional exercise, patients can aim to increase energy expenditure throughout the day by reducing sedentary behaviors. For example, car owners can park twice as far from store entrances as they used to; city dwellers can walk instead of taking a bus, subway, or taxi; and office workers can use a standing desk instead of sitting at their desk.

Behavioral therapy

As applied to weight loss, behavioral therapy entails techniques for helping patients replace habits that contribute to excess weight and poor health with those that promote weight loss and good health.12 Key components of behavioral therapy include frequent encounters with HCPs, education, stimulus control, cognitive restructuring, goal-setting, self-monitoring, and social support.20 Group weight-loss programs in community settings, commercial weight-loss programs, and programs delivered by telephone, the Internet, or text message can all be effective, depending on patient preference.12


If a patient has not lost about 5% of her body weight after 3 months, or if she has lost weight but regained some, most, or all of it over time, she and her HCP should consider use of weight-loss medication as an adjunct to lifestyle modification. In some patients with severe complications who require clinically meaningful weight loss quickly, lifestyle modification and pharmacotherapy can be initiated concomitantly.


In all human beings, calorie restriction triggers various biological adaptations designed to prevent starvation.22 These adaptations may even be potent enough to reverse the initial weight-loss success achieved with lifestyle modification. In persons with obesity, additional biological adaptations function to preserve, or even increase, their highest sustained lifetime body weight. As such, more biologically-based interventions are likely to be needed to counter the compensatory adaptations that maintain a person’s highest lifetime body weight.22 Other reasons for pharmacologic intervention in facilitating weight loss include the following:

  • Appetite-suppressing medication enhances a patient’s ability to adhere to a reduced-calorie diet.
  • Addition of a weight-loss medication consistently achieves greater weight loss, and for a longer duration of time, than that achieved by the lifestyle intervention alone.
  • Medication can help achieve the degree of weight loss needed to treat obesity-related complications.
  • The American Association of Clinical Endocrinologists (AACE), the American Society of Bariatric Physicians (ASBP), the American Heart Association (AHA), the American College of Cardiology (ACC), and The Obesity Society (TOS) all recommend use of medication for patients with obesity and sufficient health risk.20,23,24

Principles for use

The FDA indication for use of weight-loss medications is a BMI ?30 or a BMI of 27-29.9 with at least one obesity-related complication. The medication should be stopped if weight loss is <5% after 12 weeks on a maximal dosage. If one agent is ineffective or poorly tolerated, a different one can be tried. All of these agents are contraindicated for use during pregnancy. Pharmacotherapy is individually tailored to each patient’s needs. More data are needed regarding the safety of combination therapy and the use of medications beyond 2 years.


Table 1 lists FDA-approved options for treating obesity.25-31Table 2. Weight-loss medications: Clinical trial information, accessible through this link, shows the results of clinical trials demonstrating the efficacy of these agents.32-39Figure 2 illustrates the comparative efficacy of these weight-loss medications.32-36,38-45
CNe_Table 1


CNE Figure 2

Guidelines for practice

The spectrum of obesity treatment guidelines ranges from those that are BMI-centric, wherein treatment indication is based on BMI and the treatment goal is to lose a given amount of weight (e.g., 5%-10%), to those that are complications-centric, wherein treatment indication is based on risk for, presence of, and severity of obesity-related complications and the treatment goal is to treat or prevent the complications.46Obesity treatment guide­lines from the National Heart, Lung, and Blood Institute (NHLBI), at one end of the spectrum, are based primarily on BMI and WC, although risk factors and co-morbidities are taken into account.8 The AACE, at the other end of the spectrum, recommends (1) evaluating patients with obesity for cardiometabolic and biomechanical complications; (2) selecting (a) therapeutic targets for improvements in complications, (b) treatment modality, and (c) treatment intensity; and (3) intensifying lifestyle and/or pharmacologic and/or surgical treatment modalities for greater weight loss if therapeutic targets for improvements in complications are not met.23Table 3 lists percentages of weight loss needed to achieve therapeutic benefits with regard to various obesity-related complications.4CNE_Table3


The AHA/ACC/TOS obesity guideline, which is closer to that of the NHLBI, recommends (1) identifying patients who need to lose weight, based on BMI and WC; (2) informing patients with CVD risk factors that lifestyle changes that produce even modest sustained weight loss of 3%-5% can result in clinically meaningful health benefits, and that greater weight loss produces greater benefits; (3) devising dietary strategies for weight loss; (4) devising a comprehensive lifestyle program that helps patients adhere to a lower-calorie diet and increase physical activity through use of behavioral strategies; and (5) selecting patients for whom bariatric surgery is advised—that is, those with a BMI ?40 or a BMI ?35 with obesity-related conditions.24 The approach of the ASBP to obesity management, which is closer to that of the AACE, focuses on treating diseases related to increased body fat and its adverse metabolic and biomechanical consequences, which may improve patient health, quality of life, body weight, and body composition.20


Obesity is a disease that requires permanent lifestyle changes. Lifestyle modification, enabled by dietary changes, increased physical activity, and behavioral therapy, is implemented first. If a patient does not reach her goals in terms of reducing her weight and her risk for obesity-related complications, medication is added. Most medications suppress appetite, enhance a patient’s ability to follow a reduced-calorie diet, and enable significantly greater weight loss than that achieved by lifestyle changes alone. In addition, medication use can help sustain weight loss and prevent weight regain over time.

For patients with obesity and obesity-related co-morbidities, weight loss is used therapeutically to treat the obesity-related complications. The role of the HCP is to diagnose the disease of obesity, assess the patient’s risk for obesity-related complications, discuss weight-loss strategies and goals with the patient, support the patient in implementing these strategies and reaching these goals, and provide regular follow-up and encouragement over the ensuing months, years, and decades.

For readers of the online issue who wish to participate in this CE program, click here.

Visit http://www.NPWomensHealthcare.com/?p=4144 for a complete list of references.


Genitourinary syndrome of menopause: The new vulvovaginal atrophy

Menopause affects many areas of a woman’s body, including vulvar and vaginal tissue. Most women present with some degree of atrophic vulvovaginal tissue changes in the years following menopause, and up to nearly half of all menopausal women are symptomatic. In 2014, a name change was proposed to include the entire genitourinary tract, not just the vulva and vagina, with regard to all the changes that occur in this area of the body as a result of menopause: genitourinary syndrome of menopause (GSM). Women’s healthcare providers have a variety of FDA-approved options to treat women presenting with symptomatic GSM, including local hormonal therapies, a nonhormonal oral tablet, and an intravaginal CO2 laser device.

For years, the terms vulvovaginal atrophy (VVA) and atrophic vaginitis have been used to describe menopause-related changes to the vulvovaginal tissue.These terms have been used despite the negative connotation of the word atrophy and the specificity to vulvar and vaginal tissue. In May 2013, two organizations, the International Society for the Study of Women’s Sexual Health (ISSWSH) and The North American Menopause Society (NAMS), came together to develop more appropriate nomenclature through a terminology consensus conference. Late last year, the more appropriate and all-encompassing term genitourinary syndrome of menopause was adopted to replace the terms vulvovaginal atrophy and atrophic vaginitis. 1 The term genitourinary syndrome of menopause, or GSM, acknowledges the full spectrum of menopause-related atrophic changes that occur within the entire genitourinary tract. 1

The terms VVA, atrophic vaginitis, and GSM are used interchangeably throughout this column. Readers will continue to see the terms vulvovaginal atrophy and atrophic vaginitis in the literature for some time because these terms were used in research completed before adoption of the term GSM.

During perimenopause and the years following, the drastic decline in circulating sex hormones, including estrogen, progesterone, and testosterone, results in changes to multiple areas of the body. Some of the more widely recognized symptoms of menopause, including hot flashes, weight gain, and mood changes, diminish over time as the body acclimates to functioning without cyclical changes in hormone levels. By contrast, the effects of the ongoing hypoestrogenic state of menopause on genitourinary tissue intensify, at least in women who do not receive any type of treatment for them. 2 Objective findings related to this hypoestrogenic state include vaginal tissue thinning, diminished elasticity, and increased friability, which can result in petechiae, fissuring, erosions, and, in severe cases, stenosis. Symptoms related to these physical changes—hat is, the symptoms of GSM—include vulvovaginal dryness, itching and burning, painful intercourse, dysuria, urinary urgency and frequency, and recurrent urinary tract infections.1

The average age of menopause in the United States is 51 years. Because life expectancy in this country continues to climb, 4 the population of menopausal women is steadily rising, and women may expect to live up to 40% of their lives in a postmenopausal state.5 Of the millions of women who spend years or decades in a perimenopausal and then a postmenopausal state, nearly half will experience bothersome symptoms of GSM/VVA. 6 Given these numbers, GSM is an area that warrants major interest in the healthcare community.

Despite the widespread prevalence of GSM, healthcare providers (HCPs) must keep in mind that many women are not comfortable discussing symptoms of GSM with their HCP, and vice versa. According to the Women’s Voices in the Menopause international survey, nearly 80% of online respondents felt that women were not comfortable discussing vaginal atrophy.7 The Real Women’s Views of Treatment Options for Menopausal Vaginal Changes (REVIVE) survey reported that only 56% of women had ever discussed their VVA symptoms with an HCP.8 In the VIVA (Vaginal Health: Insights, Views & Attitudes) survey, 80% of respondents stated that vaginal discomfort adversely affected their lives, and 75% of respondents reported adverse consequences on their sex lives. 9

In the recent past, nonhormonal lubricants and local hormonal therapies were the only treatment options for women with GSM. To date, six FDA-approved therapies for GSM/VV are available (Box). Intravaginal CO2 laser therapy, approved in late 2014, offers a unique, nonpharmacologic option for women, including breast cancer survivors, who are not candidates for hormonal treatment.

Regardless of the treatment chosen, HCPs caring for women must encourage open communication regarding symptoms of GSM with patients who may be otherwise unlikely to initiate conversation on such sensitive matters. With healthcare advances, many treatment options are available for all degrees of GSM severity and all circumstances. =

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’ Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she serves on the speakers’ bureau for Actavis Pharma, Inc., and Shionogi Inc.


  1. Portman D, Gass M. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and The North American Menopause Society. Menopause.  2014;21(10):1063-1068.
  2. North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013  position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902.
  3. Tan O, Bradshaw K, Bruce RC. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012;19(1):109-117.
  4. U.S. Census Bureau. Statistical Abstract of the United States. 2012. https://www.census.gov/prod/2011pubs/12statab/pop.pdf
  5. Parish SJ, Nappi RE, Krychman ML, et al. Imapct of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy. Int J Womens Health. 2013;5:437-446.
  6. Santoro N, Komi J. Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med. 2009;6(8):2133-2142.
  7. Nappi RE, Kokot-Kierepa M. Women’s voices in the menopause: results from an international survey on vaginal atrophy. Maturitas. 2010;67(3):233-238.
  8. Kingsberg SA, Wysocki S, Magnus L, et al. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013;10(7):1790-1799.
  9. Simon JA, Kokot-Kierepa M, Goldstein J, Nappi RE. Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey.  Menopause.  2013;20(10):1043-1048.

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.


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


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.


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.


  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.

Postpartum depression screening in a pediatric clinic setting

Postpartum depression (PPD), which affects about 14% of mothers in the United States, 1 can occur at any time throughout the first year after giving birth. Screening for PPD usually occurs only at the 6-week visit to the mother’s obstetric healthcare provider (HCP), resulting in missed opportunities to diagnose the disorder from 6 weeks through 12 months postpartum. Implications for a child whose mother has PPD include slow growth, impaired emotional and cognitive development, and weak attachment. 2,3


Because PPD can develop in any woman at any time during the first year following childbirth, more frequent screening could help identify the disorder in more women who have it and enable them to be treated in a more timely manner. The purpose of this project was to ascertain the feasibility and usefulness of implementing PPD screening using the Edinburgh Postnatal Depression Scale (EPDS) 4and the 2-, 4-,  6-, 9-, and 12-month well-child visits in a pediatric clinic setting.


The 10-question EPDS was used to evaluate a total of 71 participants during well-child visits at 2, 4, 6, 9, or 12 months. Mothers completed the EPDS while waiting for their child to be seen by the pediatric HCP. If a score was >10, the HCP referred the mother to be evaluated for PPD.


Of the 71 participants, 6 (8.5%) scored >10 on the EPDS and were referred for further evaluation. Among these 6 mothers, 1 was referred at the 6-month visit, 2 at the 9-month visit and 3 at the 12-month visit.


The DNP project was intended to last 8 weeks, but it ended after 5 weeks because (1) the number of participants accrued at the 5-week mark was close to the desired number of participants for the project; (2) the pediatric NP who was the primary contact at the clinic resigned for reasons unrelated to the project; and (3) the clinic was in the process of implementing an electronic medical record system, which took away time from the DNP project. Further evaluation of screening for PPD in pediatric clinics is needed to ascertain whether these results can be duplicated.

Implications for women’s health

In this project, the mothers referred for additional assessment for PPD were within 6-12 months post delivery. Without the increased frequency of screening as implemented in this project, some or all of these women might now have been identified as having symptoms of PPD, and further evaluation and treatment might now have been initiated in a timely manner.

This DNP project demonstrated the feasibility of screening for PPD during the first year after birth in a pediatric clinic setting. Identifying women who need additional counseling and resources to work through the difficulties of PPD is important. Not all of these women will experience symptoms by the time of their 6-week postpartum check. The optimal place to screen mothers for PPD may be at a pediatric clinic, where mothers take their infants at regular intervals for well-child visits through the first year of the child’s life.

Ilana L. Farb is a women’s health nurse practitioner at Obstetrics, Gynecology & Infertility in Edina, Minnesota. Diane M. Schadewald is Clinical Associate Professor at the University of Wisconsin-Milwaukee.

Visit www.NPWomensHealthcare.com/?p=4158 for a complete list of references.



Will the first medication to treat low sexual desire in women be approved?

Female sexual dysfunction (FSD) affects an estimated 43% of women in the United States.1  FSDs include impaired sexual interest/arousal disorder, sexual pain disorder, and orgasmic disorder. But the most common FSD by far is hypoactive sexual desire disorder (HSDD), reported by as many as 1 in 10 women. 2 HSDD can be definitively diagnosed with reliable and validated screening tools. 3 Women’s healthcare providers are on the front line in terms of caring for women with HSDD, but we lack FDA-approved options to provide relief for them.

But now there is hope. As the August 2015 issue of Women’s Healthcare: A Clinical Journal for NPs goes to press, the FDA will have made its decision regarding whether to approve flibanserin for the treatment of HSDD in premenopausal women. Flibanserin, a non-hormonal drug, is thought to work by correcting an imbalance in the levels of neurotransmitters in the brain that affect sexual desire. 4 More specifically, flibanserin increases dopamine and norepinephrine, both of which drive sexual excitement, and transiently decreases serotonin, which drives sexual safety/inhibition.

Two months ago, an FDA advisory committee voted to recommend approval of flibanserin to treat HSDD in premenopausal women. Although the FDA is not required to accept the advisory committee’s recommendation, the agency agreed to consider it as part of the new drug application review. Readers can check www.npwh.org for the latest information on the FDA decision.

During the open comment portion of the hearing prior to this vote, Gay Johnson, CEO of NPWH, spoke on behalf of the association and in support of both women with HSDD and the providers who struggle to treat these women every day.  In her statement, Ms. Johnson said, “Women’s sexual health is complex and multidimensional and often overlooked in primary care because of many factors, including cultural conditioning of women and providers. Historically, women’s sexuality has been viewed as something tied to the obligation to have sexual relations for reproduction, but not the desire to have sexual relations to achieve personal pleasure. Thankfully, now, in the 21st century, women’s sexual health is seen as a valid component of overall wellness. Women’s sexual dysfunction is now recognized as a real health condition, of real women, that decreases quality of life and negatively impacts relationships.”

Ms. Johnson clarified that NPWH is not advocating for the approval of any specific drug. She stated, “Each HSDD medical treatment option should receive fair consideration and the side effect/adverse event profile evaluated while considering the significant impact of the condition.  Women are intelligent, insightful decision makers and can be trusted the risks of side effects/adverse events and the benefits of any treatment according to the impact of HSDD on their personal lives and relationships.”

In both its educational and advocacy endeavors, NPWH supports nurse practitioners in providing high-quality healthcare for women, which includes addressing their sexual concerns. Our Women’s Sexual Health Course for NPs, offered for the first time in June 2014 and again in June 2015, has been extremely well received, filling to capacity several weeks ahead of time and garnering positive feedback from participants. Women’s Healthcare, our journal, includes a Focus on Sexual Health department article in each issue, and our annual conference always includes course on sexual health topics. Our advocacy work is ever-present as we actively support evidence-based treatments for all FSDs. As such, we applaud the FDA’s recognition of HSDD as a health problem that merits pharmacologic treatment and we encourage the FDA to consider approval of medications that have demonstrated efficacy and safety in treating women’s most common sexual complaint.

Susan Rawlins is Director of Education for the National Association of Nurse Practitioners in Women’s Health and a women’s health nurse practitioner at the Greater Texoma Health Clinic in Denison, Texas.  The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


  1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6):537-544.
  2. Parish SJ, Rubio-Aurioles E. Education in sexual medicine: proceedings from the International Consultation in Sexual Medicine, 2009. J Sex Med. 20100;7(10):3305-3314.
  3. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol. 2015;125(2):477-486.
  4. Sprout Pharmaceuticals, Inc. FDA Advisory Committee Recommends Approval for Sprout Pharmaceuticals’ ADDYI TM (flibanserin) to Treat Hypoactive Sexual Desire Disorder in Premenopausal Women. June 5, 2015. http://www.sproutpharma.com/news-center/

Chest pain in a young woman

What is the cause of increasingly severe chest pain that developed in an otherwise healthy 23-year-old woman?

LT is a 23-year-old woman who presents to the clinic for the first time for contraception. She has never been pregnant, has regular menses, and has used only condoms in the past for birth control. Her body mass index is 22.5 kg/m2 and she is physically active, engaging in 1 hour of aerobic exercise 5 days a week. She has never smoked. At this visit, the nurse practitioner (NP) determines that LT’s health history is negative for any cardiac disease, hypertension, thromboembolism, known thrombogenic disorders, diabetes, and malignancies. Her family history is negative for cardiac disease, thromboembolism, and known thrombophilias. LT’s blood pressure (BP) is 100/70 mm Hg. She is taking no medications.

LT’s only health history of note includes diagnoses for seasonal affective disorder and panic/anxiety disorder. She had been taking escitalopram (LexaproR), a selective serotonin reuptake inhibitor (SSRI), to treat her panic/anxiety symptoms, but she discontinued the medication 2 months previously because she was feeling less anxious and was concerned about SSRI-related side effects. Her panic/anxiety symptoms had worsened when she began her graduate school program but improved when she met her current partner. She still experiences panic/anxiety symptoms (mostly chest tightness) when preparing for examinations. The chest tightness does not affect her ability to speak or exercise. Her most recent panic attack occurred 5 months ago.

LT expresses an interest in using the vaginal contraceptive ring. She has no known contraindications for use of a combined hormonal contraceptive (CHC).1 The NP provides a prescription for the vaginal contraceptive ring and instructs LT on Quick Start.

One month after starting t vaginal contraceptive ring, LT presents to the clinic with a complaint of chest pain that has been increasing in severity over the past 3 weeks. She describes having a fever and body aches that started 3 weeks ago, accompanied by chest pain, a non-productive cough, and fatigue on exertion. The fever, body aches, and cough have subsided. She describes the persisting chest pain as tightness accompanied by a feeling that she has phlegm in her throat that she cannot dislodge by coughing and an inability to get enough air on inspiration. The chest pain became more severe the previous evening while she was cheering at a sporting event.

What other elements of LT’s current health history would be useful to know now?

On further questioning, the NP finds that LT’s chest pain worsens upon exertion. LT experiences chest pain and shortness of breath (SOB) when walking up hills on which she used to run without any problem. Whereas she used to be able to talk while sprinting, she now finds talking difficult even when walking because of the pain and SOB. She reports the ability to climb three flights of stairs without stopping but has decreased her exercise to twice a week and for only 30 minutes. The chest pain is not worsened by deep breathing, coughing, or changes in body position.

The patient describes the pain as being localized bilaterally above each nipple, with the affected areas about the size of a dime. She points to the area above each nipple in the third intercostal space to indicate the location. She denies nausea or vomiting; diaphoresis; radiation of pain to the shoulder, back, neck, or jaws; palpitations; hemoptysis; leg pain or swelling; or any tearing sensation. She has had no trauma to the chest or legs and has not had any prolonged or confined travel or other prolonged immobilization recently. She has no history of respiratory conditions, including asthma. She denies having any increased stressors in her life, any intimate partner violence, or use of cocaine or other stimulants.

What differential diagnoses would you be considering at this point?

Emergent considerations that the NP wants to be able to exclude are myocardial infarction (MI), pulmonary embolism (PE), pneumothorax, and aortic dissection. Other diagnoses the NP might consider, given some of LT’s symptoms, are pneumonia, myocarditis, pericarditis, and panic disorder.

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

LT’s vital signs are heart rate, 80 beats/minute; BP, 92/70 mm Hg; respiration rate, 12/minute; temperature, 98.2°F; and oxygen saturation, 99%. The NP immediately notices that LT has rapid speech and is fidgeting. Her skin is pink, with no rashes or bruising, and is warm, without diaphoresis. Chest pain is elicited when she climbs three flights of stairs, but her oxygen saturation remains at 99%- 100%. Bilateral chest pain is reproducible upon palpation in the area above the nipples. She experiences SOB, manifested as difficulty speaking, when she and the NP climb stairs together, but she does not try to slow down.

Further chest examination reveals equal expansion, normal cardiac rhythm with no extra heart sounds or murmurs, no diminished or abnormal breath sounds, and no extra lung sounds. LT’s abdominal examination results are within normal limits. She has no tenderness, redness, or swelling of her extremities.

Can you rule out PE based on the history and physical exam findings?

The CDC estimates that 60,000-100,000 Americans die of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and PE, each year.2 Undiagnosed PE has a 25% mortality rate. VTE, although uncommon, is one of the most serious possible adverse events related to CHC use. To put the risk for this patient in perspective, the rate of VTE is 29/10,000 woman-years in pregnant women, 9-10/10,000 woman-years in CHC users, and 4-5/10,000 womanyears in CHC nonusers.3

LT does not present with the classic picture of a PE. The PE Wells rule lists specific clinical features and assigns points to each feature to predict the likelihood of PE based on clinical findings.4Point values for clinical characteristics are as follows: clinical signs of DVT, 3; alternative diagnosis less likely than PE, 3; previous DVT or PE, 1.5; heart rate >100 beats/minute, 1.5; recent (within the past 30 days) surgery or immobilization, 1.5; hemoptysis, 1; and cancer (treated within the past 6 months), 1. The clinical probability of PE is “low” with a  total score of 0-1, “intermediate” with a total score of 2-6, and “high” with a total score >6.

Using the Wells scoring system, the NP notes that LT has no signs or symptoms of DVT, her heart rate is <100 beats/minute, and she does not have hemoptysis. She has not had extended immobilization or surgery in the past 4 weeks, has no previous history of DVT/PE, and no history of malignancy, and it does not seem at this point that an alternative diagnosis is less likely than PE. The Wells score for LT would be 0, indicating a low clinical probability of PE.

Nevertheless, the NP recognizes that the Wells rule, in isolation, cannot be used to exclude PE. What other factors should the NP take into account? What should she do next?

The fact that LT’s respiratory and chest pain symptoms have persisted over a 3-week period and are worsened by exertion is troubling in this otherwise healthy young woman. A further concern is that the symptoms started after recent initiation of a CHC. Because the NP wants to rule out a potentially life-threatening condition, she sends LT to the emergency department for further evaluation. Of note, LT removed her vaginal contraceptive ring 4 days ago and is due to insert a new ring in 3 days. The NP instructs her not to insert a new ring until the reason for her chest pain is determined.

Which laboratory and diagnostic tests are indicated in this case?

The gold standard to diagnose or exclude a PE entails a plasma D-dimer enzyme-linked immunosorbent assay (ELISA), chest radiography, and/or helical computed tomography (CT) pulmonary angiography. A plasma D-dimer ELISA has a 0.95 sensitivity (0.85-1.00) for negative likelihood; a negative D-dimer can exclude PE when the chest radiograph is negative.5 A positive D-dimer alone is of little clinical value in diagnosing PE. PE has occurred in 1.5% of patients with a negative CT pulmonary angiogram at 3 months.6

LT’s chest radiogram is negative, but her D-dimer ELISA is elevated, indicating the need for CT pulmonary angiography. The diagnosis of PE is confirmed with the CT pulmonary angiogram. LT is admitted to the hospital to start anticoagulation and is discharged to home 2 days later. Prior to her discharge, LT receives education about her oral anticoagulation therapy, the possibility that her PE was an adverse effect of CHC use, and the need to discuss other contraceptive methods with her primary care provider (PCP). She is advised to follow up with her PCP in 2 weeks and with the hematologist in 6 months.

At her 2-week follow-up visit, LT states she has had no chest pain or difficulty breathing since her hospitalization. She is taking her oral anticoagulant without difficulty. She expresses concern about her future risk for another PE and reports that she read on the Internet about genetic predispositions to getting blood clots. The NP reviews measures that LT can take to reduce her risks for DVT and PE, which include not smoking, maintaining a healthy weight, and using strategies during prolonged confined travel such as taking breaks to stretch and exercising her legs to avoid venous stasis. She advises LT that she should not use hormonal contraceptives that contain estrogen. 1  LT chooses to use a nonhormonal intrauterine contraceptive, which is placed at this visit.

Should LT be tested for inherited or acquired thrombophilias?

An unrecognized acquired thrombophilia such as antiphospholipid syndrome or an inherited thrombogenic mutation (e.g., factor V Leiden; prothrombin mutation; protein S, protein C, or antithrombin deficiency) may contribute to a first VTE in a CHC user.A retrospective cohort study of 160 women with a first VTE while using a combination oral contraceptive (COC) showed that the cumulative incidence of recurrent VTE was 5.1% after 1 year and 14.2% after 5 years.7 Significant factors associated with recurrence were renewed COC use (hazard ratio [HR], 8.2 [2.1-32.2]), antiphospholipid syndrome (HR, 4.1 [1.3- 12.5]), and protein C deficiency or factor II prothrombin mutation (HR, 2.7 [1.1-7]). Use of a progestin-only contraceptive (HR, 1.3 [0.5-3.0]) and factor V Leiden (HR, 1.3 [0.5-3.4]) did not increase recurrence.

The genetic framework underlying VTE is complex and likely interplays with risk factors such as recent hospitalization, smoking, obesity, and CHC use. Decisions regarding duration of anticoagulant therapy and the need for thromboprophylaxis during pregnancy are best considered in terms of clinical risk factors. Testing for inherited thrombophilias provides an uncertain estimate of risk and is not recommended in most circumstances. 8,9

LT has a follow-up appointment with a hematologist in 6 months. She will discontinue the anticoagulant 2 weeks prior to this visit so that the workup will not be affected by the medication. The hematologist will reassess LT’s risk factors and the need for further testing.

Reflection on this case

LT’s only identified risk factor for VTE when she presented with chest pain and SOB was the use of a CHC. Results of studies looking specifically at the vaginal contraceptive ring and risk for VTE are mixed.10,11However, severa cases of VTE have been reported in women with no other identified risk factors besides vaginal contraceptive ring use.10,11

Other diagnoses such as MI, pneumothorax, myocarditis, pericarditis, and pneumonia were unlikely given LT’s history and physical exam findings. The history of panic/anxiety could have led the NP to initially consider panic attacks as the origin of LT’s chest pain. The patient’s rapid speech and fidgeting were a clear indication of anxiety, which could have been related directly to pain. Anxiety (sense of doom) and restlessness are also common findings with PE. The NP was correct to  maintain heightened suspicion for PE in this otherwise healthy young woman presenting wit chest pain and SOB who had recently initiated a CHC.

Recommendations for practice

Nurse practitioners should always conduct an appropriate workup to rule out VTE risk factors prior to prescribing a CHC for a given patient. All women using a CHC should be advised of symptoms of VTE that must be immediately reported to their provider. Routine screening for thrombogenic mutations is not appropriate because these conditions are rare and the cost of testing is high.1  NPs should re-evaluate CHC users for risk factors at regular visits. NPs should always initiate testing to rule out or confirm PE if another cause of chest pain and/or SOB in a CHC user is not apparent. An elevated D-dimer indicates the need for urgent chest radiography, and, if inconclusive, a CT pulmonary angiogram.

A helpful tool to use when considering contraceptive options for patients seeking family planning guidance is the Medical Eligibility Criteria for Contraceptive Use, published by the World Health Organization and most recently updated in 2010.12 Tables in this document include recommendations for the use of contraceptive methods by women and men with particular characteristics or medical conditions.13 Each condition was defined as representing either a person’s characteristics (e.g., age, history of pregnancy) or a known pre-existing medical/pathologic condition (e.g., diabetes and hypertension). NPs should check the CDC’s MMWR website for up-to-date information regarding medical eligibility criteria for contraceptive use=

Lisa Morrow is a graduate of the Columbia University DNP program and a family nurse practitioner and attending at Bronx Lebanon Hospital Center and Wellness Center Ambulatory Clinic, both in New York, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


The author thanks her mentors at Columbia, Elsa Wuhrman, DNP, FNP, ACNP-BC and Susan Doyle- Lindrud, DNP, AOCNP, DCC, for their guidance in the preparation of this manuscript.

Visit www.NPWomensHealthcare.com/?p=4154 for a complete list of references.


Message from the CEO

NPWH’s roots are firmly planted within the family planning movement. In May 1980, the Metropolitan Executive Director’s Council (MEXDICO) of the Planned Parenthood Federation of America passed a resolution calling for the formation of a national association of family planning nurses. Later in the year, and at the   invitation of MEXDICO, a group of nurse  practitioners (NPs) from 20 of the larger Planned Parenthood affiliates met in Denver, Colorado, to  discuss the formation of a  specialty organization focused on family planning and reproductive health. The Denver meeting participants voted to form a new organization called the National Association of Nurse Practitioners in Family Planning (NANPFP). NANPFP’s mission was “to assure accessible, quality family planning services and reproductive freedom….”

Fast forward to 2015. After having undergone two  name changes, after having fulfilled many of the early visions, and after having accomplished many of the goals set for education and professional development of NPs, NPWH—he National Association of Nurse Practitioners in Women’s Health—s celebrating its 35th anniversary! NPWH has broadened its focus over the years but still remains an organization dedicated to ensuring the provision of quality healthcare to all women by women’s health NPs and other women’s health-focused clinicians.

We will be celebrating this milestone in the life of our organization during the Welcome Reception at our 18th Annual Premier Women’s Healthcare Conference in Salt Lake  City, Utah, on October 14-17, 2015. Our program guide for this year’s conference is provided for you here in the journal on the following pages. It has always been our mission to bring you the most up-to-date information and the highest quality education.

So, mark your calendar and make arrangements to attend the NPWH  conference this year in Salt Lake City. Together, we will raise a glass in celebration of 35 years of this dynamic organization, the National Association of Nurse Practitioners in Women’s Health!

–Gay Johnson

Chief Executive Officer, NPWH


Choosing a hormone therapy that’s right for her

Most women will experience symptoms of estrogen decline as they transition through the menopausal years. These can include vasomotor symptoms (VMS)  and those related to vulvovaginal atrophy, now known as genitourinary syndrome of menopause (GSM). These VMS and GSM symptoms can have an adverse impact on quality of life (QOL). 1.2 Although some women tolerate these symptoms or can improve them with lifestyle changes or non-pharmacologic measures, other women, depending on symptom severity and QOL impact, might benefit from hormone therapy (HT).

Nurse practitioners (NPs) caring for women are familiar with HT options such as the various estrogen and progestogen formulations and the combination estrogen/selective estrogen receptor modulators. Providing patient-specific guidance regarding options is critical in improving satisfaction and compliance. This article provides a short discussion of estrogen products in general, and addresses the attributes of a transdermal gel product that some women find appealing in terms of its ease of use and efficacy in treating both VMS and the symptoms of GSM.

Exogenous estrogen options

Once it is determined that a patient is a candidate for HT and that her VMS, and possibly vaginal dryness as well, are significantly affecting her QOL, patient discussion should be initiated regarding HT options. The objective is to arrive at a mutual decision about the particular type of exogenous estrogen, dosage, and route of delivery that is a best “fit” for the woman. For those women who desire an estrogen product and who have been informed of the risks associated with estrogen use, formulations containing estradiol, conjugated equine estrogens, plant-based estrogens, or esterified estrogens are available. Some women may have a preference regarding an animal-derived estrogen, plant-based estrogen, or synthetic estrogen formulations.

Non-oral estrogen products may have a safety advantage over oral estrogen products.3 Because oral estrogen products, including oral estradiol,  undergo first-pass hepatic metabolism, they may be more likely than non-oral estrogens to lead to adverse metabolic changes such as elevated triglycerides, decreased low-density lipoprotein particle size, and increased production of certain coagulation factors and C-reactive protein. 4 A growing boyd of observational evidence suggests that transdermal estradiol, as compared with oral estrogen, may be associated with lower risks for cardiovascular disease, 7 cerebrovascular disease, 6 and venous thromboembolism. 7,8

Transdermal HT options

There are four transdermal options for VMS relief – patch, emulsion, spray, gel – and one intravaginal option. Other intravaginal estradiol products include creams, a ring, and a tablet. These products are reserved for women whose sole menopause-regulated complaints involve GSM symptoms. 9 Numerous clinical trials conducted over the past two decades have evaluated the efficacy and safety of the transdermal patch, 10-16 emulsion, 17 spray, 18 and gel 1,2,19 in controlling VMS.  One aspect of the non-patch transdermal estradiol products is that they vanish after they are applied and then dry, with no visible signs that HT is being used.

More about one estradiol gel product

Among all of the non-patch transdermal estradiol products, including the gel products, only one, EstroGel 0.06% (estradiol gel), has an FDA-approved dual indication: relief of moderate to severe VMS and relief of moderate to severe symptoms of vulvar and vaginal atrophy due to menopause.20 Clinical research showed that the use of EstroGel at a dosage of 1.25 g (containing 0.75 mg estradiol), as compared with placebo, was associated with significant reductions in the frequency and severity of moderate to severe hot flashes at weeks 4 and 12. 20 In the same study, vaginal wall cytology results demonstrated a significant increase from baseline in the percent of superficial epithelial cells at week 12 for EstroGel versus no significant change from baseline for placebo. The most commonly reported side effects of EstroGel in clinical studies were breast pain, headache, and flatulence. 20

A survey of EstroGel users (N=890) related to product satisfaction showed that 88% were satisfied or extremely satisfied with it and 89% thought it was very easy to use. 21 Among the 620 respondents who had used a previous therapy for their menopausal symptoms, 89% reported that they preferred EstroGel, 7% had no preference, and 4% preferred the previous product.

One pump of the EstroGel metered-dose dispenser supplies one dose of the gel (1.25 g), which contains 0.75 mg of estradiol. The gel is applied to clean, dry, unbroken skin at the same time each day. The patient applies the gel to one arm from wrist to shoulder; she need not massage or rub in the gel. after applying the gel, which dries in 2-5 minutes and leaves no odor or sticky residue, she should wash her hands with soap and water to reduce the chance of medication spread.

All systemic estrogen users with an intact uterus should consider adding a progestogen to their HT regimen in order to reduce the risk of endometrial cancer. 3 Several synthetic progestogens and oral micronized progesterone are FDA approved for this purpose. Oral progestogen may be added as a separate pill or a provided as a combined estrogen-progestogen pill. Combination estrogen-progestogen transdermal patches are also available. Topical cream or gel preparations of progestogen may not exert sufficient activity to protect the endometrium and are not approved for this purpose.

Regardless of which HT is used, the North American Menopause Society recommends prescribing estrogen at the lowest effective dose for the shortest time needed. 9 NPs can assist each woman in navigating through the array of HT options to facilitate selection of the regiment and/or delivery system that is most appropriate for her unique needs.

Anne Moore is the Women’s Health Clinical Trainer at the Tennessee Department of Health, Division of Family Health and Wellness, in Nashville, and a member of the Editorial Advisory Board for Women’s Healthcare: A Clinical Journal for NPs. An honorarium funded by Ascend Therapeutics has been received by Ms. Moore.

Visit https://npwomenshealthcare.com/?p=4166 for a complete list of references.


Editor-in-chief’s message

Dear Colleagues,

Three full years have elapsed since we celebrated the rollout of the Affordable Care Act (ACA) provision requiring coverage of women’s preventive services recommended by the Institute of Medicine. This provision includes a requirement that most insurance plans cover FDA-approved female contraceptive methods with no co-payment or deductible. The coverage must also include clinical services, including patient education and counseling needed for provision of these contraceptive methods.

Health insurance carriers must cover al least one product in each of the 18 distinct female contraceptive method categories that the FDA has identified in its current Birth Control Guide1 Many women who could not previously afford contraceptives or whose choices were limited because of prohibitive costs now have access to effective methods that meet their own particular needs.

Despite the existence of this ACA provision for the past 3 years, insurance carriers vary in terms of how they are adhering to the guidelines for contraceptive coverage – thereby keeping many women from fully benefitting from this provision. In fact, two recent studies evaluating health insurance coverage revealed numerous violations of the requirements by a large number of insurance carriers across several states. 2,3  The National Women’s law Center(NWLC) reviewed more than 100 plan documents from issuers in the new marketplaces in 15 states, and found that 33 insurance carriers in 13 states offered birth control coverage that did not comply with the ACA. 2 The Kaiser Family Foundation described contraceptive policies used by health insurance carriers as being not easily accessible and not clearly defined. 3

The most commonly identified violation in these studies was a failure to cover all FDA-approved methods. The method(s) not covered varied with different carriers but included progestin implants, contraceptive patches and vaginal rings, over-the-counter contraceptives, and the emergency contraceptive pill Ella. Several insurance carriers were found to impose impermissible cost-sharing on methods such as IUDs and sterilization. Some carriers imposed limitations and cost-sharing on the services associated with provision of contraceptive methods, including office visits for injectable contraceptives and birth control counseling. Other violations included requiring cost-sharing for brand-name contraceptives without generic equivalents and excluding sterilization coverage for dependent children, which includes adults up to age 26. In May 2015, as a result of these two studies’ findings, the U.S. Departments of Health and Human Services, Labor, and Treasury issued FAQs About Affordable Care Act Implementation to help insurance companies and consumers better understand the scope of coverage of preventive services required under the ACA. 4

We must ensure that our patients have access to all FDA-approved female contraceptive methods and related services, with no co-payment or deductible. We have a voice. In one state, after the regional Planned Parenthood and the NWLC brought violations to the attention of insurance regulators, a bulletin clarifying the requirements was sent to health insurance carriers. NWLC operates a national hotline (1-866-745-5487) and website to assist women having difficulty securing coverage for birth control by providing information on the requirements, assisting with filing appeals with insurance companies, and filing complaints with government agencies that regulate insurance plans.

Through the ACA, we have made a tremendous step forward in enhancing access to care for women. As always, however, there are hurdles to overcome and there are risks that the gains we have made will be reversed. Together we can be a mighty force in overcoming these hurdles and in protecting the good work that has been done.

Beth Kelsey, EdD, APRN, WHNP-BC

Visit http://www.NPWomensHealthcare.com/?p=4150 for a complete list of references.

A disease you just caught: Low-income African American mothers’ cultural beliefs about postpartum depression

Postpartum depression (PPD), which occurs in 15%-20% of women after giving birth, is the most common complication of childbirth.1PPD can have adverse effects on the mother, the newborn, and the family unit. Several factors increase PPD risk, including a past history of depression, perceived lack of social support, young maternal age, and low income.2,3Table 1 lists these and other PPD risk factors4 Additional risk factors for PPD in African Americans (AAs) include life and environmental stressors, physical health problems, and perceived racism, stigma, and discrimination.5,6Rates of PPD are nearly twice as high in low-income, non-white women as they are in higher income white women.7-9

Postpartum depression tends to go undetected and untreated in minority group members. These women are less likely to undergo PPD screening, and if they do experience PPD symptoms, they tend to minimize them or disregard them because of shame, perceived stigma, and/or cultural beliefs.2,10,11 In one study, researchers found that when low income AA women were diagnosed with PPD, they were half as likely as their white counterparts to utilize available mental health services.12

Multiple barriers to PPD treatment exist, including perception of the illness as a personal weakness; a general unwillingness to disclose negative feelings to friends, families, or healthcare providers (HCPs); and fear of being separated from one’s children because of mental instability. 10,11,13,14 Time constraints, childcare concerns, and stigma have been identified as additional barriers to seeking treatment. 15  Other major barriers to treatment are lack of health insurance coverage, financial hardship, and limited access to healthcare services.15-18By contrast, several studies have shown that ongoing communication, transportation assistance, availability of on-site childcare, availability of services in an obstetricsetting, and shared decision making with HCPs are factors that can increase PPD treatment rates.1,2,6

Cultural norms and beliefs about PPD may play a major role in terms of mothers’ and HCPs’ recognition of its symptoms.5 For example, somatization of health problems may precede or mask psychological distress among AA women.5 Culturally constructed and sanctioned expressions of language of depression are likely to be overlooked or misidentified by HCPs trained in mainstream definitions of depression. 5,19Research exploring how cultural beliefs affect the experience and manifestation of PPD symptoms among low income AA women is lacking. This study was conducted to help fill this gap.


Research design and approach— This qualitative study used semi-structured interviews in focus group settings with patients at a family services program in Houston, Texas. Focus groups were used because of case workers’ reports that clinic patients tend to be reluctant to engage with researchers in one-on- one interviews. Focus groups tend to offer opportunities for more interaction than a one-on-one interview format and may promote in-depth conversations about complex topics.20

Participants—Convenience sampling was used to recruit a homogeneous group of low income AA women. Any AA woman who had given birth in the past 18 months and had been screened for PPD was eligible to participate in the study, was notified about the study, and was asked to take part in it. Sixteen women met inclusion criteria and signed a consent form. Among the 16 women, 12 (75%) were identified as having experienced PPD. Demographics of the sample appear in Table 2.

Data collection—After the Institutional Review Board at the University of Houston approved the study, three focus groups were conducted over a 3-week period. The primary investigator moderated the groups with three research assistants in attendance. Participants were advised that researchers wanted to know their thoughts about culture and about postpartum depression. The term culture was taken from Leininger’s work and was defined for participants as “shared values and beliefs of a particular group that guide thinking and decisions.”21This group could include neighbors, friends, church acquaintances, or anyone with whom the women felt that they shared a culture. During the focus group sessions, each woman was asked the same questions:

• When I say postpartum depression, what does it mean to you?

• What do other women, men, family, community—anyone that shares the same racial or ethnic group as you—say about postpartum depression?

• What have people from your cultural group said about getting treatment from a therapist for postpartum depression?

• What do you think might help or stop moms from getting help for depression after childbirth?

Data analysis—Audio-recordings of the focus groups were transcribed verbatim and compared with the transcripts to ensure accuracy. Transcripts were read by each researcher; key words and statements were highlighted and coded. A six phase process of thematic analysis, 22 as described by Braun and Clarke,23 was used to search fo emergent themes regarding beliefs and experiences of PPD. Themes that emerged from the data were reviewed. Simila themes were grouped together and reported as results. Participants’ responses were directly quoted, without grammatical corrections.


Five themes emerged from the data: (1) lack of support, (2) differences between participants’ own experiences and their perception of their community’s beliefs about PPD, (3) participants’ perception of their community’s belief that strong mothers do not catch PPD, (4) a belief that mothers have everything to lose by seeking help for PPD, and (5) a need for culturally relevant education on PPD.

Lack of support—Depressive episodes were likened to feeling that the whole world is on your shoulders pushing you down. Most participants had family and friends residing in close proximity. Nevertheless, rather than providing support, the baby’s father, other family members, and friends provided constant criticism. Elder females (mothers, grandmothers, and aunts) held high expectations for them to parent in the same way that they had parented, and they expressed exasperation with the new mothers’ moods. Many participants were single mothers who felt overwhelmed, exhausted, and constantly stressed while simultaneously trying to be self-sufficient.

One participant stated: They’ll say like you got too many mood swings. It’s like you really moody. You need to see a doctor. It’s not that you’re moody; it’s just like you need some help and it’s like you don’t have the help that you need and it’s like— it’s making you have these different type of mood swings. You up and you down; then you up then you down and it’s like people don’t understand— especially men….It’s too much because ain’t nobody tryin’ to satisfy me. So, why should I be tryin’ to please everybody else when y’all not gonna try to please me?

Differences between participants’ own experiences and their perception of their community’s beliefs about PPD— Participants expressed feelings of overwhelming sadness, frustration, and stress, and reported periodic episodes of crying. They shared stories about long bouts of isolation and withdrawal, although most did not relate thoughts of harming themselves or others. A few did report fleeting thoughts of wanting to escape from or hurt their children.

When asked about what members of their community said about PPD, the participants believed that their family an friends considered PPD as involving extreme thoughts an crazy, dangerous behaviors (e.g., harming oneself or one’s children). Depression would be like you having thoughts of suicide, hurtin’ someone, that type of thing. Another woman described her community’s take on PPD as mothers that hear voices that tell them to kill their kids.

Even if participants described  their own struggles with PPD as follows—When he was crying, one of my kids, it would frustrate me and I thought crazy things. I wanted to kill my kid—they would give more extreme examples when asked how they perceive that their community defines PPD. For example, one participant said, She [referring to a neighbor] needed the help. Like she was to the point she left newborn, she left her 2-year-old. She would like hop in the car and leave and the babies would be alone. We be sittin’ here like “Are you serious?” She was like “I had to get away.” You don’t even let a neighbor know, your mama know. She was ill to the point she would shut down. She wouldn’t feed them. She wouldn’t clothe them. She was like seriously stressed and she was taking classes here and she would come in the meetings here and voice it. So, she was kind of beyond needing help.

According to participants’ perceptions of their community’s views, postpartum reactions that did not involve extreme and dangerous thoughts and behaviors were not PPD. There seemed to be a discrepancy between what the mothers described as their experience of PPD and their impression of how their community identified PPD.

Participants’ perception of their community’s belief that strong mothers do not catch PPD—According to the study participants, their culture promotes the idea of the strong, self-sufficient mother. Divergence from this image is discouraged. According to these women’s perceptions of their community ethos, PPD can occur when a woman is not strong enough to handle the demands of mothering. One participant imitated a family member, saying, That’s your bull crap. There is no, there is no postpartum depression. Only white people go through it. According to one participant, a neighbor said that to her, depression is something young mothers do to get out of needing to take care of their kids. A participant who had experienced PPD reported that a friend asked her: What you goin’ through depression for? Something wrong with you?

Participants shared stories about asking for help or talking about their depression and anxiety, only to be met with others’ judgments. One participant remarked: Like if I had six kids and I decided to get depressed, they gonna be like well, you shouldn’t open your legs up. Women reported that in their community, acknowledging having depressive symptoms would result in being seen as an unfit mother, as illustrated by this quote: I mean, they make it seem like, it’s like, oh, if you’re depressed, oh my God, you’re unfit. So for you to go through however you feel or whatever emotions you have they feel like you should be able to handle that….And it makes you feel like it’s, like it’s a disease that you just caught. In other words, if someone were to admit feeling depressed, she believed that the community would see her as an unfit mother. It would be safer to deny these feelings than it would be to risk being labeled unfit.

A belief that mothers have everything to lose by seeking help for PPD—In the experience of most study participants, warnings that depressed mothers would be labeled crazy and lose their children abounded. One woman described it as follows: I think a lot of it is people are scared. There are some people that either have warrants or whatever and they think that that’s gonna come up or they knew that CPS [Child Protective Services] is gonna get involved or they think that some kind of law of some sort is gonna get involved to where either they’re gonna get locked up or their children are gonna get taken away. They feel threatened. They feel scared. They feel that something’s gonna be taken away from them. If it’s not their children, it’s their freedom. So, if maybe they  think, well, maybe I’m a little crazy, but I’m not gonna go to the doctor because the doctor is gonna be asking me too many questions.

These fears create insurmountable obstacles for initiating help-seeking behaviors. The participants believed that a woman would be jeopardizing her independence and personal standing as a capable mother, not to mention her opportunity to keep her children, by admitting that something was wrong.

A need for culturally relevant education on PPD—When asked what would help them or other mothers seek help for PPD, the participants spoke of educating the community to serve as witnesses invested in their well-being. They wanted people in their community, within their own cultural group, to promote representations of what PPD looks like among their own people. Participants commented that in the AA community, depression does not look like depression. They added that crying, sad mood, and sleep difficulties were not the only symptoms of PPD and that a lack of these symptoms did not exclude a PPD diagnosis. They suggested that HCPs and mental health professionals educate our family, our community. They thought that education about PPD could increase awareness and decrease stigmas and false beliefs among the female elders and the men in their community.

One participant criticized current TV commercials for antidepressants, saying, Based on what you see on TV and their commercials and the ones holdin’ the dog by the window, that is so completely garbage. When asked how a commercial that accurately portrays PPD would look, one participant gave this vivid example: She movin’ around. She droppin’ the kids, you tired, you overworked. She doin’ the most, she cookin’, she cleanin’, she washin’ dishes. Doin’ everything at one time….Baby hollerin’, hand doin’ this here, I mean it’s just no time to stop, no time to stop.…Everything has to be done. Nobody else is gonna do it.


In this study, 16 postpartum, low-income, AA women conveyed how their community’s beliefs about depression and expectations about motherhood placed intense pressure on them—and on women like them—to hide PPD symptoms. Perceived cultural beliefs led to the view that, following childbirth, women should be self-sufficient and endure the stresses of motherhood without exhibiting weakness or developing a mental illness.

Although most study participants did reveal their symptoms to others, most of these disclosures were dismissed, denied, or even mocked. For AA mothers living in similar contexts, culture may serve as a barrier for those with PPD symptoms to seek professional help. Perceived messages about stigma and weakness were sometimes more powerful than the mother’s own recognition of feeling depressed, overwhelmed, and in need of support. Perception of depression as a character weakness and PPD as an expression of extreme behaviors such as infanticide may lead women to dismiss mild or moderate PPD symptoms that are amenable to early treatment. These symptoms, if left untreated,could progress to more extreme reactions and have much direr consequences.

An important point for HCPs: Many AAs with depression may not report feeling down or hopeless but, rather, will present as stoic, angry, or irritable.24 In the current study, participants related their stories of depression, frustration, and feeling judged with very little affect. None of them cried, even when sharing painful memories. HCPs may dismiss depressive symptoms as routine stressors of life for low-income mothers, especially if the mothers appear angry and irritable rather than sad and depressed. HCPs screening for depression may not recognize that anger and frustration can be manifestations of depression. In fact, the manifestations and the communication of symptoms vary greatly from members of one culture to those of another culture, and may not be recognizable from the HCP’s cultural vantage point.14

Asking for help in this sample of low-income AA women would have been in direct contrast to the perceived culturally embedded role of the mother as superwoman. 14 In this study, participants’ calls for help often went unanswered, even when they told their own mothers, aunts, sisters, or partners about feeling overwhelmed, stressed, and angry for long periods of time. They reported that nobody seemed to be listening. Some participants expressed a fear of being labeled crazy. The possibility of losing custody of their children stopped many of them from seeking treatment for their depressive symptoms.

These women believed that increased community awareness and education would decrease the stigma about PPD, and that more women would be likely to report their symptoms and obtain treatment. Overall, the participants wanted to feel heard and understood and not stigmatized. Many had doubts and confusion, and were unwilling to self-identify with having PPD symptoms because of the negative cultural connotations associated with this disorder.

Limitations of the study

Because this study was entirely qualitative in nature and was based in real-world community settings, it has certain limitations. The sample was obtained from a single site. Although this approach is common in qualitative studies, enrolling participants from different sites could have further supported these findings. Other mothers with similar demographics and life situations may have experiences similar to those reported in this study, but the results cannot be generalized to all urban, low income, AA mothers. In addition, AA women from rural or suburban areas and those with greater economic resources may have responded differently.

The lead investigator who conducted the focus groups was white and from an academic setting, and was thus considered an outsider. To address this potential threat to recruitment and open discourse, the investigator was accompanied by students of various cultural backgrounds and by a case worker with whom the participants were familiar and who was present during recruitment. To deal with a potential threat of researcher bias, the lead investigator disclosed to the group that she was a mother who had only professional experience with PPD and wrote reflective memos after the groups met. Three other researchers participated in the coding process to minimize bias. Despite these limitations and small sample size, the study provides valuable insight from a group of women identifying with similar cultural norms and their perceptions of PPD experiences and their attitudes toward treatment.

Clinical implications

Because of the high incidence of PPD in minority and low-income groups, PPD screening should be implemented in all obstetric practice settings serving these populations. HCPs should assess pregnant patients for a history of depression, previous PPD, antepartum depression, and past history of mental illness; these conditions are the strongest predictors of PPD.25 HCPs should discuss PPD, its symptoms, and possible treatments with patients during the prenatal period, prior to discharge after birth, and at the 6-week-postpartum visit. HCPs should ascertain the presence of support from the patient’s partner, family, and community. If a depressed mother is at least aware of community resources’ existence, she may be more likely to pursue them. Many county-based community health centers offer mental health services for no fee or reduced fees.

In this study, women with PPD described themselves as feeling overstressed and overwhelmed. HCPs may find it necessary to discuss strategies and resources for lowering mothers’ stress before even addressing the depression. Findings from this study also suggest a need for more culturally specific information about PPD and its symptoms. For urban, low-income, AA patients, increased education about the various expressions of PPD may help shift the mindset and destigmatize PPD. Educational outreach efforts could also be made in churches; spirituality has been cited as a focal point of recover from depression among low-income minority women.26

Women with lives complicated by financial constraint, social isolation, non-supportive family, and limited access to mental and physical health services experience stresses that may contribute to or worsen PPD symptoms. 27 This reality underscores the need for proficient screening and awareness of social stressors when working with low-income mothers in the perinatal phase. Women in crisis and those with severe symptoms, suicidal ideation, or symptoms of postpartum psychosis require immediate mental health assessment that may warrant hospitalization.


Postpartum depression carried tremendous stigma among this group of AA mothers. PPD was viewed as a sign of weakness and a disease prominent in other ethnic groups. This sample of low-income AA women believed that they had much to lose and little to gain by revealing depressive symptoms. Individual and community education may help address this misperception. =

McClain Sampson is Assistant Professor at the University of Houston Graduate College of Social Work in Houston, Texas. Jacquelynn F. Duron is a research associate at the University of Houston and Research Coordinator at Baylor College of Medicine, both in Houston, Texas. Melissa Irene Maldonado Torres is a research assistant at the University of Houston Graduate College of Social Work in Houston, Texas. Michele R. Davidson is Coordinator of the PhD Nursing Program and Associate Professor of Nursing & Women’s & Gender Studies at George Mason University School of Nursing in Fairfax, Virginia.


The authors gratefully acknowledge Neighborhood Centers Inc. or their collaboration in data collection.


  1. Davidson MR. A Nurse’s Guide to Women’s Mental Health. New York, NY: Springer; 2012.
  2. Beck CT. Predictors of postpartum depression: an update. Nurs Res. 2001;50(5):275-285.
  3. Stewart DE, Robertson E, Dennis C, et al. An evidence-based approach to postpartum depression. World Psychiatry. 204;3(2):97-98.
  4. Masmoudi J. Postpartum depression. Int Clin Psychopharmacol. 2012(28):21-23.
  5. Brown C, Abe-Kim JS, Barrio C. Depression in ethnically diverse women: implications for treatment in primary care settings. Prof Psychol Res Pract. 2003; 34(1):10-19.
  6. Dailey DE, Humphreys JC. Social stressors associated with antepartum depressive symptoms in low-income African American women. Public Health Nurs. 2011;28(3):203-212.
  7. Satcher D. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.  U.S. Department of Health and Human Services, Washington, DC; 2001.
  8. Hobfoll SE, Ritter C, Lavin J, et al. Depression prevalence and incidence among inner-city pregnant and postpartum women. J Consult Clin Psychol. 1995; 63(3):445-453.
  9. Zayas LH, Cunningham M, McKee MD, et al. Depression and negative life events among pregnant African American and Hispanic women. Womens Health Issues. 2002; 12(1): 16-22.
  10. Dennis CL, Chung-Lee L. Postpartum depression help seeking barriers and maternal treatment preferences: a qualitative systemic review. Birth. 2006;33(4):323-331.
  11. Abrams LS, Dornig K, Curran L. Barriers to service use for  postpartum depression symptoms among low-income ethnic minority mothers in the United States. Qual Health Res. 2009;19(4):535-551.
  12. Song D,  Sands RG, Wong Y-LI. Utilization of mental health services by low-income pregnant  and postpartum women on medical assistance. Women Health. 2004;39(1):1-24.
  13. Amankwaa L. Postpartum depression among African American women. Issues Ment Health Nurs. 2003; 24(3):297-316.
  14. Amankwaa LC. Postpartum depression, culture and African American women. J Cult Divers. 2003; 10(1) :23-37.
  15. Goodman JH. Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009; 36(1):60-69.
  16. McKee MD, Zayas LH, Fletcher J, et al. Results of an intervention to reduce perinatal depression among low-income minority women in community primary care. J Soc Serv Res. 2006:32(4): 63-81.
  17. Miranda J, Chung JY, Green BL, et al. Treating depression in predominantly low-income young, minority women. A randomized controlled trial. JAMA. 2003; 29(1):57-65.
  18. Patel SR, Wisner KL, et al. Decision making for depression treatment during pregnancy and the postpartum period. Depress Anxiety. 2011;28(7):589-595.
  19. Barbee E. African-American women and depression: a review and critique of the literature. Arch Psychiatr Nurs. 1992; 6(5): 257-265.
  20. Krueger RA. Focus Groups: A Practical Guide for Applied Research. 2nd ed. Thousand Oaks, CA: Sage; 1994.
  21. Leininger MM, ed. Culture Care Diversity and University. A Theory of Nursing. Boston, MA: Jones &Bartlett; 2001.
  22. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: Sage, 1998.
  23. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77-101.
  24. Baker FM. Diagnosing depression in African Americans. Community Ment Health J.  2001; 37(1):31-38.
  25. O’Hara M. Swain A. Rates and risk of postpartum depression: a meta-analysis. Int Rev Psychiatry. 1996; 8(1): 37-54.
  26. Nadeem E, Lange JM, Miranda J. Mental healthcare preferences among low-income and minority women. Arch Womens Ment Health. 2008;11(2):93-102.
  27. Templeton L. Velleman R, Persaud A., Milner P. The experiences of postnatal depression in women from black and minority ethnic communities in Wiltshire, UK. Ethn Health. 2003;8(3):207-221.


Editor-in-chief’s message

Dear Colleagues,

In so many ways, NPWH and its members are showing that women’s health is about much more than just obstetrics and gynecology. But then, we have know this for a long time. Here are a few examples.

Sue Kendig, NPWH Director of Policy, describes the process and outcome of revising the Women’s Health Nurse Practitioner: Guidelines for Practice and Education in this issue of the journal. As a member of the task force for this 7th edition and for the previous edition of the Guidelines, I can confirm that we definitely did our homework to produce a document that reflects the expanded scope of practice for today’s WHNP. NPWH members have free access to the Guidelines on the NPWH website.

NPWH is a leading organization in the field of evidence-based sexual healthcare, providing the first national Women’s Sexual Health Course for NPs in 2014. The course was so successful that it will be offered again this year. We at Women’s Healthcare, NPWH’s official journal, are proud to present a new department, Focus on sexual health, in this issue. Brooke M. Faught, MSN, WHNP, Clinical Director of the Women’s Institute for Sexual Health in Nashville, Tennessee, has authored the inaugural article for this department. This issue of the journal also features an article on female sexual dysfunction by Casey B. Giebink, MSN, NP-C, WHNP-BC, and Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN. And in our Assessment & management department, Wendy Grube, PhD, CRNP, a member of the task force that developed Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice, summarizes the key points in this groundbreaking publication.

NPWH is developing  strong presence with regard to mental health as well. In the past year alone, we have offered articles on depression in women, self-esteem, postpartum depression, sexual assault, and depression in adolescents. Appearing now or coming soon are articles on binge eating disorder, PCOS psychosocial effects, and anorexia in adolescents.

To honor our Million Hearts partnership commitment, we have been providing many evidence-based continuing education (CE) activities that give advanced practice nurses the tools they need to promote heart health. In the August 2014 issue of Women’s Healthcare, we published a CE article by Tamera Lea Pearson, PhD, MSN, FNP, ACNP, entitled Cardiovascular Disease in Women: A Journey Toward a Focus on Prevention.At the 2014 NPWH conference in Savannah, Megan McCarthy, MSN, NP-C, presented The Angina Monologues – Update on New Ways to Detect and Prevent Heart Attacks in Women and Jaye M. Shyken, MD, presented Long-Term Health Consequences of Pregnancy Complications, which included a discussion about the relationship between pre-eclampsia and gestational diabetes with future cardiovascular disease. In that vein, Suzanne Shugg, DNP, ACNP, a clinical lipid specialist who runs a Preventive Cardiology Clinic in Berkeley Heights, New Jersey, shares her insights on this topic in her article Pregnancy’s Effect on Cardiovascular Health: A Woman’s First “Cardiac Stress Test” in this issue of the journal. This issue also provides a Million Hearts tip sheet on Improving Medication Adherence Among Patients with Hypertension. This upcoming year, an NPWH task force will develop a white paper on evidence-based best practices and policy recommendations to promote cardiovascular health and wellness for women, including those who are at high risk for cardiovascular disease.

You can rely on NPWH, and Women’s Healthcare, to continue to provide cutting-edge, evidence-based women’s healthcare information to support you in providing high quality care for women from menarche through senescence.

Beth Kelsey, EdD, APRN, WHNP-BC

Use of screening tools for depression in adolescents: An evidence-based systematic review

Depression  in adolescents is a growing health concern. Signs and symptoms (S/S) of depression in adolescents tend to be overlooked by parents and primary care practitioners (PCPs), including nurse practitioners, and are instead considered a normal part of growing up.  However, many adolescents do have clinical depression that is identifiable and treatable.1 Some adolescents are at a greater risk for developing depression than others. Risk factors for depression in this age group are listed in Table 1.2

Common S/S of depression are listed in Table 2.3 Adolescents may be particularly prone to experiencing sadness, hopelessness, poor sleep, decreased appetite or concentration, loss of pleasure in activities, irritability, anger, an social withdrawal.4In addition, adolescents with depression are at an increased risk for suicide.Instead of seeking help from a  healthcare practitioner, many adolescents with depression self-medicate by using alcohol or drugs and/or by participating in high-risk sexual behavior.5

The estimated prevalence of a major depressive disorder (MDD) in adolescents aged 13-18 is 5.6%,6 with MDD being slightly more common in girls than in boys (5.9% vs 4.6%). The rate is higher in members of minorities.7Despite increased awareness about depression in teens, this mental disorder continues to go unrecognized and untreated.7,8 About 75% of adolescents in the United States are seen routinely in a primary care setting, but only 16%-38% of PCPs correctly identify the presence of a mental health condition.4

The United States Preventive Services Task Force (USPSTF) recommends routine screening for depression in 12- to 18-year-olds in the primary care setting when appropriate mental health services, including confirmation of diagnosis, psychotherapy, and follow-up, are available.6,9 The recommendation statement also includes depression screening for any child or teen with one or more of these four risk factors: parental depression, a co-morbid mental health condition, a chronic health problem, or recent experience of a negative life event.

The study

The purpose of this systematic review was to critically evaluate current evidence regarding use of depression screening tools in the adolescent population. The search focused on use of the Center for Epidemiological Studies Depression Scale for Children (CES-DC) 10and the second revise Beck Depression Inventory (BDI-II).11 Because of the paucity of such studies conducted in the primary care setting, the author included studies done in an emergency department (ED) or a school.


Formulating a PICO question. This PICO (P, Population; I, Intervention; C, Comparison; and O, Outcome) question was written to guide the search: In adolescents aged 12-18 years (P), is use of a screening tool for depression (I), compared with the usual standard of care (C), more accurate in detecting depression (O)? The author’s goal in posing this PICO question was to determine whether enough evidence exists to support screening adolescents for depression using an appropriate screening tool. This PICO question itself facilitated the search strategy and guided the selection of key words.

Search strategy. The author searched multiple databases, including Medline, Cochrane Library, CINAHL, Eric, PsycINFO, Google Scholar, and the Agency for Healthcare Research and Quality. Key words were mental health, depression, depressive disorder, adolescents, teens, screening, CES-DC, and Beck or BDI-II. The author examined publishe and unpublished works and performed a complete hand search of reference lists of the systematic reviews and other relevant articles from 2005 to 2010. All articles examining use of a screening tool specific for depression in the adolescent population were included, regardless of whether the setting was a primary care practice, an ED, or a school. Thirteen studies met inclusion criteria. A 1999 study was added because it was one of the few conducted in a primary care setting.


The search revealed two systematic reviews on adolescent depression screening,6,12but no randomized controlled trials (RCTs). Five descriptive studies using the CES-DC or BDI-II were identified.13-17 Zuckerbrot et al18 also published guidelines delineating identification, assessment, and initial management of depression in adolescents. Six studies using the designated screening tools had cross-sectional, predictive, or correlational designs. 5,19-23Table 3 lists the results and recommendations of these studies.5,6,12-17,19-23

Systematic reviews. The most robust systematic review was conducted by Williams et al6 for the USPSTF. The search did not yield any data on health outcomes among screened versus unscreened populations or any studies examining the harms of screening. Although the literature was limited with regard to the use and accuracy of screening tools, several tools, including the Patient Health Questionnaire for Adolescents (PHQ-A),24 the Beck Depression Inventory for Primary Care (BDI-PC),25 and the CES-DC,10 all performed well.

In their systematic review, Zuckerbrot and Jensen12 aimed to determine existing evidence for the various methods used to identify adolescent depression in primary care and the identification practices that were in use a the time. The investigators concluded that self-report screening tools were available and that these tools had adequate psychometric properties and feasibility for use in primary care. They discussed two important findings: (1) self-report screening tools were more accurate than physician interviews in identifying depression; and (2) PCPs who relied on patients’ presenting chief complaints to detect depression would miss many teens with depression or depressive symptoms. In addition, they found that, with regard to the usual standard of care, physicians who received additional training improved their ability to detect depression, but not to the same level as that achieved with self-report tools. Although the HEADDSS (home, education, activities, drugs, depression,  safety, and sexuality)  assessment26 is widely used in adolescent health care, Zuckerbrot and Jensen12 did not find any studies examining its effectiveness in detecting depression. In addition, they found no studies that combined three essential elements: a screening component, an intervention, and an assessment of patient outcomes  at follow-up.

Randomized controlled trials. No RCTs examining the screening  process for MDD in adolescents  were identified in the  search. Hallfors et al5 used data from the National Longitudinal Study of Adolescent Health to determine whether gender-specific  patterns of substance use and sexual behavior predicted  depression or vice versa. They used the CES-DC to assess for depression. Overall findings showed that sex and drug behaviors predicted a higher likelihood of depressive S/S, especially among girls, but that depression did not predict high-risk behavior.

Descriptive studies. Scott et al21used the BDI-II to ascertain the prevalence of depressive S/S in 351 adolescents presenting to an ED in the Midwest. Significant differences were noted among certain groups of patients: Trauma patients were more likely to refuse screening; patients presenting with a psychiatric diagnosis were more likely to be hospitalized; and patients with a previous history of a mental illness reported significantly more depressive S/S. Rutman et al22 compared the CES-DC with a two-question screening tool in 121 adolescents presenting to an ED, and found that 37% had a positive screen on the CES-DC, with 21% being positive for suicidality, and 40% were positive on the two-question screen. Consistent with other reports, these researchers found higher rates of depressive symptoms in girls.

Lazaratou et al13 aimed to clarify the prevalence of depressive S/S in high school students in Athens, Greece, and to evaluate risk factors for these S/S using the CES-DC. A total of 713 students aged 15-18 years were enrolled. Depressive S/S were found to be linked to gender (girls had higher scores than boys), school record (students with better records had lower scores), and the interaction of gender a grade (males had higher scores as they grew older).

Using a school-based sample of more than 20,000 adolescents in grades 7-12, Rhee14 examined the race-specific prevalence of 10 physical symptoms (head – ache, stomachache, musculoskeletal pain, fatigue, sore throat, dizziness, feeling hot, chest pain, painful urination, cold sweat) in adolescents and the extent to which socioeconomic status and depressive S/S explained racial differences in those symptoms using the CESDC screening tool. Headache was the most common complaint in white students (32%). American Indians had greater complaints of musculoskeletal pain (35%), feeling hot (14%), and chest pain (10%), and blacks reported more urinary symptoms (4%). Differences between whites and blacks were significant for family income and depression. Overall depression scores were higher in blacks than in whites.

Robles-Pina et al 15 examined students held back one grade during the elementary school years (early school retention) as a predictor of depression in 191 Hispanic urban teens. No significant differences were found between males and females in selfconcept, rate of retention, past feelings of sadness, or gradepoint average (GPA). Females had higher mean scores on the CES-DC than did males, with the gender difference showing a low effect size. Thirty-six percent of Hispanic adolescents had CESDC scores indicating moderate to severe depression. Adolescents retained in school had lower self-concept, greater past feelings of depression, a lower GPA, and higher rates of depression than did non-retained adolescents. All results were significant. The highest predictor of depressionwas lower self-concept.

Chisolm et al16 used the CESDC and the PHQ-A single-question tool for detecting adolescent depression, and observed the use of mental health services following screening. In this population (N = 996), 24% screened positive for depression and 14% screened positive for suicidal thoughts. Only 16% of adolescents who screened positive for depression accessed mental healthcare services within the next 180 days (P <.01). However, adolescents who acknowledge having suicidal thoughts were 8 times more likely than those who screened negative for suicidal ideation to use behavioral health services. Overall findings showed that adolescents who were screened were more likely to seek physical or mental health services. One plausible explanation of this finding was that the screening process opened lines of communication between patients and practitioners.

Zuckerbrot et al17 conducted the first and only study examining the feasibility and acceptability of screening for adolescent depression in primary care. Average time for completion of a pencil-and-paper screening tool was 4.6 minutes; the refusal rate for screening was low. Practitioners and parents reported greater satisfaction than dissatisfaction with the screening process. The time burden was not significant.

Winter et al23  performed one of the few studies assessing screening for adolescent depression in the primary care setting using one of the most reliable screening tools, the BDI-PC. This report focused primarily on the BDI-PC’s psychometric properties. Although the sample size was small (50 females and 50 males), recruitment of subjects was halted because the effect size was so large. Eighty-nine adolescents screened negative and 11 screened positive for MDD. The mean BDI-PC score of the 11 adolescents with positive screens was about 9 times higher than that of the 89 negatively screened teens.


Strengths and limitations of the evidence. Research on adolescent depression has increased over the past 10 years, but few studies have evaluated the screening process in primary care or the use of specific screening tools. The two systematic reviews discussed previously contain the strongest evidence available (Level 1), according to the Rating System for Levels of Evidence.27 However, most of the research is Level VI—evidence from descriptive studies. Each study was also evaluated using the John Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal, with the quality of the scientific evidence ranking as high, good, or low with major flaws.27Studies included in this review were deemed of good quality.

Studies varied in terms of validity, reliability, and applicability. Most were not conducted in a primary care setting. All but one was conducted in the U.S., which increases generalizability of the results. Despite their limitations, all the studies helped answer the PICO question and helped provide evidence for practice guidelines for screening for adolescent depression by PCPs. Guidelines set forth in the USPSTF are supported by the National Institute of Mental Health (NIMH),1,28 the American Academy of Pediatrics (AAP),29 and the National Association of Pediatric Nurse Practitioners (NAPNAP).3

A critical examination of available research studies regarding screening processes for adolescent depression reveals several gaps. Few RCTs investigated the screening process in primary care settings, and only one study assessed the feasibility of screening. 17  No studies examined all three critical elements—screening,treatment, and outcomes.

Two screening tools for primary  care use. The BDI-II is a widely accepted instrument for outpatient screening, performs consistently, and is linked to Diagnostic and Statistical Manual, Fourth Edition-Text Revision (DSMIV- TR) criteria.30 However, several disadvantages hamper its use in the primary care setting. Use of the tool incurs a fee, and practitioners must have additional training to use it. The BDI-II has high item difficulty and may require additional assistance in completing it. It appears more appropriate for use in intervention studies examining various treatment options in adolescent depression. The BDI-PC, by contrast, is a self-report instrument designed for primary care use in patients aged 13 years or older.

The CES-DC has not been used consistently in studies reported before 2005. This tool has gained greater popularity and been used more frequently in research  studies in the past few years. The CES-DC has been criticized for not being linked to DSM-IV-TR criteria.13,29On the plus side, this tool is readily available free of charge and does not require additional training for use. The CESDC’ reliability, validity, mean scores, and case rates of adolescent depression remain consistent across the literature. Therefore, the CES-DC is considered appropriate for use in screening adolescents for depression in the primary care setting.

Recommendations for practice

The USPSTF, in conjunction with the NIMH, has increased awareness of the need for screening for depression in adolescents and  has made practitioners more aware of the prevalence of this  mental illness in this population. 1,9 The AAP and NAPNAP have launched special tool kits and fellowship programs promoting  screening for mental  health problems in primary care.3,29Zuckerbrot et al17 found  that screening for depression in a primary care setting is quick, feasible, effective, and well accepted by patients and practitioners. Recommendations for practice include instituting a universal screening program for depression in adolescents aged 12-18 years when mental health services are available to aid in accuracy of the diagnosis, initiation of treatment, and follow-up.9

Primary care practices with available mental health support should begin screening adolescents annually for MDD at well-or acute-care visits. The CES-DC is free of charge and easy to use, and has adequate reliability and validity for use in primary care settings. Screening tools can be completed while patients are waiting to see their PCP. Partnering with a mental health practitioner to facilitate transitioning of adolescents from primary care depression screening to engagement in more in-depth psychiatry evaluation and treatment  could enhance the clinical utility of this screening endeavor.


Early identification of depression  in adolescents is a national health priority. PCPs, including primary care NPs, must learn to recognize the subtle S/S of this often-silent epidemic because most patients with undiagnosed depression present to their PCP first.8 PCPs must be aware of the common S/S of depression and how these S/S vary in different age groups. Many parents dismiss these S/S as a normal part of growing up. PCPs must be aware of current recommendations for screening, as outlined in the USPSTF 2009 statement.

More research is needed regarding screening for depression in primary care settings. In particular, studies examining the feasibility of screening, identifying efficient procedures for completing the screening and referral processes, and further testing of screening tools would be beneficial. PCPs will then be able to translate these research findings into practice. =

Sharolyn K. Dihigo is a clinical assistant professor and Interim Director of the DNP Program and Lead Teacher in the Primary Care Pediatric Nurse Practitioner  Program at The University of  Texas at Arlington. The author  states that she does not have a financial interest in or other relationship  with any commercial product named in this article.


  1. National Institute of Mental Health. Depression in children and adolescents. Updated January 29, 2013. www.nimh.nih.gov/health/ topics/depression/depression-inchildren-and-adolescents.shtml

  2. Mayo Clinic. Teen depression: Risk factors. Updated 2011. www.mayoclinic.com/health/teendepression/DS01188/DSECTION=risk-factors.

  3. Melnyk BM, Moldenhauer Z. Child and Adolescent Mental Health Fellowship Guide to Child and Adolescent Mental Health Screening, Early Intervention and Health Promotion. Kyss Fellowship ed. New Jersey: Joint Special Initiative of The National Association of Pediatric Nurse Practitioners (NAPNAP) and the NAPNAP Foundation; 2006.

  4. Melnyk BM, ed. Assessment & Evidenced-based Management o Mood Disorders in Children and Teens: Part 1. Kyss Program ed. New Jersey: Joint Special Initiative of The National Association of Pediatric Nurse Practitioners (NAPNAP) and the NAPNAP Foundation; 2009.

  5. Hallfors DD, Waller MW, Bauer D, et al. Which comes first in adolescence— sex and drugs or depression? Am J Prev Med.  2005;29(3):163-170.

  6. Williams SB, O’Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009;123(4):e716-e735.

  7. Barclay L. Managing child and adolescent depression: an expert interview with Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN. Medscape Med News. April 28, 2010. www.medscape.com/viewarticle/720910

  8. Melnyk BM, ed. Nuts and bolts of child and adolescent mental health screening and assessment: Part 1. Kyss Fellowship ed. New Jersey: Joint Special Initiative of The National Association of Pediatric Nurse Practitioners (NAPNAP) and the NAPNAP Foundation; 2006.

  9. US Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2009;123(4):1223-1228. http://www.ncbi.nlm.nih.gov/pubmed/19336383

  10. Radloff LS. The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth Adolesc. 1991;20(2):149-166.

  11. Beck AT, Steer RA, Brown GK. Beck Depression Inventory (BDI-II). San Antonio, TX: The Psychological Corporation; 1996.
  12. Zuckerbrot RA, Jensen PS. Improving recognition of adolescent depression in primary care. Arch Pediatr Adolesc Med. 2006;160:694-704.

  13. Lazaratou H, Dikeos D, Anagnostopoulos D, Soldatos C. Depressive symptomatology in high school students: the role of age, gender, and academic pressure. Comm Mental Health J. 2010;46:289-295.

  14. Rhee H. Racial/Ethnic differences in adolescents’ physical symptoms. J Pediatr Nurs. 2005;20(3):153-162.

  15. Robles-Pina RA, DeFrance E, Cox DL. Self-concept, early childhood depression and school retention as predictors of adolescent depression in urban Hispanic adolescents. School Psychology Int. 2008;29:426-441.

  16. Chisolm DJ, Lima J, Gardner W, Kelleher KJ. Adolescent behavioral risk screening and use of health services. Adm Polichy Ment Health. 2009;36:374-380.

  17. Zuckerbrot RA, Maxon L, Pagar D, et al. Adolescent depression screening in primary care: feasibility and acceptability. Pediatrics. 2007;119(1):101-108.

  18. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. identification, assessment, and initial management. Pediatrics. 2007;120:1299-1312.

  19. Perreira KM, Deeb-Sossa N, Harris KM, Bollen K. What are we measuring? An evaluation of the CES-D across race/ethnicity and immigrant generation. Social Forces. 2005;83(4):1567-1602.

  20. Phillips GA, Shadish WR, Murray  DM, et al. The Center for Epidemiologic  Studies Depression Scale with a  young adolescent populations: a confirmatory factor analysis. Multivar Behav Res. 2006;41(2):147-163.

  21. Scott EG, Luximore B, Alexander H, et al. Screening for adolescent depression in a pediatric emergency department. Soc Acad Emerg Med. 2006;13(5):537-542.

  22. Rutman MS, Shenassa E, Becker BM. Brief screening for adolescent depressive symptoms in the emergency department. Acad Emerg Med. 2008;18(1):17-22.

  23. Winter LB, Steer RA, Jones-Hicks L. Beck AT. Screening for major depression disorder in adolescent medical outpatients with the Beck Depression Inventory for primary care. J Adolesc Health. 1999(24):389-394.

  24. Johnson JG, Harris ES, Spitzer RL, Williams JB. The patient health questionnaire for adolescents. J Adolesc Health. 2002;30(3):196-204.

  25. Beck AT, Steer RA, Ball R, et al. Use of the Beck Anxiety and Beck Depression Inventories for Primary Care with medical outpatients. Assessment. 1997;4:211-219.

  26. Stephans M. Preventative health counseling for adolescents. Am Fam Physician. 2006;74(7):1151-1156.

  27. Melnyk BM, Fineout-Overton E. Evidenced-Based Practice in Nursing and Healthcare.  Philadelphia, PA Lippincott; 2005.
  28. National Institute of Mental Health. Depression in boys and adolescent males. Updated January 22, 2013. www.nimh.nih.gov/health/publications/men-and-depression/depression-in-boys-and-adolescentmales.shtml

  29. American Academy of Pediatrics. Enhancing pediatric mental health care: Report from the American Academy of Pediatrics Task Force on Mental Health. Pediatrics.2010;125(suppl 3):S69-S160.

  30. American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision. Arlington, VA:American Psychiatric Publishing; 2000.


An update on progestins and venous thromboembolism risk: What clinicians need to know *

A mandated FDA warning about the risk for venous thromboembolism (VTE) is included in package inserts for all hormonal contraceptives. However, many practitioners do not consider VTE risk with use of the progestin-only “mini-pill” containing norethindrone, the progestin-releasing intrauterine device containing levonorgestrel (LNG), or the depot medroxyprogesterone acetate (DMPA) injection as being equal to that linked to combined hormonal contraceptives (CHCs) containing estrogen and a progestin. During an educational session about insertion of the progestin-only implant Nexplanon, which contains the progestin etonogestrel (ENG), the speaker emphasized that this product was absolutely contraindicated in women with a history of thrombosis or an increased risk for thrombosis. A session participant asked why the ENG implant was singled out in this way. It was explained that ENG is “estrogen friendly, whereas DMPA is an estrogen antagonist” (personal communication, December 1, 2012). The speaker’s comment implied a risk beyond that of the routine FDA warning about VTE with respect to all hormonal contraceptives, and promoted this review of the literature on progestins and VTE risk.

The media and professional healthcare journals have reported conflicting information regarding the relationship between the progestin type used in CHCs and VTE risk. According to a meta-analysis,1 the data from studies showing an increased VTE risk with some progestins used in third-generation oral contraceptives (OCs), including desogestrel (DSG), gestodene (not available in the United States), and drospirenone (DRSP), may have been flawed.2-4 No controversy exists regarding the level of estrogen and VTE risk, however. Experts agree that estrogen doses greater than 35 mcg are associated with increased risk.5 However, what does the evidence show about the presence of DSG or DRSP in combined OCs (COCs) or of ENG, which is derived from DSG, and which is used in combination with estrogen in a vaginal contraceptive ring and by itself in subdermal implants?

In 2010, the Society of Obstetricians and Gynaecologists of Canada (SOGC) released a clinical practice guideline concluding that all COCs increase VTE risk.5 In the guideline, the rate of VTE risk rose from 4-5/10,000 woman-years in COC nonusers to 9-10/10,000 woman years in COC users, independent of progestin type. VTE risk was greatest in the first few months of use. The guideline also identified risk for VTE in pregnancy as 29/10,000 woman-years. The authors of the guideline concluded that for most healthy women of reproductive age, COC benefits will outweigh the risks.5

The SOGC guideline implied that the various types of progestin do not differ with respect to their association with VTE risk. However, if that is the case, why would the ENG implant, but not DMPA, be absolutely contraindicated in women with a history of VTE? One small statement in the Canadian guideline points to a possible reason: “The precise effects of different hormonal contraceptives on the hemostatic system continue to be studied and debated.…”5 pg 1154

Reports suggest that the use of DSG and DRSP, as compared with LNG, in COCs is associated with higher levels of sex hormone-binding globulin (SHBG) and greater resistance to the anticoagulant action of activated protein C (APC).4 However, these changes have not been thought to fully explain an increase in risk for thrombosis. The impact of higher levels of SHBG and greater resistance to APC was further evaluate in a study of the metabolic effects of another progestin, Nestorone, which is combined with estrogen in a contraceptive ring.6Rad et al6 used discriminant analysis to identify which hemostatic variables might be affecting VTE risk. These investigators hypothesiz that the increase in SHBG is indeed associated with APC resistance, but that there also are associated changes in procoagulant factor VII (FVII) and the fibrinolytic factor plasminogen (PLG). These changes cause an imbalance, the magnitude of which may explain the difference in thrombotic risk.

By stating that ENG was estrogen friendly, perhaps the speaker meant that its use is associated with higher levels of SHBG and, therefore, increased risk for changes in APC, FVII, and PLG, which increase VTE risk. This finding provides some explanation as to why the ENG implant is absolutely contraindicated for women with a history of thrombosis. The findings of Rad et al6 may also provide support for old warnings regarding increased risk for clotting with use of contraceptives that contain DSG or DRSP. Perhaps the studies by Rosing et al,2Vandenbroucke et al,3 and van Vliet et al4were flawed in relationship to the outcome measured rather than other methodology.

The European Medicines Agency (EMA), the European equivalent of our FDA, announced in late January 2013 that its Pharmacovigilance Risk Assessment Committee (PRAC) would study whether a need exists to restrict use of third- and fourth-generation CHCs because of VTE risk. In 2001, the EMA had conducted a similar review and concluded that women using third-generation pills have a small increased risk for VTE. On balance, however, the benefits and  risks were favorable for all CHCs.

Conclusions from the PRAC’s recent review were released in October 2013.7 A baseline VTE risk of 2/10,000 was reported for women not pregnant and not taking CHCs. Women taking CHCs containing LNG, norgestimate, or norethisterone (norethindrone) had the lowest increase in risk (5-7/10,000). The intermediate risk category included CHCs containing either ENG or norelgestromin, which is use in the patch (6-12/10,000), and the highest risk was noted with CHCs containing gestodene, DSG, or DRSP (9-12/10,000). The PRAC recommends that women taking CHCs without problem continue with their regimen. However, the use of certain progestins can be associated with a small increased risk for VTE. Therefore, prescribers should take into consideration both individual- and progestin-related risk factors for women just starting CHCs.7,8 =

Diane Schadewald is Clinical Associate Professor at the University of Wisconsin-Milwaukee and Chair of the National Organization of Nurse Practitioner Faculties Sexual and Reproductive Health  Special Interest Group. Joyce Cappiello is Assistant Professor of Nursing at the University of New Hampshire and Director of the ROE Consortium in Nursing, Cambridge, Massachusetts.


  1. Kemmeren JM, Algra A, Grobbee DE. Third generation oral contraceptive and risk for venous thrombosis: meta-analysis. BMJ. 2001;323(7305):131-134.
  2. Rosing J, Tans G, Hemker H, et al. Oral contraceptives and venous thrombosis: different sensitivities to activated and protein C in women using second- and third-generation oral contraceptives. Br J Haematol. 1997;97(1):233-238.
  3. Vandenbroucke J, Helmerhorst F, Bloemenkamp K, Rosendaal F. Third-generation oral contraceptive and deep venous thrombosis: from epidemiologic controversy to new insight in coagulation. Am J Obstet Gynecol. 1997; 177(4):887-891.
  4. van Vliet H, Frolich M, Helmerhorst F, et al. Association between sex hormone-binding globulin levels and activated protein C resistance in explaining the risk of thrombosis in users of oral contraceptives containing different progestogens. Hum Reprod. 2005;20(2):563-568.

  5. Reid R, Leyland N, Wolfman W, et al; Society of Obstetricians and Gynaecologists of Canada. SOGC clinical guidelines: Oral contraceptives and the risk of venous thromboembolism: an update: no. 252, December 2010. Int J Gynaecol Obstet. 2011;112(3):252-256.

  6. Rad M, Burggraaf J, de Kam M, et al. Discriminant  analysis of the metabolic effects of a new combined contraceptive vaginal ring containing Nestorone/EE vs. a second- generation oral contraceptive containing levonor – gestrel/EE.  Contraception. 2012;86(3):231-237.

  7. European Medicines Agency. PRAC confirms that benefits of all combined hormonal contraceptives (CHCs) continue to outweigh risks. October 11, 2013. www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Combined_hormonal_contraceptives/Recommendation_provided_by_Pharmacovigilance_Risk_Assessment_Committee/WC500151959.pdf

  8. Wood S. European Review: VTE risks differ for combo birth-control pills. Medscape Pharmacists. October 11, 2013. http://www.medscape.com/viewarticle/812476



Message from the CEO

NPWH is dedicated to the continuing education (CE) and professional development of nurse practitioners; we are always pursuing new ways to improve our educational offerings. We are excited about our latest program, the Women’s Sexual Health Course for NPs, which is being held on June 27-29, 2014, at  the Sheraton Dallas Hotel by The Galleria in Dallas, Texas. We are pleased to offer this course in collaboration  with the International  Society for the  Study of Women’s Sexual Health  (ISSWSH). The program  guide is presented here in the journal on the next five pages.

Nurse practitioners see many female patients who have sexual health concerns. The purpose of  this course is to provide education on  state-of-the-art diagnostic and management  strategies available for clinicians  treating women with sexual health problems. This course will provide NPs with up-to-date evidence and expert consensus on the evaluation of female sexual dysfunction and therapeutic strategies to improve the sexual health  of women. The expert faculty will impart the necessary knowledge, skills, and professional attributes that are required for excellence in the practice of sexual healthcare today.

In addition to receiving CE credits,  attendees will receive a Certificate of Completion for the Women’s Sexual Health Course that will document for patients, employers, and peers the knowledge gained in the area of women’s sexual health. We hope that you will take advantage of this exciting new educational opportunity.

– Gay Johnson

Chief Executive Officer, NPWH


Caring for survivors of sexual violence: A guide for primary care NPs

Sexual violence (SV) affects hundreds of thousands of females each year in the United States and many more throughout the world. Although most primary care practitioners, including nurse practitioners, do not attend to the immediate needs of females following a sexual  assault, they see these patients for follow-up and routine care. Familiarity with the basics of the forensic and  physical examinations, including post-exposure  prophylaxis provided in acute care settings, is important  so that NPs can plan follow-up care and educate patients. Because SV affects survivors’ short- and long-term physical and mental health, as well as the way in which they tolerate future pelvic examinations, screening for a history of SV is essential at each visit. By screening female patients for this history, NPs can provide more competent and individualized care. The purpose of this article is to familiarize primary care NPs with the acute and long-term management of SV survivors, including the necessity of screening all patients for a history of SV, in order to improve care and health outcomes for this population.

Improving care for survivors of sexual violence

Sexual violence (SV) is a common event, affecting millions of females across the globe. In the United States, 1 in 6 females experiences a rape or attempted rape over the course of a lifetime and about 300,000 females are so victimized each year. However, estimates of SV may represent only a fraction of the true number of sexual assaults. Few survivors seek physical evaluation following an assault and even fewer report the crime to law enforcement or seek prosecution. 2About 26% of women undergo a physical examination following a sexual assault and only 19% of incidents are reported to police.3 SV survivors may not seek care or report the attack out of shame, humiliation, denial of need, fear of retaliation, lack of faith in the system, or a myriad of other reasons. As a result, the true prevalence of SV is difficult to ascertain.

The World Health Organization defines rape as sexual intercourse forced physically or psychologically and involving vaginal and/or anal penetration.4  Sexual violence is a broader term that includes rape but also incorporates unwanted sexual contact such as oral sex, touching, fondling, kissing, or threats.4 Eighty percent to 90% of SV survivors are females, with rates being highest for those aged 16-24 years.5,6 About 65% of survivors know their attacker,6 who may be an acquaintance, a friend, a partner, a spouse, or  relative.

Survivors of SV deserve individualized, compassionate, competent care immediately following an assault and in the weeks, months, and years thereafter to prevent detrimental health effects Nurse practitioners who encounter  these patients in primary care must be at least familiar with physical and forensic examination protocols immediately following an assault, even if they do not perform these exams themselves. In addition, they must be aware of the physical and mental health sequelae of SV and how such a history affects the way in which females tolerate pelvic exams during routine gynecologic care.

For these reasons, and for the sake of the approximately 300,000 U.S. females who experience a rape or attempted rape each year and the many more who experience a sexual assault of any kind, NPs need to screen all female patients for this history. By comparison, 202,964 females are diagnosed with breast cancer each year and 12,280 with cervical cancer—two conditions for which NPs screen routinely.7,8 Familiarity with proper history-taking and screening, as well as the ability to provide a patient-centered exam and sensitive care, is essential to better serve this population and ensure future engagement with healthcare.

Immediate care

A female who has recently experienced a sexual assault is most likely to seek care at a rape crisis center or emergency department (ED). After life-threatening in juries have been ruled out and the SV survivor’s safety ensured, the sexual assault response team is activated. The team typically includes a sexual assault nurse examiner (SANE)/sexual assault forensic examiner (SAFE)/forensic nurse examiner (FNE), a sexual assault advocate, and a law enforcement member if the survivor plans to report the assault to police. This multidisciplinary approach improves outcomes.9,10 All SV survivors need an advocate— someone who provides emotional support, has knowledge about the physical/forensic exams and legal proceedings (but does not perform any of these exams), and serves as a liaison to community resources.11,12

Physical and forensic examinations— Examination of SV survivors is performed only by clinicians qualified to do so. These clinicians must know the legalities of their jurisdiction, the proper techniques of physical evaluation/ treatment, and the process of evidence collection and chain of custody; be willing to testify in court; and be able to perform the exam in a compassionate, patient-centered manner.12, 13 SANEs/SAFEs/FNEs are clinicians who have received additional didactic and clinical training in caring for SV survivors and are often utilized in these situations, although other clinicians may be authorized to perform these exams at their institutions.11,13

As with any encounter, the examiner begins by taking a detailed history. Care is taken to prevent re-traumatizing the survivor as she recounts the history, which is taken in a quiet, private area.12 The health history includes chronic and acute conditions, surgeries, history of interpersonal violence, the date of the most recent menstrual period, and the date of the most recent consensual sexual encounter.11, 12,14The assault history covers (1) details of the incident such as date, time, and location; (2) the identity of the perpetrator(s) if known or a description of the perpetrator(s) if unknown; (3) the types of sex acts performed; (4) whether restraints, objects, or weapons were used; (5) whether drugs or alcohol was consumed; and (6) whether a condom wasused or whether the perpetrator ejaculated inside or on the woman.11,12 The examiner documents the SV survivor’s history of bathing, showering, douching, urinating, defecating, inserting tampons, and brushing, flossing and rinsing the teeth since the time of the assault.11,12

Although the forensic and physical examinations are performed concurrently, they have different goals. The purpose of the forensic exam is to collect evidence in case the SV survivor chooses to report the sexual assault to police and pursue prosecution. Most jurisdictions use 72 hours as the cut-off to collect forensic evidence following an assault, although some jurisdictions have lengthened this time to 5 or 7 days as DNA technology improves. 12, 15 The aim of the physical exam is to assess and treat injuries and provide prophylaxis against sexually transmitted infections (STIs) and pregnancy.

Consent must be obtained from the SV survivor for each step of the physical and forensic examinations. Each step is explained, including its nature and rationale, before proceeding to the next step.12 The survivor needs to understand that she can stop the exam at any time or have only certain steps performed. 11, 12 Consent enables the survivor to begin to regain control after an assault has occurred. 12, 16

The examiner notes the SV survivor’s  behavior, appearance, and orientation as she presents for care.12 Upon arrival, a survivor may appear to be calm, indifferent, distraught, fearful, in disbelief, angry, or combative.12,16 All these responses are normal. Reassurance is essential. The forensic examination begins with the survivor undressing over a sheet covered by a piece of white paper spread on the ground.12 She is properly draped as the clothing is collected for evidence. Consideration is given to how much clothing to collect; some SV survivors may not have expendable clothing. Coats and shoes are generally not taken unless they are strongly suspected of containing evidence. Facilities providing sexual assault forensic examinations should be equipped with seasonally appropriate replacement clothing in a range of sizes.

The examiner assesses for injuries and documents them with photography, bearing in mind that absence of injury does not mean absence of an assault.12One study showed that 17% of premenopausal women and 37% of postmenopausal women sustained a genital injury from a sexual assault.17The anogenital examination can be enhanced through the use of a colposcope and toluidine dye to elucidate small lacerations.12 Specimen swabs are collected from any orifices or areas that may contain evidence of the assault, including areas where the SV survivor indicates the perpetrator may have kissed, licked, or ejaculated. If the survivor reports having scratched the perpetrator, fingernail scrapings or clippings may be collected. Combings of head and pubic hair may uncover stray hairs of the perpetrator.

STI, HIV, and pregnancy prophylaxis— Testing for STIs immediately after an assault is typically not done because of SV survivors’ poor follow-up rates.11,12,18 Instead, STI prophylaxis is offered for gonorrhea, chlamydia, and trich – omoniasis—the most common post-assault infections.11,12,18Recommended prophylaxis regimens are listed in Table 1.18-21 Cultures are collected if the SV survivor refuses prophylaxis.12 The importance of follow-up is emphasized. Hepatitis B vaccine for survivors previously unvaccinated is indicated.11-18 If pregnancy is a concern, emergency contraception needs to be offered (Table 1).18

The risk of HIV transmission from a known positive male to a female during a single consensual sexual episode is 0.1%-0.2% for vaginal intercourse and 0.5%-3% for anal intercourse.4-18 Therefore, the risk of acquiring HIV from a single sexual assault is low. Certain factors could increase HIV transmission risk during an act of SV (eg, presence of vaginal lacerations and lesions, lack of condom use, multiple assailants).4,12,18,19The utility of universal HIV prophylaxis is debatable; therefore, the risk is assessed considering all factors.12,18,19If risk is high, the Centers for Disease Control and Prevention recommends a 28-day course of a highly active antiretroviral therapy regimen initiated no later than 72 hours post-assault (Table 1).18-20 Survivors must agree to take the full course of medication, with strict adherence to follow-up. Referral to an HIV specialist is indicated for patients accepting HIV prophylaxis.19-20

Follow-up care

Follow-up care for SV survivors should last at least 6 months.22If STI prophylaxis was not provided post-assault, testing is done 1-2 weeks later.12-18 If the survivor did prophylaxis, she needs to return for follow-up 2-4 weeks after her initial visit. Depending on the patient’s history, the NP rules out pregnancy, assesses adherence to therapy, re-evaluates injuries, and schedules hepatitis B vaccinations for 1 and 6 months after the initial dose.11,12,22Follow up serology for syphilis and HIV is performed at 6 weeks, 3 months, and 6 months post-assault. 16,18 Each visit provides an opportunity to determine which services the survivor may need, such as counseling or social work, and to provide education in order to promote self-care, reduce risky behaviors, and provide reassurance and support.

Physical sequelae—Although the immediate physical concerns following SV are well known (e.g., injury, STIs, pregnancy), certain physical sequelae can develop after the initial period (Table 2).5,22-24 Forced penetrative sex that causes traumatic injury to the vagina, anus, and/or urethra may lead to persistent complications.23 SV survivors are more likely than females in the general population to develop urogynecologic problems such as urinary tract infections, vaginal bleeding, vaginal infection, pelvic pain, symptomatic fibroids, and dyspareunia.24In addition, SV survivors report significantly more non-gynecologic concerns such as headache,  back pain, digestive problems, loss of appetite, and abdominal pain.24 Immune suppression secondary to stress may lead to an increased incidence of colds and influenza.23Because health problems may persist long after the SV has ended, survivors may not associate their symptoms with past episodes of violence, which is why universal screening for this history is important. Presence of physical complaints with no other obvious cause raises suspicion of a possible history of SV.

Mental sequelae—SV survivors may experience lasting mental health effects that require attention (Table 2). Rape trauma syndrome, post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, and suicidality are of concern.22,23 Rape trauma syndrome consists of two phases. The acute phase is marked by shock and disbelief that may present as outward emotional lability or as stoic, well-controlled behavior.22Sleep and appetite disturbances, anxiety, and depression are common during the acute phase but may persist into the long-term phase, during which the survivor begins to restructure her life and return to normal routines. Because each survivor reacts to trauma differently, she must be reassured that emotional reactions vary and that counseling is available if she needs it.

About one-third of SV survivors develop PTSD or depression. 5,23PTSD is characterized by flashbacks, nightmares, and preoccupation with the assault, resulting in repeatedly reliving the experience.22Many survivors attempt to cope with these disorders through the use of drugs and alcohol.23 Survivors are 13 times more likely than females with no history of SV to attempt suicide.5 Other psychological disturbances such as stress, fatigue, sleep/appetite problems, nightmares, and sexual dysfunction may be more vague, but they are common and warrant just as much attention as major disorders. 22 In the absence of other causes, these subtle changes in function suggest the need for screening for an SV history. Mental health referrals are indicated for the management of survivors experiencing psychological sequelae of SV.

Screening for sexual violence history

Given the high prevalence of SV,  NPs are likely to encounter patients with this history. Most female patients do not disclose a history of SV unless specifically asked.16In a study by Hilden et al,25 20.7% of patients presenting for a gynecologic examination had a history of SV, but only 7.6% reported it to their clinician. A history of SV can significantly affect a survivor’s physical and mental health, as well as increase the anxiety she feels about gynecologic exams. All female patients need to be screened for a history of SV, which can be done as NPs ask about other forms of interpersonal violence. In 2011, the Institute of Medicine recommended that all women be screened for inter personal violence, which includes SV, at every visit in an effort to identify current abuse, prevent it in the future, and decrease adverse effects of it.26 Some NPs may hesitate to ask questions about SV because of concern about offending the patient, not knowing the right action to take if the patient does disclose SV, or having adequatetime to handle the disclosure.

To overcome practitioners’ hesitation or concern about screening for SV, the National Sexual Violence Resource Center recommends approaching the interaction by (1) normalizing it by stating that it is part of a routine health history and that these questions are posed to all female patients; (2) providing context for the questions by acknowledging that SV is widespread; (3) connecting SV to health status by informing the patient that this violence can affect her health; and (4) asking about any unwanted sexual experiences (Table 3).27

NPs can ask simply, “Have you ever experienced unwanted sexual activities with a partner, acquaintance, or stranger?” This question is posed when the patient is alone, without judgment. Terms such as rape, sexual assault, abuse, and sexual violence are avoided; many SV survivors may not describe their experience with these terms.27 The New York State Coalition Against Sexual Assault developed the SAVE screening tool, which stands for Screen all patients for sexual assault, Ask direct questions in a non-judgmental way, Validate the patient’s response, and Evaluate, educate, and refer (Table 3).28 If a patient does disclose a history of SV, NPs assess her immediate safety, ask her what help she needs, and refer her to appropriate counseling or community resources.28

Pelvic examination of sexual violence survivors

Many female patients experience anxiety before and during pelvic examinations because of embarrassment about exposing intimate body parts, concern about hygiene, fear of pain, and worry about possible diagnoses.25  SV survivors are even more likely to experience anxiety and discomfort with this type of exam because it can elicit feelings of vulnerability reminiscent of the violence they have experienced. 16, 22,25 This anxiety and discomfort may ultimately lead them to avoid gynecologic care altogether. Simple techniques that increase involvement and education of the patient during the exam may make pelvic examination more tolerable for SV survivors, as well as for any females presenting for routine care.

The first step is simply developing a rapport with the patient,  which is of particular importance in an SV survivor who may feel vulnerability and distrust.29Acknowledging a patient’s anxiety, taking time to listen to her thoughts or worries, and providing information on what she can expect during the exam can attenuate her distress and discomfort. 25, 30-32The patient begins to understand that she is in control of the exam and can end or modify it at any time. A pelvic exam should never be forced. If the patient requests that the exam end, reassure her that it is okay and that the exam can be preformed at another time.32

Her sense of control can be heightened by offering her a mirror (if she feels comfortable using it) so that she can inspect her own genitalia while the clinician explains normal anatomy, thereby demystifying a part of her body over which she may feel she has lost control.31Another way to shift the power differential is to allow the patient to insert the speculum herself.33 Studies have shown that patients who are examined in modified lithotomy positions without the use of stirrups report less discomfort and vulnerability.34 Compared with simply urging a patient to relax during a pelvic exam, providing information and guidance about what is being performed and what the patient can expect to experience makes the exam more tolerable.31


Many SV survivors present to  rape crisis centers or EDs for immediate evaluation and potential evidence collection. NPs need to be familiar with the components of the immediate care offered to SV survivors, including the forensic exam and post-exposure prophylaxis protocols, so that they will know which services have already been provided and will be able to meet patients’ ongoing needs  for follow-up care. Some patients may present to their NP explicitly for SV-related follow-up. Other patients will be seeking routine care and make no mention of a history of SV. Therefore, NPs must be adept at screening for this history and capable of recognizing the common physical and mental sequelae of SV in order to make proper diagnoses and offer appropriate treatments and referrals. NPs must take the time and effort needed to perform gynecologic exams in a way that decreases anxiety on the part of the patient and promotes future engagement with  healthcare practitioners. Internet resources are listed in the sidebar Internet resources. =

Laurie Ray is a recent graduate  of the Women’s Health Nurse Practitioner program and Mary- Jane McEneaney is the WHNP Program Director, both at Columbia University School of  Nursing in New York, New York. The authors state that they do not have a financial interest in or other relationship with any  commercial product named in  this article.


  1. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women. Washington, DC: U.S. Department of Justice, Office of Justice; 2000.
  2. Basile KC, Saltzman LE. Sexual Violence Surveillance: Uniform Definitions and Recommended Data Elements. Atlanta, GA: National Center for Injury Prevention and Control, Center for Disease Control and Prevention;  2002.
  3. Resnick HS, Holmes MM, Kilpatrick DG, et al. Predictors of post-rape medical care in a national sample of women. Am J Prev Med. 2000;19(4):214-219.
  4. Krug EG, Dahlberg LL,  Mercy JA, et al. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002.
  5. Patel A, Panchal H, Piotrowski ZH, Patel D. Comprehensive medical care for victims of sexual assault: a survey of Illinois hospital emergency departments. Contraception. 2008; 77(6):426-430.
  6. U.S. Department of Justice. Criminal Victimization in the United States, 2008 Statistical Tables. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2010.
  7. Centers for Disease Control and Prevention. Breast Cancer Statistics. November 23, 2010. www.cdc.gov/cancer/breast/statistics/
  8. Centers for Disease Control and Prevention. Cervical Cancer Statistics.  November 23, 2010. www.cdc.gov/cancer/cervical/statistics/
  9. Lewis-O’Connor A. The evolution of SANE/SART – are there differences? J Forensic Nurs. 2009;5(4):220-227.
  10. Plichta SB, Clements PT, Houseman C. Why SANEs matter: models of care for sexual violence victims in the emergency department. J Forensic Nurs. 2007;3 (1):15-23.
  11. McConkey TE,  Sole ML, Holcomb L. Assessing the female sexual assault survivor. Nurse Pract. 2001;26(7):28-40.
  12. U.S. Department of Justice. A National Protocol for Sexual Assault Medical Forensic Examination: Adults/Adolescents. 2nd ed. Washington, DC: U.S. Department of Justice, Office on Violence Against Women; 2013.
  13. Stermac L. Dunlap H, Bainbridge D. Sexual assault services delivered by SANEs. J Forensic Nurs. 2005;1(3):124-128.
  14. Boykins AD.  The forensic exam: assessing health characteristics of adult female victims of recent sexual assault. J Forensic Nurs. 2005;1($):166-171.
  15. Ledray L. Expanding evidence collection time: Is it time to move beyond the 72-hour rule? How do we decide? J Forensic Nurs. 2010;81(4):489-495.
  16. Luce H, Schrager S, Gilchrist V. Sexual assault of women. Am Fam Physician. 2010;81(4):489-495.
  17. Morgan L, Dill A, Welch J. Sexual assault of postmenopausal women: a retrospective review. BJOG. 2011;118(7):832-843.
  18. Workowski KA, Berman S. Sexually Transmitted Disease Treatment Guidelines, 2010. Atlanta, GA: Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2010.
  19. Wieczorek K. A forensic nursing protocol for initiating human immunodeficiency virus post-exposure prophylaxis following sexual assault. J Forensic Nurs. 20100;6(1):29-39.
  20. Smith DK, Grohskopf LA, Black RJ, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States. Atlanta, GA: Centers for Disease Control and Prevention; 2005.
  21. Update to CDC’s Sexually transmitted diseases treatment guidelines, 2010: oral cephalopsporins no longer a recommended treatment for gonococcal infections.  MMWR Morb Mortal Wkly Rep. 2012;611(31):590-594.
  22. Tavara L. Sexual Violence. Pract es Clin Obstet Gynaecol. 2006;20(3): 395-408.
  23. Campell JC. Health consequences of intimate partner violence. Lancet. 2002;359(9314):1331-1336.
  24. Campbell J, Jones AS, Dienemann J, et al. Intimate partner violence and physical health consequences. Arch Intern Med. 2002; 162(10):1157-1163.
  25. Hilden M, Sidenius K, Langhoff-Roos J, et al. Women’s experience of the gynecologic examination: factors associated with discomfort. Acta Obstet Gynecol Scand. 2003;82(11):1030-1036.
  26. IOM (Institute of Medicine). Clinical Preventive Services for Women:  Closing the Gaps. Washington, DC: Institute of Medicine of the National Academies, Committee on Preventive Services for Women; 2011.
  27. National Sexual Violence Resource Center. Assessing Patients for Sexual Violence: A Guide for Health Care Providers. Enola, PA: National Sexual Violence Resource Center; 2011.
  28. Basile KC, Hertz MF, Back SE. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2007.
  29. Murphy SB, Potter SJ, Pierce-Weeks J, et al. Providing context for social workers’ response to sexual assault victims. Affilia. 2011;26(1):90-94.
  30. Fontenot HB, Fantasia HC. Understanding feminism: considerations for nurses working to end violence against women. J Forensic Nurs. 2011; 7(1):37-31.
  31. Huber JD, Pukall CF, Boyer SC, et al. “Just relax”: physicians’ experiences with women who are difficult or impossible to examine gynecologically. J Sex Med. 2009;6(3):791-79.
  32. Alison MD, Cromwell PF. How to perform a pelvic exam for the sexually active adolescent. Nurs Pract. 2002;27(9):28-43.
  33. Wright D, Fenwick J, Stephenson P, Monterosso L.  Speculum ‘self-insertion’: a pilot study. J Clin Nurs. 2005;14(9):1098-1111.
  34. Seehusen DA, Johnson DR, Earwood JS, et al. Improving women’s experience during speculum examinations at routine gynaecological visitsL randomized clinical trial. BMJ. 206;333(7560):171.


Editor-in-chief’s message

Dear Colleagues,

I want to take this opportunity to update you on a change in out Guidelines for Authors. 

When we first established the guidelines, we decided that we would not consider student manuscripts, primarily for practical reasons. We do not have sufficient editorial staff to review dozens of manuscripts of DNP students who, as a requirement for graduation, must submit a paper to an advanced practice nursing (APN) journal. And even though our journal is published online, we are still limited in terms of the number of pages that each issue can contain. So we decided to limit the pool of prospective authors to APNs who are in practice and to those who are doing research and/or teaching.

However, we realize that we may be missing out on excellent manuscripts written by DNP students or recent DNP graduates that would be worthy contributions to the APN literature. In addition, NPWH, our managing editor Dory Greene, and I want to support doctoral students and recent graduates in becoming authors and in giving them the opportunity to share up-to-date information with a clinical focus that is useful n everyday practice. Therefore, we are now accepting manuscript submissions from master’s-prepared APNs who are enrolled in a program granting a doctoral degree. Students who have previously authored an article in a peer-reviewed journal may submit a manuscript as a solo author (documentation of this previously published work must be provided at the time of manuscript submission). Otherwise, we require that the student’s faculty advisor or another faculty member, as appropriate, serve as second author on the manuscript.

To qualify as a second author, this person must make a substantive intellectual contribution to drafting the manuscript or revising it critically for important intellectual content and must approve the version of the manuscript to be submitted. In addition, if the manuscript is a report on research that has been conducted, all authors must have made a substantive intellectual contribution to the conception and design of the study, or the acquisition of the data, or analysis and interpretation of the data. These requirements are in accordance with those of the International Committee of Medical Journal Editors. All authors assume responsibility for the content of the manuscript.

Although Dory will know about an author’s status as a doctoral student when a manuscript is submitted to us, our peer reviewers and I receive blinded versions of the manuscript. We do not know the names, credentials, or educational or professional status of any authors until a paper is accepted for publication. Our editorial and peer reviewer decisions are made solely on the merits of the manuscript.

As an alternative to submitting a manuscript in capstone project or dissertation-style, you can disseminate key points or important aspects of your doctoral work using one of these formats:

  • Case study: This relatively short article (maximum, 3000 words, excluding references and graphics) addresses complex women’s health situations and is presented in a way that challenges readers to “solve the case.” The particular challenge may include co-morbidities and/or psychosocial, cultural, or ethical dimensions that complicate the situation. Case studies provide an opportunity to include evidence-based information on diagnostic tests,  pharmacologic and nonpharmacologic aspects of treatment, and the most up-to-date guidelines.
  • Assessment and Management: This department presents short pieces (1000-1300 words) focusing on health promotion/disease prevention screening and counseling or on assessment and management of a specific condition or presenting complaint. You can include short case scenarios to add to the interest, weaving in the assessment and management pieces in a patient-centered manner.
  • Systematic review: If, in the development of your capstone project or dissertation, you used a systematic search method of relevant studies that included identification of those that met pre-determined eligibility criteria and assessment of validity of findings, you might consider using this format. Systematic reviews require several explicit and reproducible steps. Use the PRISMA statement website as a guideline. This website provides a 27-item checklist and a 4- phase flow diagram for systematic reviews and meta-analyses of studies.
  • Research study: Your original research study, with clinical implications, is eligible for consideration and acceptance.

So, let this be a call for manuscripts to all APN authors, including doctoral students.

Need an idea for a manuscript topic? Members of our Editorial Advisory Board have offered these suggestions: abnormal uterine bleeding, anal neoplasia, bacterial vaginosis (persistent/recurrent), benign breast diseases, bleeding in early pregnancy, clinical skills (e.g., pessary insertion, simple cystometrography, pelvic floor electromyography, vulvar biopsy), colposcopic evaluation of lower genital tract disease, common adolescent problems (e.g., abnormal menses, dysmenorrhea, teen pregnancy), contraceptive options for women with chronic health conditions, evidence-based pre-conception care, female sexual dysfunction, HPV update, infertility, IUC placement pearls, mammography guidelines, medication effects on lactation and the newborn/ infant, management of nongynecologic conditions in pregnancy (e.g., epilepsy, asthma, migraine, lupus, coagulation defects, heart disease, rheumatoid arthritis, thyroid disease), nonpharmacologic management of perimeno pausal vasomotor symptoms, Pap test guidelines, pelvic floor wellness, oral neoplasia, parental grieving following an unanticipated pregnancy outcome, post-abortion care, sterilization for women and men, STI prevention counseling, and transgender sexual and reproductive health care.

We look forward to learning from all of you! As a reminder, please follow the author guidelines available on our website. For DNP students, recent graduates, and their faculty advisors, a useful resource is an article by Lorraine Steefel and Cynthia Saver, From Capstone Project to Published Article,” which was published in the May 2013 issue of American Nurse Today.

Beth Kelsey, EdD, APRN,  WHNP-BC

Individualizing contraception

Contraceptive counseling: Why is it so important?

The disconnect between two seemingly contradictory facts— effective contraception is widely available, but almost half of pregnancies in the United States are unintended—highlights the need for better communication between healthcare practitioners (HCPs) and their patients about contraception and the development of strategies to increase patient adherence to and satisfaction with contraceptive regimens. Women also need more information about how to use and obtain emergency contraceptives (ECs).

Among the 6.4 million pregnancies that occur in the United States each year, 49% are unintended. 1 Of these unintended pregnancies, 29% happen earlier than desired and 20% happen after women have reached their desired family size. In addition, of these unintended pregnancies, 52% occur in the absence of the use of contraception, 43% occur with inconsistent or incorrect use, and 5% occur with consistent use and method failure. When asked about reasons for their nonuse of contraception, women report problems accessing or using methods (40%), infrequent sex (19%), lack of caring about whether pregnancy occurs (18%), underestimation of the risk of pregnancy (7%), and other reasons (16%).1

Contraceptives vary in terms of efficacy. Although all contraceptive are highly effective with perfect use, the most effective agents—the hormonal intrauterine contraceptive (IUC), the copper T-380A intrauterine device (IUD), and the subdermal implant— have high levels of efficacy with typical use because there is no user component that may result in incorrect or inconsistent use. Based on typical-use data, the oral contraceptive (OC), the vaginal ring, the patch, and the injection are less effective than IUCs and the implant—primarily because they require user actions and decision making. The least effective options are those that are coitus dependent: condoms, withdrawal, other barrier  methods, and spermicides.2Of note, the highest levels of satisfaction with contraceptives are reported by users of IUCs and the ring.3

Forty-six percent of women discontinue a birth control method because of dissatisfaction. 4 To reduce this discontinuation rate, HCPs need to provide effective counseling. Such counseling requires asking patients about their goals and attitudes regarding contraception and then listening carefully to their answers. That way, HCPs can be confident that they are prescribing the form of contraception that will best meet patients’needs and with which they will be most satisfied. Reports suggest that inconsistent use of combined OCs (COCs)—that is, those containing an estrogen and a progestogen—is more common among women who are not completely satisfied with their method.4

Healthcare practitioners must provide each patient with a knowledge base so that she can make informed decisions about birth control and birth control options. In the process, HCPs may need to correct deeply entrenched misinformation. HCPs also must provide anticipatory guidance about the use and the side effects of contraceptives and ECs. The bottom line: Patients need to leave the office knowing what to expect from the contraceptive they have selected and they need to know how to obtain and use an EC in the event of contraceptive mishap (e.g., torn condom, dislodged diaphragm) or nonadherence.

Strategies for selecting a contraceptive

Strategy 1: Set the stage for an effective visit. Although HCPs are pressed for time, they can obtain key information to help them partner with a patient and help her select the most appropriate contraceptive option for her before she even enters the examination room. When a patient calls to schedule an appointment with a goal of contraceptive counseling, she can be referred to the Association of Reproductive Health Professionals method match website.

This website will enable the patient to become familiar with the options and evaluate them prior to her visit. On standard forms that a patient completes in the waiting room, HCPs can include questions about pregnancy plans. Do you desire a pregnancy within 1 year? Within 1-3 years? Within 3-5 years? Not for 5-10 years or more? Not at all? Her answer will help you narrow down the list of options. Next, ask the patient about her contraceptive history: What forms of contraception have you used? What did you like/dislike about each method?

Discuss contraception prior to the physical examination, while the patient is still clothed; she is unlikely to give you her full attention if she is trying to keep the paper drape closed. Have samples of the contraceptive products in the exam room so that the patient can see and handle them.

Strategy 2: Analyze perfect use versus typical use. The level of participation and decision making required of patients in the use of a contraceptive method accounts for the gap between perfect use and typical use. The more user participation that is needed (e.g., remembering to take a pill every day), the greater the gap between perfect use and typical use. Although all contraceptives used correctly and consistently offer excellent efficacy, first-year rates of unintended pregnancy associated with typical use range from 8% with OCs to less than 1% for long-acting reversible contraceptives (LARCs; i.e., IUCs and implants) that require no patient participation or decision making.5

Therefore, each patient should be asked about how she will manage the use of contraceptives that require daily, monthly, or quarterly actions on her part. Ask her, “If you choose condoms or OCs, will you be able to manage them? These forms of contraception take more work on your part. Conversely, a long-acting method frees you from having to think about it; put it in and forget it.” The rate of non-LARC contraceptive failure is particularly high for adolescents. Among users of OCs, the patch, or the ring, the yearly failure rate in the first year of use is 8.2% among women aged 30 years or older and 13.4% among adolescents.6,7

Strategy 3: Teach patients that LARCs are more effective than other methods in preventing unplanned pregnancy, especially over time. Long-term use of agents that require decision making on a patient’s part, as compared with long-term use of LARCs, is associated with increased risk of incorrect or inconsistent use and pregnancy. This finding was confirmed in a recent study of 7,486 women using LARCs (i.e., IUCs or implants) or another commonly prescribed contraceptive (OC, patch, ring, or depot medroxyprogesterone acetate [DMPA] injection).7The contraceptive failure rate among participants using non-LARCs— that is, OCs, the patch, or the ring—was 4.55 per 100 participant- years, as compared with 0.27 among participants using LARCs (adjusted hazard ratio [HR], 21.8; 95% confidence interval (CI), 13.7-34.9). Rates of unintended pregnancy were similarly low among participants receiving the DMPA injection and those using an IUD or an implant. In this investigation, for users of OCs, the patch, or the ring, the contraceptive failure rate increased over time, from about 5% in year 1 to nearly 8% in year 2 and more than 9% in year 3. LARCs, including DMPA, had failure rates of less than 1% for each of the 3 years. Therefore, the need for correct and consistent use of contraception should be reviewed at each patient visit, year after year.

Strategy 4: Assess the options that best meet an individual patient’s needs. Ask each patient how the methods that interest her will fit into her life—now and, in light of ongoing concerns regarding adherence, in the future. How will each method fit into her schedule? For example, how will she remember to take the pill or change the patch? Which bleeding patterns will be acceptable? If, in the first few months, a patient does not know when bleeding is likely to occur, will this be a problem for her? Is privacy of the method a concern? Are there any financial barriers? If so, are there assistance programs or installment payment plans available? Review the patient’s record for any conditions (e.g., dysmenorrhea, heavy menstrual bleeding, menstrual migraine, acne) that could be simultaneously managed by specific methods. Finally, determine whether the patient has any contraindications to any birth control methods. For example, use of combined hormonal contraceptives is contraindicated in patients with migraine with aura and in users of certain types of anticonvulsants.

Strategy 5: Dispel myths, especially those related to IUCs. To dispel common misconceptions about IUCs, discuss their mechanism of action with patients These devices prevent fertilization; they do not cause abortions.2,8 Another myth to dispel is any association between IUC use and an increased risk of ectopic pregnancy. The contraceptive effectiveness of these devices is 99.9%; the risk of pregnancy is very small. In the event that pregnancy should occur, the possibility of an ectopic pregnancy is of concern, but the likelihood  such an occurrence is minute.2,8

Testing for sexually transmitted infections (STIs) in women scheduled to undergo IUC insertion is generally not done unless they are at risk for chlamydia and gonorrhea (e.g., women aged 25 years or younger). Risk of pelvic inflammatory disease is higher at IUC insertion only if a woman tests positive for chlamydia or gonorrhea.2,8

Strategy 6: Help your patient be successful in adhering to her contraception regimen. Once a woman has selected a contraceptive, help her be successful in its use. This checklist can help ensure that she has the tools she needs for success. Your patient…

Leaves the office knowing, in simple terms, how the option she has selected works;

Understands how to use the method correctly;

Is aware of the side effects, which you have explained using simple terms;

Knows the warning signs that signal potential complications and what her course of action should be;

Understands the indications for EC use and knows where and how to obtain an EC;

Realizes that, if she doesn’t like her contraceptive choice, she can return to your office for assistance in choosing a different method that is better suited to her needs;

Has resources to help her remember key points about the contraceptive she has chosen, including handouts and information about websites that provide accurate information;

Knows that she will still need to protect herself against STIs.

Emergency contraception

Many HCPs are uncomfortable with the topic of emergency contraception and do not discuss it unless a patient asks about it. In patients’ best interest, though, HCPs need to use every visit as an opportunity to discuss contraception and the potential need for an EC. ECs are defined as contraceptives intended to prevent pregnancy within the first few days of unprotected sex. The most commonly used ECs contain oral levonorgestrel (LNG). Ulipristal acetate, a selective progesterone receptor modulator, is another oral EC. Another effective method of EC available is the copper IUD, which is used off label for this indication.

Levonorgestrel agents are available in two over-the-counter dosing regimens.9-14The onetablet regimen contains LNG 1.5 mg. On label, this product is taken within 72 hours after unprotected intercourse, when it is most effective. Off label, it can be used up to 120 hours after intercourse. The second regimen is a two-tablet product that also contains a total of 1.5 mg of LNG (0.75 mg per pill). The package labeling states that one pill is taken immediately after unprotected intercourse and the second pill, 12 hours later. Off-label directions are to take both pills at  once, preferably within 72 hours of unprotected intercourse. For both LNG regimens, greatest efficacy  is achieved when the medication is taken within 72 hours of unprotected intercourse, but efficacy has been demonstrated up to 120 hours after unprotected intercourse. After EC use, a highly effective contraceptive should be started; a backup method (e.g., condoms) is needed for 7 days.

Ulipristal acetate 30 mg is available by prescription.13-16 This product can be used during the first 120 hours after unprotected intercourse. Unlike other agents, ulipristal acetate maintains efficacy during the full 120 hours after intercourse. This EC, which is highly effective in obese women as well as their normal-weight counterparts, may be ordered from an online prescription service. After use, a highly effective contraceptive should be started; a backup method is needed for 14 days.

The copper IUD can provide emergency contraception within 5 days of unprotected intercourse. Although use of the copper IUD is off label for this indication, one advantage is that this product can then be retained as a long-acting contraceptive. Efficacy of this EC method was shown in a prospective study of 542 women who presented for emergency contraception. 17The 1-year cumulative pregnancy rate in women choosing the copper IUD was 6.5%, as compared with 12.2% in those choosing oral LNG (HR, 0.53; 95% CI, 0.29-0.97; P = .041]. Thus, 1 year after presenting for emergency contraception, women choosing the copper IUD were half as likely as those choosing oral LNG to have a pregnancy.

Strategy 7: Ensure access to ECs. Results of a 2013 patient survey by NPWH have shown that more than 75% of HCPs do not discuss emergency contraception with their patients. However, patients who find themselves in need of an EC should learn about it through communication with their HCP. Furthermore, a 2011 survey distributed to the email database of NPWH (N = 10,800) and completed by 699 clinicians showed important gaps in best practices in patient care among the respondents:

• 55.3% reported that they review EC options with each reproductive aged patient.

• Although 88.2% of respondents  said that they tell patients about LNG, only 26.5% reported discussing ulipristal acetate; 21.9%, the copper IUD; and 16.1%, the Yuzpe method.

• Only 44.3% of respondents said that they provide information and/or a prescription for an EC to all patients who do not desire pregnancy.

In view of the fact that 49% of pregnancies in the U.S. are unintended, HCPs are advised to review EC use and availability at each office visit by (1) explaining what EC does, how it works, and when to use it; (2) providing an anticipatory prescription; and (3) reviewing and dispelling myths about ECs. Concerns about ECs’ mechanisms of action remain associated with major barriers to use.14 Many women believe that ECs are abortifacients with long-term effects on health and fertility. 18A patient’s poor understanding of reproductive physiology may result in confusion as to when ECs are most effective. 19,20

Case studies

Case 1: Tanya is 24 years old, is 5’5″, weighs 121 lb (body mass index [BMI], 20.1 kg/m2), and has no prior pregnancies or health problems. Tanya schedules a visit to request a different OC because of bothersome light bleeding for the past 3 months.  She currently uses a COC containing ethinyl estradiol 20 mcg and norethindrone. Further discussion reveals that Tanya skips taking her birth control pill no more than once a week. She has had three male partners in the past 3 months and reports condom use about half the time. She reports smoking about 10 cigarettes a day,

Assessment. Begin by doing a workup concerning the abnormal bleeding, which may or may not be related to the COC regimen. Rule out pregnancy and STIs and perform speculum and bimanual examinations. Because Tanya has no mucopurulent cervicitis, discharge, or tenderness, and her test results are all negative, you conclude that the irregular bleeding is a side effect of the COC use. As you recall, the longer a patient uses a method, the more likely she is to use it incorrectly.

Counseling. Develop strategies to encourage correct and consistent COC use. In this case, consider changing formulations to reduce side effects. Review all the options with Tanya. Take this opportunity to discuss nondaily methods. Although Tanya is not a heavy smoker, remind her that her nicotine intake could be sufficient to induce breakthrough bleeding. Discuss safer sex and the importance of protecting herself from STIs. Review the indications for EC use. Make sure she knows how and where to obtain an EC. Provide a prescription for an EC product.

Patient decision. Tanya is interested in using a nondaily contraceptive and wants to try the ring. Discuss the use, side effects, and warning signs, and reinforce the fact that the ring will not protect against STIs. If the device is expelled or if Tanya is not punctual about replacing the ring, she will need to use an EC following unprotected intercourse. Schedule a follow-up visit to discuss Tanya’s satisfaction with the ring. At a follow-up visit, Tanya indicates that she likes the ring and has had no episodes of unscheduled bleeding.

Case 2: Annette is 17 years old, is 5’7″, weighs 220 lb (BMI, 34.5 kg/m2), and has had no prior pregnancies. Annette has scheduled her appointment for contraceptive counseling and looks to you for advice.

Assessment. Annette’s history includes obesity, migraine with aura, dysmenorrhea, and menorrhagia. Her partner uses condoms about half the time. She worries about weight gain with hormonal contraceptives. She is uncertain about her ability to remember to take a daily pill. Because of her migraine with aura, methods that contain estrogen are contraindicated. A patient with migraine without aura could use estrogen products as long as her blood pressure is monitored and her headache severity and frequency are not adversely affected. Progestin-only pills (POPs) would be a good option if Annette had indicated a willingness to use them consistently. DMPA can be associated with weight gain, which is already a concern for her.

The LNG intrauterine system (IUS) represents a good option because it may help alleviate Annette’s cramping and bleeding, which would be likely to increase her satisfaction with this method. An implant might be a good choice, but she likes the longer duration associated with the LNG IUS. The 10-year duration of the copper IUD appeals to her, but she would like the reduction in menstrual problems that may result from use of the LNG IUS.

Patient decision. Annette selects the LNG IUS. Review the mechanism of action, side effects, and warnings, with an emphasis on the transitional bleeding interval. Although bleeding patterns will likely normalize within 3 months, tell her that it may take 6 months. This strategy accounts for the variability in duration and reduces the potential for frustration. Review safer sex and condom use at the initial discussion and before and after placement of the device.

Case 3: Regina is 44 years old, is 5’5″, weighs 200 lb (BMI, 33.3 kg/m2), and has no history of pregnancy. Regina has scheduled a visit for her well-woman examination. She has not been sexually active since her divorce, but she has started a relationship that she believes may become serious. Therefore, you initiate a discussion about contraception.

Assessment. Regina’s history is unremarkable except for a cholecystectomy at age 30. Her menstrual history remains normal, with menses marked by predictable intervals, duration, and cramps, all of which indicate ovulation. She takes naproxen sodium for moderate to severe cramps. Regina has a demanding job in advertising and travels often, noting fatigue associated with erratic schedules and frequent time zone changes. Her variable schedule makes it difficult to sustain an exercise regimen. She indicates that she would like to exercise more regularly to lose weight. Regina and her husband got divorced 5 years ago; early in the marriage, they had decided not to have children. He underwent a vasectomy. A nonsmoker, she drinks wine 1-2 times a week in social settings.

Counseling. Regina does not use contraception. However, data show that unplanned pregnancy is most likely among younger and older women. Convey to Regina that in women of her age, pregnancy is associated with an increased risk for maternal mortality, spontaneous abortion, and fetal abnormalities. Discuss ECs, safer sex, and STI risk.

Patient decision. Based on her profile, Regina is eligible for any contraceptive, although the patch may be less effective because she weighs more than 198 lb. Other less-than-optimal choices are COCs or POPs because she has indicated that she has an irregular daily routine and schedule. She is more interested in an IUD; either the LNH IUS or the copper IUD is appropriate for her. She considers each option: 5-year versus 10-year efficacy and hormonal versus nonhormonal characteristics.

Regina wants to do some research on her own. Refer her to a reliable website such as www. arhp.org/methodmatch. She plans to start Weight Watchers and a swimming routine that she can implement in many of the hotels at which she stays. You and Regina decide that she will call you as soon as she makes her decision about which IUC to use, and that, in the meantime, she will keep condoms available for use if needed. At her next visit, Regina informs you that she has decided to use the copper IUD because she prefers a nonhoromal method.

A final word about contraceptives and weight gain

Two of the tree cases discussed in the article involve women who are obese. Sixty-four percent of women in this country are overweight and 36% are obese. 21 Therefore, body weight may be an important consideration when choosing a contraceptive; some options may be associated with a tendency for a weight gain and some may not be as effective in obese women.

In terms of the former concern, four randomized, placebo-controlled trials showed no evidence supporting a casual association between use of COCs or a combination patch and weight gain. 22 Results of a similar review were inconclusive with regard to progestin-only contraceptives. 23 However, a prospective study of 450 adolescents showed that among those using DMPA, those who were already obese gained significantly more weight than did their non-obese counterparts. 24 Also, the obese DMPA users gained significantly more weight than did obese COC users or obese nonusers of hormonal contraception. With regard to contraceptive efficacy, the patch may be less effective in women weighing 198 lb or more. 25 With regard to EC efficacy in obese women, ulipristal acetate may be a better choice than LNG-containing ECs.  26


Even though information about contraceptives is readily available in print and online, and even though contraceptives themselves are easily available and, in many cases, fully covered by health insurance payments to pharmacies, many adolescents and women are not using these products correctly, consistently, and persistently. HCPs, including nurse practitioners, can fill in the knowledge gap by making sure to discuss contraceptive needs with all their patients, and to find the product or products that will work best for them.


1.  Frost JJ, Darroch JE, Reme L. Improving contraceptive use in the United States. In Brief. Guttmacher Institute. 2008. www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf

2. Hatcher RA, Trussell J, Nelson AL, el al, eds. Contraceptive Technology: Twentieth Revised Edition. New York, NY: Ardent Media, Inc.;2011.

3. Revisiting Your Women’s Health Care Visit. Harris Interactive for the Association of Reproductive Health Professionals. Conducted June 30–July 14, 2004.

4. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception. 2007;

5. Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al, eds. Contraceptive Technology: Twentieth Revised Edition. New York, NY: Ardent Media; 2011:45-74.

6. Kost K, Singh S, Vaughan B, et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception.2008;77(1):10-21.

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

8. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet. 2000;356(9234):1013-1019.

9. Arowojolu AO, Okewole IA, Adekunle AO. Comparative evaluation of the effectiveness and safety of two regimens of levonorgestrel for emergency contraception in Nigerians. Contraception. 2002;66(4):269-273.

10. Piaggio G, von Hertzen H, Grimes DA, Van Look PF. Timing of emergency contraception with levonorgestrel or the Yuzpe regimen. Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1999;353(9154):721.

11. von Hertzen H, Piaggio G, Ding J, et al; WHO Research Group on Postovulatory Methods of Fertility Regulation. Low dose mifepristone and two  regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002;360(9348):1803-1810.

12. Ngai SW, Fan S, Li S, et al. A randomized trial to compare 24 h versus 12 h double dose regimen of levonorgestrel for emergency contraception. Hum Reprod. 2005;20(1):307-311.

13. The Emergency Contraception Website. www.not-2-late.com

14. Reproductive Health Technologies Project website. www.rhtp.org

15. Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011;84(4):363-367.

16. Moreau C, Trussell J. Results from pooled Phase III studies of ulipristal acetate for emergency contraception. Contraception. 2012;86(6):673-680.

17. Turok DK, Jacobson JC, Dermish AI, et al. Emergency contraception with a copper IUD or oral levonorgestrel: an observational study of 1-year pregnancy rates. Contraception. 2013 Nov 22. Epub ahead of print.

18. Corbett PO, Mitchell CP, Taylor JS, Kemppainen J. Emergency contraception: knowledge and perceptions in a university population. J Am Acad Nurse Pract. 2006;18(4):161-168.

19. Gemzell-Danielsson K, Berger C, P G L L. Emergency contraception —mechanisms of action. Contraception. 2013;87(3):300-308.

20. Shoveller J, Chabot C, Soon JA, et al. Identifying barriers to emergency contraception use among young women from various sociocultural groups in British Columbia, Canada. Perspect Sex Reprod Health.

21. National Institute of Diabetes and Digestive and Kidney Diseases. Weight-control Information Network. Overweight and Obesity among Adults Age 20 and Older, United States, 2009–2010. http://win.niddk.nih.gov/statistics/#b

22. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;(9):CD003987.

23. Lopez LM, Edelman A, Chen-Mok M, et al. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;(4):CD008815.

24. Bonny AE, Ziegler J, Harvey R, et al. Weight gain in obese and non-obese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Arch Pediatr Adolesc Med. 2006;160(1):40-45.

25. Ortho Evra website. JanssenPharmaceuticals, Inc. 2014. http://www.orthoevra.com/

26. Batur P. Emergency contraception: separating fact from fiction. Cleve Clin J Med. 2012;79(11):771-776.



Use of osteoporosis drug with anti-inflammatory medication linked to lower risk of hip fracture

Among older patients using medium to high doses of the anti-inflammatory steroid prednisolone, treatment with the osteoporosis drug alendronate was associated with a significantly lower risk of hip fracture, according to a study published by JAMA. Read more.

Freezing Ovarian Tissue May Be a Promising Fertility Treatment

By 2018, some 76,000 women in the U.S. will freeze their eggs every year to preserve their fertility and increase their odds of getting pregnant later in life. Yet egg freezing is by no means a solid insurance policy. Some estimates suggest that just under 24% of procedures will result in a live birth. The fertility field is looking for other options.

In a new study published in the journal Reproductive Sciences, two fertility experts argue that ovarian tissue freezing—a procedure that removes and freezes ovarian tissue for later use—could offer an alternative, especially for women who can’t undergo egg freezing for medical reasons.

Read more at Time.

Message from the CEO

Welcome to the dog days of summer! August is the time of year when we should try to take a little break to decompress from our jobs; rejuvenate our minds, bodies, and spirits; and enjoy some family time before revving up for school to start and jobs to kick into high gear for the fall and winter seasons. We should take a lesson from those European countries that virtually shut down for the month of August. But the question I always ask myself is, “How do they do that?!”

By the time you’re reading this message, our inaugural Women’s Sexual Health Course for NPs will have been completed. I am happy to report to you that the course was a huge success! With the encouragement of more than 150 satisfied attendees, we have already started planning for another Women’s Sexual Health Course for NPs in 2015!

In this issue of the journal, we present the program guide for the 17th Annual NPWH Premier Women’s Healthcare Conference, which will be held in Savannah, Georgia, on October 15-18, 2014. We continue to strive to bring you, as providers of women’s healthcare, the most up-to-date, clinically relevant information possible. As you will see in the program guide, this conference promises to deliver all things women’s health.

If you haven’t already registered for the conference, please take a look at our offerings and make plans now to attend. You will be sure to gain the in-depth knowledge and specialized skills needed to provide high-quality healthcare to women of all ages. In addition, the conference provides you with a wonderful opportunity to network with your colleagues; where better to meet with colleagues than in beautiful Savannah?! While you’re there, take a carriage ride through the lovely neighborhoods, participate in a ghost tour, and soak up all  the hospitality that the South is known for.

We hope to see you at our conference in October. But for now, go grab that cool drink, relax in your chair, and enjoy this issue of Women’s Healthcare: A Clinical Journal for NPs.

– Gay Johnson

Chief Executive Officer, NPWH


A message from editor-in-chief

Dear Colleagues,

August is National Immunization Awareness Month. As nurse practitioners providing primary care for female adolescents and adults, we have a public health responsibility to educate our patients (and, when applicable, their parents) about the importance of vaccinations and to make the recommended vaccinations easily accessible. In honor of National Immunization Awareness Month, let us review our current vaccination practices and consider whether we might be able to do an even better job.

Although all vaccinations are important, I would like to focus on the HPV vaccine in particular because we have so much room for improvement in reaching all females and males who can benefit from receiving this cancer-preventing and potentially lifesaving vaccine. Eight years ago, the Advisory Committee on Immunization Practices (ACIP) began recommending routine HPV vaccination of girls at age 11 or 12. Leading health and professional organizations have called for universal vaccination for preteen girls. Despite this recommendation, the CDC reported that in 2012, only 33.4% of 11- and 12-year old girls received all three doses of the series. In 2011, ACIP began recommending HPV vaccination for boys aged 11 or 12. The CDC reported that in 2012, only 7% of boys this age received three doses of the vaccine.1

Whether or not you see pre-teens in your clinical practice, you likely see teens and you certainly see pre-teens’ and teenagers’ mothers and aunts and maybe even their grandmothers. We can all improve HPV vaccination rates by focusing on three major areas:

Educate parents, adolescents, and young adult women and men about the effectiveness of the vaccine in preventing HPV infection and cervical cancer as well as other genital, anal, and oropharyngeal cancers. Emphasize what we know about the vaccine’s safety. Lack of knowledge about HPV and the vaccine and unfounded fears about HPV vaccine safety are among the top reasons that parents are not getting this vaccination for their children.

Increase the consistency and strength of the recommendations we make regarding HPV vaccination. Another top reason reported by parents for not getting the vaccination for their children is that their healthcare provider simply did not recommend it.

Reduce missed vaccination opportunities by using every healthcare visit, whether routine or for an acute problem, to assess immunization status and provide recommended vaccines when indicated.

The following strategies have demonstrated success in improving rates for all types of vaccinations and can be easily implemented in most practice settings:

Standing orders

Computerized record or chart reminders

Patient reminders via mail, email, or phone

Patient education: see pages 50-51 for a patient education handout on HPV

Personal health records

Expansion of access in healthcare settings

Performance feedback

You can learn more about each of these strategies and how they might fit into your clinical practice at the CDC’s WhatWorks website.

If we all get involved in this effort to increase vaccination awareness, we can make a big difference. Each year in the United States, approximately 26,200 new cancers attributable to HPV are identified. 1 I know that, in my lifetime, I would like to see these vaccine-preventable cancers become a thing of the past.

Beth Kelsey, EdD, APRN, WHNP-BC


1. Centers for Disease Control and Prevention. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013 – United States. MMWR Morb Mortality Wkly Rep. 2013;62(29):591-595. www.cdc.gov/mmwr/preview/mmwrhtml/mm6229a4.htm


After Hobby Lobby: Where do women’s rights fit in?

The Affordable Care Act (ACA) seeks to improve population health outcomes by making preventive health services affordable and accessible. To achieve this aim, the ACA requires health plans to cover preventive services that have strong scientific evidence of their health benefits, with no cost sharing by patients (i.e., no co-payment, co-insurance, or deductible) when these services are delivered by a network provider. With limited exceptions, all FDA approved contraceptive methods are covered under the Women’s Preventive Services Guidelines. 1

However, on June 30, 2014, the U.S. Supreme Court issued one of its most highly anticipated rulings regarding women’s health. In a 5-to-4 ruling in Burwell v. Hobby Lobby Stores,2 the Court stated that “closely held” corporations do have religious rights and, as such, should be permitted an exemption from compliance with the contraceptive mandate issued by the U.S. Department of Health and Human Services (HHS).

How did we get here?

In accordance with the ACA, required preventive services, to be covered with no cost sharing on the patient’s part, include (1) evidence-based services that have received a U.S. Preventive Services Task Force (USPSTF) rating of “A” or “B”; (2) immunizations recommended by the CDC’s Advisory Committee on  Immunization Practices; (3) evidence-informed screenings and guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA, a division of HHS); and (4) USPSTF breast cancer screening, mammography, and prevention recommendations considered the most current other than those issued in or around November 2009.3

The Institute of Medicine (IOM) was then charged with convening an expert committee to review which preventive services are necessary for women’s health and should be considered in the development of comprehensive guidelines for preventive services for women, as well as with identifying any gaps in the USPSTF’s A- and B-rated preventive services for women.4 The IOM panel included recommendations for women that met the following criteria:

The condition to be prevented affects a broad population;

The condition to be prevented has a large potential impact on health and well-being; and

The quality and strength of the evidence is supportive of the recommendation.

Within this framework, the IOM panel recommended that preventive services for women that are to be provided without cost sharing include the “full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity.” 4In making this recommendation, the IOM panel cited systematic evidence reviews and other peer-reviewed studies pointing to the efficacy of these interventions in reducing the number of unintended pregnancies, as well as their favorable effect on women’s health and pregnancy outcomes.4 (pp102-110) Based on the IOM recommendation, HRSA issued regulations requiring inclusion of all FDA-approved contraceptive methods as a preventive health benefit.

Exempt from this contraceptive mandate were religious employers; non-profit entities, including churches, their integrated auxiliaries, and conventions or associations of churches; and the exclusively religious activities of any religious order.1,5 In addition, HHS rules issued in June 2013 provided an accommodation for other non-profit religious organizations that object to the contraceptive mandate. The accommodation permitted religious organizations that met certain requirements to self-certify as non-profit religious organizations. Such organizations could then avoid contracting, paying for, or otherwise making available contraceptive coverage by notifying their health insurance issuer of their self-certified status as a religious organization.6

Understanding Hobby Lobby

Burwell v. Hobby Lobby Stores arose from cases brought by three closely held, for-profit corporations. 2 These companies sued HHS, seeking to prohibit application of the contraceptive mandate in – sofar as it required them to provide coverage for four “objectionable” contraceptive methods. In particular, Conestoga Wood Companies, a woodworking company owned by the Hahn family, sought to prohibit application of the contraceptive mandate with regard to two forms of emergency contraception and two types of intra uterine devices. The Hahns, devout Mennonites, believed that because these contraceptive methods may operate after fertilization of the egg, these products are “against their moral conviction to be involved in the termination of human life.”2(p12)

Likewise, Hobby Lobby, a chain of arts and craft stores, and Mardel, an affiliated business that operates 35 Christian bookstores, brought suit to stop application of the contraceptive mandate with regard to the same four contraceptives that the Hahns found objectionable.2 Hobby Lobby is owned by David Green and family and Mardel by one of Davi Green’s sons. Like the Hahns, the Greens believe that life begins at conception. Therefore, providing access to contraceptives with potential to operate after fertilization of the ovum would violate their religious beliefs. The owners of Conestoga, Hobby Lobby, and Mardel do not object to the other FDA-approved methods of birth control.2 (p14) The decisions by lower courts in this matter differed, resulting in the matter being brought to the Supreme Court.

In a narrow 5-4 opinion, the Court held that the HHS contraceptive mandate, as it applies to closely held corporations, violates the Religious Freedom Restoration Act (RFRA). The RFRA prohibits the federal government from taking any  action that substantially burdens a person’s exercise of religion, unless that action constitutes the “least restrictive means” of serving a “compelling government interest.” 7Although the RFRA does not define the term “person,” the Court here applied the definition under the Dictionary Act, which defines “person” to include “corporations, companies, associations, firms … as well as individuals.”8Although the Court acknowledged that the contraceptive mandate may serve a compelling government interest, requiring these closely held companies to arrange for coverage of the objectionable contraceptive methods or to suffer penalties if they refuse to do so, it also posed a “substantial burden” on their free exercise of religion.2

In an eloquent dissent, Justice Ruth Bader Ginsburg challenged the majority’s assertion that the ruling was narrow in scope, and referred to the Court’s holding as a decision of “startling breadth” that would allow commercial entities to “opt out of any law (save tax laws) they judge incompatible with their sincerely held beliefs.”9The dissent argued against the interpretation of the word “person” to include a for-profit corporation in this instance. In addition, Justice Ginsburg pointed out that the decision to claim contraceptive health benefits is a woman’s decision, and that women with beliefs similar to those of the Hahns and Greens would not be compelled by the plan to access the objectionable methods. In closing, Justice Ginsburg accused the Court of “stepping onto a minefield … by its immoderate reading of the RFRA.”9

Where are we now?

Following the Hobby Lobby decision, Senators Patty Murray (D-WA) and Mark Udall (D-CO) introduced the Protect Women’s Health from Corporate Interference Act.10 This bill was intended to restore the ACA’s contraceptive coverage requirement and protect coverage of other health services from being denied based on an employer’s beliefs by prohibiting employers from refusing to provide health coverage guaranteed to employees under Federal law. The procedural vote to take up the bill narrowly failed in the Senate, by a vote of 56-43, just 4 votes short of the 60 votes needed to move the bill forward.11

In the wake of Hobby Lobby, various executive departments have issued guidance and fact sheets, and have proposed rules regarding ACA implementation with regard to contraceptive coverage. In July 2014, the U.S. Department of Labor issued a Frequently Asked Questions (FAQ) response regarding health plans’ disclosure of changes to contraceptive coverage.12 According to the FAQ, a plan subject to the provisions of the Employee Retirement Income Security Act (ERISA) must disclose information relevant to coverage of preventive services. The Department of Labor regulations require that the summary plan description include an explanation of preventive services, including contraception, covered by the plan. Expedited disclosure requirements are in place for plans that reduce or eliminate aspects of preventive services coverage after having provided the services.13

In August 2014, HHS issued a proposed rule in response to the Hobby Lobby decision in an attempt to help ensure that women whose contraceptive coverage is being threatened continue to receive the coverage to which they are entitled under the ACA.14 The proposed rule expands the availability of the accommodation for non-profit religious organizations to avoid contracting, arranging, paying, or referring for contraceptive services to include a closely held, for-profit entity that has a religious objection to providing coverage for some or all contraceptive services. Under the proposed rule, the closely held, for profit entity may not be publicly traded and must be owned by a limited number of persons or have a minimum percentage of ownership concentrated among a smaller group of people. The comment period for the proposed rule is scheduled to close prior to publication of this article.


The Supreme Court’s Hobby Lobby decision has the potential to undermine the ACA’s provision establishing a federal guarantee of coverage for a full range of FDA-approved contraceptive methods as a key preventive health service for women.1 By limiting the ability of some women to choose among all FDA-approved contraceptive methods, based on their employer’s values and belief system, this decision may create uneven access to evidence-based healthcare services shown to have a profound impact on women’s overall health and well-being. =

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


1. Health Resources and Services Administration website. Women’s Preventive Services Guidelines. 2012.


2. Burwell v. Hobby Lobby Stores. 13-354, s.l. : U.S. Supreme Court, June 30, 2014.

3. 42 USC § 300gg-13 (a)(1)-(5). 2010. Coverage of preventive health services.

4. Institute of Medicine. Clinical Preventative Services for Women: Closing the Gap. Washington, DC: National Academies Press; 2011.

5. 26 USC § 6033(a)(3(A)(1)(3). Returns by exempt organizations.

6. U.S. Department of Health and Human Services. Coverage of Certain Preventive Health Services under the Affordable Care Act – Final Rules. 78 Fed. Reg. 39870-39899. July 2, 2013.

7. Religious Freedom Restoration Act (RFRA). 42 USC § 2000bb-1(a)(b).

8. Dictionary Act. 1 USC § 1.

9. Ginsburg RB. Burnwell v. Hobby Lobby (dissent). 13-354 and 13-356 , s.l. : U.S. Supreme Court, 2014.

10. Murray/Udall. Protect Women’s Health from Corporate Interference Act. s.l. : 113th Congress, 2014.

11. Cunningham PW. Democratic bid to reverse Hobby Lobby fails. July 16, 2014. http://dyn.politico.com/printstory.cfm?uuid=74A8B33D-2EF4-4C9B-ADBE-19F7D09DA6BA

12. U.S. Department of Labor. FAQs about Affordable Care Act implementation (Part XX). July 17, 2014. http://www.dol.gov/ebsa/faqs/faq-aca20.html

13. Centers for Medicare and Medicaid Services website. Center for Consumer Information & Insurance Oversight. Women’s Preventive Services Coverage and Non-Profit Religious Organizations. Fact Sheet: Women’s Preventive Services Coverage, Non-Profit Religious Organizations, and Closely-Held For-Profit Entities.  CMS-CCIIO. August 22, 2014. http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven-02012013.html

14. U.S. Department of Health and Human Services. Coverage of Certain Preventive Services Under the Affordable Care Act. 79 Fed. Reg. 51118. August 27, 2014.

Incorporating provision of aesthetics services into NP practice

According to the American Society for Aesthetic Plastic Surgery, approximately $11 billion was spent on cosmetic procedures in the United States in 2012.1 Of that amount, $2 billion was paid for procedures involving injectables such as botulinum toxin type A (Botox® Cosmetic) and various fillers (e.g., calcium hydroxylapatite, collagen, hyaluronic acid, poly-L-lactic acid). Nonsurgical procedures accounted for 83% of the total number of cosmetic procedures performed, representing 39% of total expenditures.1

A wide variety of healthcare providers (HCPs) now offer aesthetics services, which can serve as an important source of revenue for their practice. For example, according to the American Society for Aesthetic Plastic Surgery, the average cost of botulinum toxin type A treatment is $326.1The cost of treatment for crow’s feet (wrinkles around the eyes) ranges from $280 to $700. Charges for dermal fillers can be even higher. The cost per treatment averages $650 for calcium hydroxylapatite (Radiesse®), $550 for hyaluronic acid (Juvéderm®), and more than $900 for poly-L-lactic acid (Sculptra®).1 Of note, these numbers reflect the cost of the product alone; they do not include the injection fee or office visit fee.

Consumers can access selected aesthetics procedure from dermatologists, OB/GYNs, plastic surgeons, ophthalmologists, orthodontists, and other HCPs. Within many of these practice settings, nurse practitioners, physician assistants, or registered nurses are often the HCPs who deliver the actual service or treatment. In addition, non-licensed aestheticians may perform Botox and filler injections in these healthcare settings, as well as in boutique clinics and spas—a growing trend in the United States.

Qualifications of the providers of these aesthetics services var by state and, in some cases, by county. No specific training programs are nationally mandated, but various organizations, including the American Association of Aesthetic Medicine & Surgery,2 the International Association for Physicians in Aesthetic Medicine,3 the American Academy of Facial Esthetics,4 and Aesthetic Medical Educators Training, Inc.,5 offer courses in administering Botox and fillers. These courses typically occur in a condensed format at locations throughout the U.S. and last 3 days to 2 weeks. Organizations providing these courses request attendees’ licensing information prior to registration and require a fee of $1,600 or more.1

Should NPs incorporate aesthetics services into their practices? In essence, overhead expenses are related solely to the costs of the products, which are passed on to patients within the global fee. But what about the cost of formal education/training and licensing requirements? The American Society of Plastic Surgeons has attempted to influence national legislation to restrict provision of these services by non-physicians. To date, however, no such mandate exists and various “clinicians” can provide these services.

Should academia embrace aesthetics as an opportunity to provide high-quality, evidence-based education/training to NP students? This approach may not only result in tuition revenue for the university but may also increase the marketability of the graduate. A post-master’s certificate or elective within the curriculum involving didactic coursework, a clinical laboratory experience, and a preceptorship opportunity would be ideal. A comparison could be made to colposcopy training, wherein NPs are certified as colposcopists.

The process would be fairly simple and straightforward. Didactic course work detailing facial anatomy (muscular and nerve innervation) would be foundational to performing injections. The specifics surrounding patient selection and product selection—including dosing, mechanisms of action, side effects, and contraindications—would be essential classroom elements. A clinical laboratory experience with volunteer patients would follow successful completion of classroom instruction and evaluation. Supervision by faculty members well versed and experienced in performing aesthetics services would support students transitioning into a short preceptorship.

Because aesthetics services are in such high demand, and because no specific training requirements for many of these procedures exist, now is an ideal time to claim administration of these services as an advanced nursing practice role. The American Society of Plastic Surgical Nurses has recently developed a certification examination that tests and demonstrates one’s knowledge and competency in providing aesthetics services.6 For now, eligibility requirements for taking this examination cite RN licensure only. As women’s health nurse practitioners and other advanced practice nurses strive to redefine their roles in the evolving arena of providing healthcare to women, we should consider the addition of aesthetics to the armamentarium. To meet the demand, academic institutions should investigate the feasibility of adding training in the provision of aesthetics services to their curricula. =

Anne Moore is a Nurse Practitioner/Women’s Health Clinical Trainer with the Tennessee Department of Health and a Women’s Health Nurse Practitioner in Private Practice in Nashville, Tennessee.


1. American Society for Aesthetic Plastic Surgery website. Cosmetic Procedures Increase in 2012. www.surgery.org/media/news-releases/cosmetic-procedures-increase-in-2012

2. American Association of Aesthetic Medicine & Surgery. Teaching the Art of Aesthetics. 2014. www.theaaams.com/courses/aesthetics-101-basic-training-course/fees/

3. International Association for Physicians in Aesthetic Medicine. Add Non-Insurance Practice Revenues Today!


4. American Academy of Facial Esthetics. http://www.facialesthetics.org/

5. Aesthetic Medical Educators Training, Inc. Botox® Training/Dermal Filler Training. 2014. https://www.aestheticmedicaltraining.com/botox_training.asp

6. American Society of Plastic Surgical Nurses. http://www.aspsn.org/


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.


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.

A note from Gay Johnson, CEO of NPWH

Wow, time does fly! It has been one year since we launched our new NPWH journal, Women’s Healthcare: A Clinical Journal for NPs. Since last November, we have distributed the journal to more than 31,000 nurse practitioners, and the journal has experienced sustained growth. The open rates—that is, the proportion of NPs to whom the journal is distributed who actually open and read the issue—are well above the industry standard and confirm that our readers are utilizing the journal as an educational resource to help them optimize their patient care.

Along with high open rates, we are seeing incredible engagement numbers, with readers spending an average of more than 15 minutes viewing our content at any one time. The journal’s companion website, www.NPWomensHealthcare.com, has  seen tremendous growth in recent months as thousands of NPs engage with us and utilize our cutting-edge digital platforms. Since the website’s launch in November 2013, we have seen a 160% increase in  page views and a 250% increase in our monthly unique visitors. Visitors are also spending increased time on the website and interacting with more content—all strong indicators that our editorial focus is resonating with our action-oriented NP community.

To top it off, we are receiving a large number of manuscript submissions from NP thought leaders, NPs in clinical practice, and DNP candidates. All of these manuscripts add to the depth and breadth of the content. So, please keep reading our journal and writing for us! In addition, we invite you to provide us with feedback regarding our articles and departments so that we can continue to provide the highest-quality content for you. It has definitely been a busy year for NPWH, with many successful new ventures. Among these new ventures are (1) publication of the 7th edition of the WHNP Guidelines for Practice & Education, which can be used to support NPs in practice and ensure that new WHNPs are prepared for practice in today’s healthcare environment; (2) development and launch of the first Well Woman Visit Mobile App; (3) presentation of the first Women’s Sexual Health Course for NPs; (3) participation in several ACOG committees and task forces; (5) strengthening of our relationships and an increase in our collaboration with a variety of organizations; and (6) implementation of the new NPWH WHNP Student Reporter Program.

We could never have accomplished all these goals without our conscientious and hardworking staff. These individuals include Carol Wiley, our Director of Membership & Office Administrator, who has been a long-time employee of NPWH; Lilly Pinto, our Communications and Outreach Manager; Pam Henry, our Special Projects Coordinator; Vanice Dunn, our Continuing Education Coordinator and Administrative Assistant; Susan Rawlins, our Director of Education; and Sue Kendig, our Director of Policy. I have the privilege of working with these talented and dedicated women every day. I am always gratified by how much work gets done by such a small staff!

NPWH has a lot to be proud of. We hope that you share our pride in this wonderful nurse practitioner organization and visit our websiteA regularly. If you are not already a member of NPWH and wish to join us, please click hereB. It has been a terrific year for NPWH and we thank you for all your support!

– Gay Johnson

Chief Executive Officer, NPWH

Web resources

A. http://www.npwh.org

B http://www.npwh.org/i4a/ams/public/memberapp2.cfm


A message from editor-in-chief Beth Kelsey, EdD, WHNP-BC

Dear Colleagues,

What a great first year for Women’s Healthcare: A Clinical Journal for NPs! Gay Johnson, our NPWH CEO, established the journal to provide you, our readers, with comprehensive, timely, useful information to empower you to set a new standard for women’s healthcare. Gay created her NPWH news &  updates column as one more avenue to keep you  informed about what the association is doing to ensure the provision of quality healthcare for women by nurse practitioners.

We have covered a wide variety of topics in the journal, including breast cancer, cardiovascular disease prevention, contraception, depression in adolescents, menopause, ovarian cancer, sexual assault, sexual dysfunction, and vulvar dermatoses. In each issue, one of these topics is developed as a feature article for continuing education credit. We also have a great variety of departments, including Assessment & management, Commentary, Clinical resources, and Patient education. Through her Policy & practice points column, Sue Kendig, NPWH Directorof Policy, keeps us up to date about issues such as the Affordable Care Act, the Consensus Model, and the concept that women’s health is more than just an annual event (i.e., the yearly well-woman visit).

Here are ways for you, our readers, to get involved with the journal:

Write an article: Based on what readers tell us in surveys, we have set a goal to expand the number of practical, evidence-based articles that NPs providing healthcare for women will find interesting, illuminating, and relevant in everyday practice. We especially invite submission of manuscripts that provide (1) updates on clinical guidelines, (2) case studies on complex health situations, (3) innovative strategies for teaching and learning clinical procedures and skills, or (4) tips on the business aspects of clinical practice. Because we want to offer more articles that are both topical and brief, we have updated our author guidelines—available on our journal website at www.npwomenshealthcare.comto provide prospective authors with information about how to structure articles that are shorter than those reporting on research studies or reviewing the literature.

Serve as a peer reviewer: We have placed our peer reviewer forms on the journal website to help authors better understand the criteria used for manuscript review. But you may also want to look at these forms to see if you are interested in serving as a peer reviewer. You need not have had an article published or work in an academic setting in order to serve as a peer reviewer, although we definitely appreciate this experience. We are always looking for NPs who are experts in the clinical setting to review manuscripts with an eye on the usefulness and applicability of the information in daily practice. Our peer reviewers are crucial to ensure the integrity and quality of the journal.

On that note, thank you to our year 1 peer reviewers!

I want to express a special thank you to the following individuals, who reviewed manuscripts submitted during our first year of publication:

Kelly Ackerson Elizabeth Heavey

Helen Carcio Anne Moore

Melanie Deal Suzy Reiter

Brooke Faught Kerri Schuiling

Aimee Chism Holland Carolyn Sutton

A call to action!

I know that our readers represent a wealth of knowledge and expertise worth sharing. If you would like to discuss a potential women’s health topic for an article and/or are interested in serving as a peer reviewer, please contact Dory Greene, our Managing Editor, at dgreene@healthcommedia.com, or me at bkelsey@healthcommedia.com.

I look forward to continuing to serve as Editor-in- Chief of Women’s Healthcare: A Clinical Journal for NPs and to hearing from you about what you want to see in upcoming issues.

Beth Kelsey, EdD, APRN, WHNP-BC


Promoting self-esteem in overweight and obese girls

Childhood obesity has reached epidemic rates in the United States, affecting all socioeconomic classes. At the same time, girls in this country are being bombarded with media images of the ideal female body, which is likely more slender and more muscular than their own. Preadolescence and adolescence are tumultuous periods of development for any girl, but they present a particular challenge for girls who are overweight or obese (OW/O) and who are at risk for experiencing a loss of self-esteem because their own shape and size do not match those of the media portrayed ideal. Providers of healthcare to girls in these age groups are in a position to identify those girls at high risk and guide them and their parents to available interventions and resources to help enhance their self-worth and possibly control their weight or lose weight in the process.

The American Academy of Pediatrics defines obesity as an excess percentage of body weight due to fat that puts persons at risk for many health problems.1 Among children aged 2-19 years, 31.7% are at or above the 85th percentile of body mass index (BMI)-for-age growth charts in weight, defining them as overweight or obese.2Nearly 17% of children in this age range are defined as obese—that is, they have BMIs greater than the 95th percentile. Among children and adolescents in the United States, OW/O prevalence is most concentratedin African American(AA) females, Hispanic males, and Native Americans.1-8

Statement of the problem

A direct link between OW/O and the development of health problems later in life, including cardiovascular, endocrine, pulmonary, renal, and orthopedic disorders, has been well established.1-8 In addition, OW/O can have adverse effects on children’s current physical and emotional health. In pre-adolescent and adolescent girls, for example, OW/O is strongly correlated with low self-esteem, which can lead to depression, anxiety, disordered eating, substance abuse, social isolation, and even suicidal ideation.4,9-11 Jasik and Lustig4 identified the ages of 9-12 years in girls as being key for development of excess adiposity. During this age period, many girls tend to be less active than when they were younger, and they tend to eat less healthy foods, causing the to gain weight. Higher levels of adiposity translate to higher systemic levels of estrogen and to an earlier onset of thelarche. A vicious cycle is set in motion:  Early breast development leads some girls to become self-conscious  and isolate themselves,  perhaps avoiding physical activities and eating extra food to soothe themselves, thereby aggravating the situation. To add to the complexity, this age period can be a challenging one in which to stage interventions because of these girls’ rapidly  changing cognitive and emotional development.

Factors that lower self-esteem or preserve it in girls

According to McClure et al,12 self-esteem represents one’s capacity to feel worthy of happiness. Self-esteem is an important determinant of adolescent mental health and development. One in three girls has a distorted interpretation of her appearance— either that she feels she is overweight when she is normal or that she feels she is normal when she is overweight.10 McClure et al12found that obesity was the most strongly correlated, modifiable risk factor for low self-esteem in pubescent girls.

Documented risk factors for low self-esteem include adolescence itself, female gender, low socioeconomic status, non-traditional family structure, having healthcare/special needs, exposure to school bullying, parental aggravation and family stress, elevated BMI, sedentary behavior, and higher rates of television viewing.13 During pre-puberty, a girl’s self esteem is not significantly tied to BMI; however, by age 13-14 years, the shift to a significant negative correlation exists.13

Low self-esteem does not appear to be a significant contributor to the development of obesity but, rather, a primary result of it.14 Factors that help preserve a girl’s self-esteem include physical activity, perception of good health, family communication and closeness, authoritative parenting, perceived teacher support, being part of a religious community, and feeling safe at school.12

Effects of maternal and societal factors

The initial and most powerful influence on a girl’s self-esteem is her mother.10As a girl enters late childhood/early adolescence, though, an increased desire to fuse with her peer group often takes precedence—with increased attention paid to the media. Pop culture bombards girls with “ideal” female images on television, in movies, in magazines, and on the Internet— girls of today have a much higher exposure to advertising than did previous generations. Girls are also exposed to mixed messages by the media; they are encouraged to love themselves the way they are, but they are also told that being OW/O is undesirable. Susceptibility of an adolescent to all these peer and pop culture pressures largely depends on both her mother’s values and actions and on the relationship she has with mother. For example, if a girl has a strong bond with a mother who has a good image of herself, she is less likely to be vulnerable to outside influences.15

Other factors that increase the risk for psychosocial complications of OW/O are race and ethnicity.15In general, AA girls do not experience as extreme downward spiral in self-esteem as do their Caucasian peers.14Identifying oneself with an ethnic group has been thought to be protective against low self-esteem.14 This theory is demonstrated in the study by McClure et al,12 which showed that even though female Hispanic and AA populations in the U.S. had higher rates of OW/O than their white counterparts, they had higher self-esteem and a more positive body image. AA girls also reported less desire for thinness. This difference ma have been due to a cultural acceptance by AAs, even an admiration, of “curvy” women. These findings warrant further investigation to determine whether the values of a particular ethnic group can overcome the negative self-esteem typically related to being OW/O.

Raising self-esteem in overweight/obese girls

Several studies have shown that programs with a primary focus on exercise as a means to increase self-esteem are detrimental to participants’ body image and have not produced a sustained, significant reduction in BMI.9,14,16 O’Dea9 theorized that the most effective model would focus primarily on building self-esteem itself, with secondary promotion of a healthy attitude toward diet and exercise. As the time period of greatest potential for weight gain coincides with psychological immaturity, the best course of action in girls ma be an early intervention to promote self-esteem and positive body image—starting just before the onset of thelarche, at age 8 or 9.8As these girls enter middle adolescence after menarche at age 12-14, the focus on nutrition and physical activity can gradually increase.11 At this point, the girls’ weight gains will have stabilized and they will have become more emotionally mature.9

According to Piaget’s developmental stages, young adolescents cannot grasp the concept that OW/O may lead to obesity related health problems during adulthood.17These individuals will not understand this concept until their late teenage years, when most of the psychological stigma of obesity has already occurred. This notion reinforces O’Dea’s theory that the most important concern to address in young adolescents is the adverse psychosocial effects of OW/O.9,17In other words, a therapeutic approach should focus on raising self-esteem, not on weight loss or exercise or the potential adverse health consequences of OW/O in the distant future.

Selected approaches

Available programs to address low self-esteem in OW/O girls vary in intensity, strategy, and primary focus. Nurse practitioners must ascertain each patient’s values and goals before recommending a specific approach for her. Options range from patient-centered, motivational interviewing to participation in community- wide programs.

Motivational interviewing— Use of this approach is based on the idea that OW/O is maintained by faulty cognitions and beliefs.18The motivational interviewer must identify, evaluate, and restructure the patient’s maladaptive cognitions and beliefs. In this approach, the NP identifies factors contributing to the patient’s poor self-image and works with both the patient and parents (as indicated) to create an environment to foster a positive body image. Success of this type of intervention depends heavily on a desire to change. Motivational interviewing has been shown to work with adults, but little research has been conducted with younger patients. This intervention may be beneficial for older adolescents, who tend to be more independent and self-motivated. In dealing with pre-adolescent to early adolescent patients, NPs might want to include the parents in the process. Motivational interviewing is a code-able intervention for primary care practitioners, does not require referral and outside expenses to the family,and is minimally invasive.

School-based programs— Many school programs address self-esteem and body image at around the fifth-grade level.19,20In a survey by Wilson,19 adolescents indicated that an ideal obesity prevention program at school would include their peers, take place during school hours, involve “fun” physical activities, and not require family members to participate directly—although they stated that they valued family support outside the program. The Nutrition and Enjoyable Activity for Teen Girls (NEAT Girls) study targeted girls in disadvantaged secondary schools who had been identified as being less active.20No parental involvement was included in the program. The researchers found that the program helped improve participants’ body image, although no significant reduction in BMI was noted between the intervention and control groups. The researchers theorized that parental involvement in the program might have had a significant impact on BMI while preserving the observed improvement in body image.

Female-specific extracurricular programs—Programs such as Girl Scouts of America, Girls on the Run, New Moves, the Memphis Girls Health Enrichment Multi-site Studies (GEMS), GoGirlGo, and Loozit have had a significant positive impact on adolescent participants’ self-esteem. 6-8,10,16,21 Compared with school-based programs, these programs are more tailored to participants’ needs and have a lower leader-to-participant ratio. The main emphasis of many of these programs is to address the issue of low self-esteem and poor body image, with a secondary emphasis in some groups on increased physical activity. Many studies have shown that noncompetitive physical activity improves feelings of self-worth; girls who participate in any kind of physical activity report feeling good about themselves, regardless of their weight.6,16,20 The curricula vary in content and length, for example, from weeklong summer camp (GoGirlGo) to longer, regular involvement through age 17, such as is available in Girl Scouts of America.7,10

According to Walker’s theory of intentionality, a program will have the best outcome if it is tailored to the essential needs and the inherent nature of a particular child.22 Even though the GoGirlGo program lasted only a week, participants stated that they felt empowered and had fun in the process.7 The authors of this report ascribed the program’s success to tailoring discussion topics to participants’ needs and to the mentor having a pre-existing relationship with the participants—establishing a level of trust prior to the camp.7

The GEMS programs were specific to AA girls aged 8-10 years, took place at local YMCAs, and were led by AA women, who were the adults most likely to foster a mother–daughter-type relationship with the girls.16Participants met weekly for 14 weeks and then monthly for the remainder of the 2 years. The intervention group’s goals were to follow a balanced diet, to decrease sedentary behaviors, and to increase physical activity. Psychological interventions included positive reinforcement, social support, and goal setting. The girls’ parents/guardians were encouraged to participate by increasing the availability of healthy foods at home. In the control group, the goal was to improve self-esteem and social efficacy; the family unit was not involved. Despite a rather intensive and well-planned study, the researchers found no significant prevention of weight gain among intervention participants versus the controls.

Family-driven and community-wide programs—NEAT girls, Girl Scouts, and the GEMS are family-oriented programs that rely on a child’s parents, who are often the ones preparing meals, to lead by example with positive attitudes regarding body image and increased physical activity. 10,16,20Perhaps the largest program is Let’s Move, a comprehensive national health initiative spearheaded by First Lady Michelle Obama5 Let’s Move addresses preventive measures for childhood obesity, starting with the mother’s prenatal care and progressing through encouragement of breastfeeding and childrearing practices (e.g., following a healthful diet, limiting exposure to digital media). This program does not specifically address interventions for the social stigma of obesity; rather, it aims to decrease the psychosocial side effects by eliminating the cause.

The U.S. Department of Health and Human Service Office on Women’s Health has constructed websites such as womenshealth.orgA that address body image in children.23This resource offers simple recommendations for parents/ guardians to promote both a healthy body image and a healthy relationship with food. Recommendations from this resource include maintaining open lines of communication, discussing media images, praising the child’s accomplishments, and avoiding negative comments regarding dieting and body shape.

In an effort to combat poor self-image in New York City, the organization New York City Girls placed posters of girls in areas of high visibility (e.g., subways, buses) proclaiming “I’m a Girl; I’m beautiful the way I am.”24The program aimed to counter the media bombardment of stick thin fashion models. The posters featured normal-appearing girls of all ethnic backgrounds. The second phase of the program included outreach, with several in-school and after-school programs as well as free fitness classes for further promotion of a healthful lifestyle.

Role of the nurse practitioner

Most NPs do not have adequate time during a typical well-patient visit to both identify low self-esteem in an OW/O girl and counsel her appropriately. NPs may need to schedule additional appointments with the patient and parents to focus discussions on self-esteem and body image or to make a referral to a mental health specialist when deemed necessary. NPs also need to consider the family’s social background, financial constraints, and goals. Above all, the most successful intervention is one in which the patient feels invested. By encouraging girls’ participation in early interventions, NPs are not only curbing the risk for future health problems, but also helping shape the ideas and attitudes of the future generation by creating strong role models and mothers.


The inverse relationship between BMI and self-esteem escalates as girls enter puberty. Although this phenomenon does not affect all ethnic groups equally, plummeting self-esteem is a widespread occurrence in this age group and, without intervention, may lead to problems such as substance abuse, depression, anxiety, social isolation, and suicidal ideation. Although low self-esteem in the presence of OW/O is common, a higher BMI is more socially acceptable in some cultural subgroups. Participation in motivational interviewing or in school or community programs can lead to improvements in self-esteem and body image. Preadolescent and adolescent girls may also develop a healthy attitude toward nutrition and physical activity. Reduction of BMI should not necessarily be emphasized in this age group unless a patient’s BMI poses immediate risks to her health; she may experience more psychological damage through intense intervention during this fragile period of social uncertainty. Because NP are often trusted primary points of contact within the healthcare field, they are in an ideal position to provide guidance to both the child and parent(s).

Meaghan Eddy is a family nurse practitioner at Cape Fear Center for Digestive Diseases in Fayetteville, North Carolina. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


1. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity. 2013. http://www2.aap.org/obesity/about.html

2. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303(3):242-249.

3. Raj M, Kumar RK. Obesity in children & adolescents. Indian J Med Res. 2010;132(5):598-607.

4. Jasik CB, Lustig RH. Adolescent obesity and puberty: the “perfect storm.” Ann N Y Acad Sci. 2008;1135:265-279.

5. White House Task Force on Childhood Obesity. Solving the problem of childhood obesity within a generation. Report to the President. May 2010.

6. Neumark-Sztainer DR, Friend SE, Flaitum CF, et al. New Moves—preventing weight-related problems in adolescent girls: a group-randomized study. Am J Prev Med. 2010;39(5):421-432.

7. Warner S, Dixon, MA, Schuman C. Enhancing girls’ physical activity and self-image: a case study of the GoGirlGo program. Women Sport Phys Activ J. 2009;18(1):28-41.

8. Shrewsbury VA, O’Connor J, Steinbeck KS, et al. A randomized controlled trial of a community-based healthy lifestyle program for overweight and obese adolescents: the Loozit Study protocol. BMC Public Health. 2009;9(119):1-12.

9. O’Dea JA. Self-concept, self-esteem, and body weight in adolescent females: a three-year longitudinal study. J Health Psychol. 2006;11(4):599-611.

10. Girl Scout Research Institute. Weighing In: Helping Girls Be Healthy Today, Healthy Tomorrow: Research Review. New York, NY: Girl Scouts of the United States of America; 2004.

11. Rojas A, Storch EA. Psychological complications of obesity. Pediatr Ann. 2010;39(3):174-180.

12. McClure AC, Tanski SE, Kingsbury J, et al. Characteristics associated with low self-esteem among U.S. adolescents. Acad Pediatr. 2010;10(4):238-244.

13. Strauss RS. Childhood obesity and self-esteem.  Pediatrics. 2000;105(1):1-5.

14. Wang F, Veugelers PJ. Self-esteem and cognitive development in the era of the childhood obesity epidemic. Obes Rev. 2008;9(6):615-623.

15. Franklin J, Dener G, Steinbeck KS, et al. Obesity and risk of low self-esteem: a statewide survey of Australian children. Pediatrics. 2006;118(6):2481-2487.

16. Klesges RC, Obarzanek E, Kumanyika S, et. al. The Memphis Girls Health Enrichment Multi-site Studies (GEMS): an evaluation of the efficacy of a two-year obesity prevention intervention in African-American girls. Arch Pediatr Adolesc Med. 2010;164(11):1007-1014.

17. Piaget J. Inhelder B. Memory and Intelligence. London, UK: Routledge and Kegan Paul; 1973.

18. Walpole M, Dettmer E, Morrongiello B, et al. Motivational interviewing as an intervention to increase  adolescent self-efficacy and promote  weight-loss: methodology and design. BCM Public Health. 2011;11:1-9..

19. Wilson LF. Adolescents’ attitudes about obesity and what they want in obesity prevention programs. J School Nurs. 2007;23(299):229-238..

20. Luban DR, Morgan PJ, Dewar D, et al. The Nutrition and Enjoyable Activity for Teen Girls (NEAT girls) randomized controlled trial for adolescent girls from disadvantaged secondary schools: rationale, study protocol, and baseline results. BMC Public Health. 2010;10:1-14.

21. Girls on the Run website. 2014. http://www.girlsontherun.org/

22. Walker J. Intentional youth programs: taking theory to practice. New Dir Youth Dev. 2006;Winter(112):75-92.

23. U.S. Department of Health and Human Services Office on Women’s Health. Body Image and Your Kids. Last updated September 22, 2009. http://www.womenshealth.gov/bodyimage/kids/

24. Dockterman, E. Bloomberg v. Pop Culture: NYC’s Campaign to Boost Girls’ Self-esteem. October 2, 2013. http://healthland.time.com/2013/10/02/bloombergs-quixotic-campaign-to-boost-girls-self-esteem/?iid=sr-link1

Web resource

A. http://www.womenshealth.gov/bodyimage/kids/


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 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


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


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 (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, 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 (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


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 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


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.



  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.

UTI, Chronic HTN Ups Stroke Risk in Women with Preeclampsia

Infection such as a urinary tract infection (UTI) on admission, chronic hypertension, and prothrombotic conditions all increased the risk of pregnancy-associated stroke among women with preeclampsia, a large retrospective study found.

Women with preeclampsia and pregnancy-associated stroke were three times more likely to have an infection on admission (adjusted OR 3.0, 95% CI 1.6-5.8) and cardiovascular complications such as chronic hypertension (adjusted OR 3.2, 95% CI 1.8-5.5) or prothrombotic states (adjusted OR 3.5, 95% CI 1.3-9.2) — albeit with wide confidence intervals, reported Eliza C. Miller, MD, of Columbia University in New York City, and colleagues. Read more.

via www.medpagetoday.com

Research reveals which breast implants pose the greatest risk of implant-associated cancer

Researchers at Macquarie University’s MQ Health have revealed that women implanted with textured breast implants are at a significantly higher risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Read more at medxpress

USPSTF: Screen All Pregnant Women for Pre-eclampsia

All pregnant women should be screened for preeclampsia with blood pressure measurements throughout their pregnancy, according to the U.S. Preventive Services Task Force (USPSTF).

There is “adequate evidence” that screening for preeclampsia has a “substantial benefit” for both mother and infant and that any harms resulting from screening and treatment are “no greater than small,” stated Kristen Bibbins-Dimingo, PhD, MD, of the USPSTF, and colleagues.

Read more at MedPage Today.

Age linked to decreased pelvic floor strength

A new study published in Female Pelvic Medicine & Reconstructive Surgery found that decreased pelvic floor strength after childbirth is 2.5 times more likely to affect women over age 25 years than younger women (Female Pelvic Med Reconstr Surg 2017; 23: 136-140).

“In multivariate analysis, age alone was a predisposing factor for pelvic floor weakness after childbirth, even though we also assessed variables such as race, BMI, length of second stage labor, vacuum delivery, and episiotomy,” said lead author Lieschen Quiroz, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City.

“The issue of pelvic floor weakness is important, because one in five women are affected by pelvic floor dysfunction during their lifetime—often in the fifth or sixth decade of life—but the event that puts them at risk may have occurred years before at the time of vaginal delivery,” Dr. Quiroz said.

Since older women are at increased risk for pelvic floor weakness after vaginal delivery, it’s important that clinicians assess the pelvic floor strength of women over age 25 or 30 before childbirth, Dr. Quiroz noted. “If pelvic floor weakness is found, women can be referred to physical therapy to improve their pelvic floor strength,” she added.

In the study, 68 women with a singleton pregnancy planning a vaginal delivery were assessed for pelvic floor strength at 24 to 37 weeks and between 4 weeks and 6 months postpartum. The median follow-up time was 7 weeks postpartum. Sixty-six percent of the women experienced a vaginal delivery while 34% went into labor but had a Cesarean delivery. Pelvic floor strength was evaluated with a Peritron perineometer during pelvic floor contractions, and the women also underwent physical exams and 3D vaginal ultrasounds during pregnancy and postpartum clinical visits.

via ModernMedicine

Anti-inflammatory diet could reduce risk of bone loss in women

Anti-inflammatory diets — which tend to be high in vegetables, fruits, fish and whole grains — could boost bone health and prevent fractures in some women, a new study suggests.

Researchers examined data from the landmark Women’s Health Initiative to compare levels of inflammatory elements in the diet to bone mineral density and fractures and found new associations between food and bone health. The study, led by Tonya Orchard, an assistant professor of human nutrition at The Ohio State University, appears in the Journal of Bone and Mineral Research. Read more.

Researchers provide new insights into age-related female infertility


Researchers at the University of Montreal Hospital Research Center (CRCHUM) have discovered a possible new explanation for female infertility. Thanks to cutting-edge microscopy techniques, they observed for the first time a specific defect in the eggs of older mice. This defect may also be found in the eggs of older women. The choreography of cell division goes awry, and causes errors in the sharing of chromosomes. These unprecedented observations are being published today in Current Biology. Read more.


Obesity May Make Rheumatoid Arthritis Tough to Spot, Track

Blood tests to diagnose and monitor rheumatoid arthritis may be thrown off by obesity in women, a new study suggests.

“Physicians might assume that high levels of inflammation mean that a patient has rheumatoid arthritis or that their rheumatoid arthritis requires more treatment, when in fact a mild increase in levels of inflammation could be due to obesity instead,” explained study author Dr. Michael George, who’s with the University of Pennsylvania Health System in Philadelphia.

Blood tests for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can help physicians check the severity of inflammation in rheumatoid arthritis patients, the researchers said.

Previous studies have suggested that obese women may normally have higher CRP and ESR levels. So, the authors of this study decided to take a closer look at the issue.

The study included information from more than 2,100 people with rheumatoid arthritis. The researchers then compared that information to data from the general population.

A higher body mass index (BMI — an estimate of body fat based on weight and height) was associated with greater CRP in women with rheumatoid arthritis and women in the general population, especially in severely obese women. There was also a modest association between obesity and ESR.

Conversely, in men with rheumatoid arthritis, a lower BMI was associated with greater CRP and ESR.

The findings may help improve understanding of the link between weight and inflammation. It may also help doctors learn more about how this relationship differs between women and men, the study authors added.

The findings were published April 10 in the journal Arthritis Care & Research.

Read more at Medline

Sex trafficking and other violence prevention resources from the CDC

Sex trafficking exploits women, men, and children across the United States and around the world. Preventing this violation of health, safety, and human rights is necessary for the well-being of people and communities. People can learn more about the problem, and prevention practitioners can use resources to help prevent sex trafficking.

Read more here.

Early Use of Triple Drug Cocktail Improves Ovulation in PCOS

Early intervention with a combination of antiandrogen and insulin-sensitizing agents in adolescents with polycystic ovary syndrome (PCOS) may help improve their fertility and overall health later on, a small new study suggests.

The findings were presented April 4 at ENDO 2017: The Endocrine Society Annual Meeting by Lourdes Ibáñez, MD, PhD, professor of pediatrics and director of the fellowship program in pediatric endocrinology, University of Barcelona, Spain.

In a randomized trial of 36 adolescent girls who were not sexually active  who had polycystic ovary syndrome — characterized by hirsutism and oligomenorrhea — a three-drug combination of low-dose spironolactone, pioglitazone, and metformin (SPIOMET) improved ovulation rates more effectively than did the standard oral contraceptive ethinylestradiol-levonorgestrel treatment.

Read more here

More Hot Flashes May Signal CVD Risk

Frequent hot flashes in younger middle-aged women may be a sign of a higher risk of vascular disease, researchers found.

Writing in Menopause, the authors examined 272 non-smoking women ages 40 to 60 years. They examined their endothelial cell function and the effect of hot flashes on the ability of the inner lining of these blood vessels to dilate. While there was a significant association between hot flashes and endothelial cell function among women ages 40 to 53 years, there was no association for older women (ages 50 to 64 years). These associations occurred independent of other heart disease risk factors.

Read more here

Birth control pills may protect against some cancers for decades

When it comes to oral contraceptives, women often hear about the increased cancer risk they pose. A new study, however, finds that the using birth control pills may protect against certain cancers for at least 30 years.
From an analysis of more than 46,000 women, researchers from the University of Aberdeen in the United Kingdom found that women who had ever used oral contraceptive pills were at lower risk of colorectal, ovarian, and endometrial cancers, compared with women who had never used the pill.

Furthermore, the study found no link between the use of oral contraceptives during reproductive years and increased risk of new cancers in later life.

The study was led by Dr. Lisa Iversen, of the Institute of Applied Health Sciences at Aberdeen, and the findings were recently published in the American Journal of Obstetrics and Gynaecology.

According to the Centers for Disease Control and Prevention (CDC), around 16 percent of women in the United States aged between 15 and 44 years are currently using oral contraceptive pills as a method of birth control.

The “combined pill” is the most common form of oral contraceptive used. This contains synthetic versions of the hormones estrogen and progesterone.

Since naturally occurring estrogen and progesterone have been associated with cancer development, numerous studies have investigated whether oral contraceptives might play a role in cancer risk.

Read more at Medical News Today 

Test Strips For Early Cervical Cancer Detection

Purdue researchers are developing a test strip, similar to the common pregnancy test, to detect cervical cancer and eventually other types of cancer and diseases.

Cervical cancer, the fourth most common type of cancer for women, is often detected too late, especially among women living in poor countries. The World Cancer Research Fund International says about 84 percent of cases occur in underdeveloped nations.

Current detection is based on the human papillomavirus, or HPV, test, which doctors say isn’t always able to correctly classify whether somebody has a disease or not.

“This field really needs an additional way to test for cervical cancer. A test that can report cervical cancer right away is very instrumental in a lot of low- and middle-income countries where women often get HPV tests and then never come back,” said Joseph Irudayaraj, professor of biological engineering in Purdue’s School of Agricultural and Biological Engineering. “In higher-income countries, it’s important that anything beyond HPV tests have the ability to complement those tests.”

Here’s how it works:

The strip’s color changes within 15-30 minutes to indicate the presence of specific proteins associated with cervical cancer. Irudayaraj says he’s proven the concept and is working on a prototype.

One day researchers think this test could detect other types of cancers and other diseases, including infectious pathogens.

A USDA grant is funding the research in part. Scientists are also looking for corporate funding to advance the research.

via WVXU

No benefit in treating mildly low thyroid function in pregnancy according to NIH study

There appears to be no benefit to treating mildly low thyroid function during pregnancy, according to a study by a National Institutes of Health research network.

Markedly low thyroid function during pregnancy has long been associated with impaired fetal neurological development and increased risk for preterm birth and miscarriage. Similarly, some studies have indicated that even mildly low thyroid function (subclinical hypothyroidism) could possibly affect a newborn’s cognitive development and increase the chances for pregnancy and birth complications. Read more here.

World’s first ‘menstrual cycle on a chip’ created to develop individualized treatments for women suffering from reproductive problems

The world’s first ‘menstrual cycle on a chip’ could change the future of research into gynecological problems, scientists claim.

The cube-shaped device, called Evatar, is a palm-sized recreation of the female reproductive tract.

It is made with human tissue cultured from stem cells and contains 3D models of ovaries, fallopian tubes, womb, cervix and vagina, as well as the liver.

The creation of the novel tool marks the first time scientists have been able to mimic the interplay between tissues and hormones.

Researchers plan to use the device to investigate conditions such as endometriosis, fibroids, reproductive organ cancers and infertility.

Dr Teresa Woodruff, a professor of obstetrics and gynecology at Northwestern University in Chicago, Illinois, where the device was created, said: ‘This is nothing short of a revolutionary technology.

‘If I had your stem cells and created a heart, liver, lung and an ovary, I could test 10 different drugs at 10 different doses on you and say, “Here’s the drug that will help your Alzheimer’s or Parkinson’s or diabetes”.

‘This will help us develop individualized treatments and see how females may metabolize drugs differently from males.’

The landmark study shows how the 28-day menstrual cycle can be mimicked using ‘organ on a chip’ technology.

The researchers used human stem cells to culture a combination of tissues of the ovary, fallopian tube, womb, cervix and liver in the device for four weeks.

Each ‘organ’ occupies its own brown cube and a special fluid pumps through each pea-sized organ to perform the function of blood.

The organs are able to communicate with each other via secreted substances, including hormones such as estrogen, to closely resemble how they all work together in the body.

The project is part of a larger effort by the US National Institutes of Health to create a ‘body on a chip’.

Read more at The Daily Mail


How dietary factors influence disease risk

Having too much sugar, salt, or fat in your diet can raise your risk for certain diseases. Healthy eating can lower your risk for heart disease, stroke, diabetes, and other health conditions. A healthy eating plan emphasizes vegetables, fruits, whole grains, and fat-free or low-fat dairy products; includes lean meats, poultry, fish, beans, eggs, and nuts; and limits saturated and trans fats, sodium, and added sugars.

The major cardiometabolic diseases—heart disease, stroke, and type 2 diabetes—pose substantial health and economic burdens on society. To better understand how different dietary components affect the risk of dying from these diseases, a research team led by Dr. Dariush Mozaffarian of Tufts University analyzed data from CDC’s National Health and Nutrition Examination Survey (NHANES) and national disease-specific mortality data. The study was supported in part by NIH’s National Heart, Lung, and Blood Institute (NHLBI). Results appeared on March 7, 2017, in the Journal of the American Medical Association.

The researchers investigated the relationships of 10 different foods and nutrients with deaths related to heart disease, stroke, and type 2 diabetes. They also compared data on participants’ age, sex, ethnicity, and education. They found that nearly half of all the deaths in the United States in 2012 that were caused by cardiometabolic diseases were associated with suboptimal eating habits. Of 702,308 adult deaths due to heart disease, stroke, and type 2 diabetes, 318,656 (45%) were associated with inadequate consumption of certain foods and nutrients widely considered vital for healthy living, and overconsumption of other foods that are not.

The highest percentage of cardiometabolic disease-related death (9.5%) was related to excess consumption of sodium. Not eating enough nuts and seeds (8.5%), seafood omega-3 fats (7.8%), vegetables (7.6%), fruits (7.5%), whole grains (5.9%), or polyunsaturated fats (2.3%) also increased risk of death compared with people who had an optimal intake of these foods/nutrients. Eating too much processed meat (8.2%), sugar-sweetened beverages (7.4%), and unprocessed red meat (0.4%) also raised the risk of heart disease, stroke, and type 2 diabetes-related deaths.

The study showed that the proportion of deaths associated with suboptimal diet varied across demographic groups. For instance, the proportion was higher among men than women; among blacks and Hispanics compared to whites; and among those with lower education levels.

“This study establishes the number of cardiometabolic deaths that can be linked to Americans’ eating habits, and the number is large,” explains Dr. David Goff, director of the NHLBI Division of Cardiovascular Sciences. “Second, it shows how recent reductions in those deaths relate to improvements in diet, and this relationship is strong. There is much work to be done in preventing heart disease, but we also know that better dietary habits can improve our health quickly, and we can act on that knowledge by making and building on small changes that add up over time.”

These findings are based on averages across the population and aren’t specific to any one person’s individual risk. Many other factors contribute to personal disease risk, including genetic factors and levels of physical activity. Individuals should consult with a health care professional about their particular dietary needs.

—Tianna Hicklin, Ph.D.

via National Institutes of Health

New thinking about urinary tract infections

Urinary tract infections (UTIs) can be tricky in older age. They’re not always as easy to spot or treat as in youth. And the decades-long approach to treatment is changing. “We’ve been hasty in using antibiotics, and we’re learning there are significant consequences that can range from side effects of medication to infections with antibiotic-resistant bacteria,” says Dr. Helen Chen, a geriatrician at Harvard-affiliated Hebrew Rehabilitation Center.

About UTIs

UTIs can occur anywhere in the urinary tract. The most common places are the bladder (where urine is stored) and the urethra (the tube through which you urinate). Less common, but more serious, is infection of the kidneys, which filter waste and extra water from the blood and make urine. Infections may be triggered by sexual activity, catheters, kidney stones, decreased estrogen in the lining of the vagina, or urine that’s pooled in the bladder.

Classic symptoms include a burning feeling with urination, a sense of urgency to urinate, increased frequency of urination, blood in the urine, and fever. Some older adults with a UTI also develop confusion.

The tricky part

Some of these UTI symptoms are similar to the symptoms of other conditions common in older people. “That makes it hard to decide if you have a new infection, or if an existing problem is worse, or if you have something else,” says Dr. Chen. For example:

  • Many older adults already have issues with frequency or urgency from bladder problems or (for men) an enlarged prostate.
  • Confusion can be a medication side effect or a sign of another problem, such as dehydration or a disturbed metabolism (which might occur with abnormal blood levels of calcium or sugar).

Also complicating diagnosis is UTI testing. A urine sample checks for the presence of bacteria and white blood cells (which would suggest an infection). If this initial test is positive, it’s usually necessary to grow the bacteria in a lab to identify the specific type of bacteria. But older women can carry bacteria in their bladders without any symptoms. Doctors call this asymptomatic bacteruria rather than a bladder infection.

Rushing to judgment

Treating a UTI without classic symptoms, based instead on the presence of some bacteria and white blood cells in urine, may have several consequences. It may mean that an underlying condition (or a worsening condition) is not being addressed. And since treatment involves a course of antibiotics, unnecessary treatment may lead to antibiotic resistance.

While the risk of not giving an antibiotic to rid the bladder of bacteria is small, it can sometimes allow bacteria to spread to the kidney and then to the bloodstream. This can lead to sepsis, the body’s toxic and sometimes deadly response to infection.


“Anyone with new classic symptoms should probably be treated for a UTI. However, if the only symptom is confusion, considering other causes or waiting a day or two to see if it resolves may be appropriate, if the family can observe the person and is okay with this,” says Dr. Chen.

If your doctor does prescribe an antibiotic, talk about potential side effects. Certain commonly used antibiotics called fluoroquinolones — such as levofloxacin (Levaquin) and ciprofloxacin (Cipro) — can be associated with damage to tendons, joints, nerves, and the central nervous system. The FDA advises that these medications should not be used as a first-line treatment for uncomplicated UTIs. Dr. Chen says other antibiotics, such as amoxicillin and clavulanic acid (Augmentin), cotrimoxazole (Bactrim), or nitrofurantoin (Macrobid), may be better options.

via Harvard Health Publications

AHA Guidelines: Time to Revisit Thinking on Pregnancy in Women with Complex Congenital Heart Disease

In a notable twist on conventional wisdom, a new American Heart Association scientific statement on managing pregnancy in patients with complex congenital heart disease (CHD) supports the notion that most women with complex CHD can have a successful pregnancy and normal vaginal delivery. To optimize outcomes, the statement notes, care should be collaborative and involve both a high-risk obstetrician and a cardiologist versed in CHD.

The new guidelines alter the idea that patients with complex CHD should avoid pregnancy out of concern about potential risks to the mother and child.

A stepped plan for complex pregnancies

“This is an excellent statement that provides a much-needed framework for caring for these patients, covering everything from pre-pregnancy counseling to pregnancy care to post-delivery care,” says obstetrician Jeff Chapa, MD, Head of Maternal-Fetal Medicine at Cleveland Clinic.

The guidelines provide a stepped assessment plan for general cardiologists to follow.

“The process makes it easy to assess risk prior to pregnancy, determine the frequency of follow-up needed once the patient becomes pregnant and identify the level of disease that warrants tertiary care,” says Dr. Chapa. “Knowing the changes that will occur can help with risk stratification and provide an idea of how well a patient is likely to do.”

Cardiologist David Majdalany, MD, Director of Cleveland Clinic’s Adult Congenital Heart Disease Center, trained under several members of the writing group behind the AHA guidelines, so he found no surprises in the document. But he’s delighted that a summary of the latest recommendations is finally at the disposal of all providers.

“Until now, we had only bits and pieces of information from various papers primarily written on individual defects,” Dr. Majdalany explains. “These guidelines coalesce what we know in a detailed document that discusses the pros and cons of pregnancy by every class of congenital lesion. This is very helpful.”

Validated by experience

The new guidelines’ recommendations align with the experience of Drs. Chapa and Majdalany in Cleveland Clinic’s Cardio-Obstetrics Clinic, where a high-risk obstetrician and a CHD cardiologist co-manage patients, with support from colleagues in virtually every subspecialty available when needed.

The decision of whether to proceed with a vaginal delivery is made jointly. “For example, with defects such as aortic root dilation, the patient is at risk for aortic dissection, so we would suggest avoiding natural delivery in such a case,” Dr. Majdalany notes.

Read more at Cleveland Clinic


Duke Team Reaches Milestone with Portable Cervical Cancer Screening Device

January was Cervical Health Awareness Month, and this year, that designation held special significance for Nimmi Ramanujam, professor of biomedical engineering and global health and director of the Center for Global Women’s Health Technologies.

Since 2012, she and her research team have been developing and testing a portable colposcope, called the “Pocket Colposcope,” to increase access to cervical cancer screening in primary care settings. Last month, 20 of these devices were produced for distribution to international partners.


According to the World Health Organization (WHO), more than 85 percent of the more than 270,000 annual deaths from cervical cancer occur in low and middle income countries. The disease is easily treatable if identified early, but because access to effective screening is limited in low-resource settings, early detection is often not possible.

And even if access to screening is available, for example via human papilloma virus (HPV) testing, a confirmatory test is needed before a woman can receive treatment. In the United States, this test is performed through colposcopy. However, a clinical colposcope is typically not available in a primary care setting, and in many low and middle income countries, often the alternative is to visualize the cervix with only the naked eye—a method that often results in missed diagnoses. The cost of a clinical colposcope—upwards of $20,000—presents yet another barrier.

The Pocket Colposcope is designed to address these barriers. It brings that secondary test—traditionally performed using a clinical colposcope by physicians at referral centers—to the primary care setting. In addition, it’s easy for a broad range of health care providers with different levels of training to use.


After four generations of development, the team has created a beta prototype of the Pocket Colposcope in collaboration with product design and development company 3rd Stone Design, Inc.

The Pocket Colposcope is significantly less expensive, smaller and lighter than a traditional clinical colposcope. Weighing less than two pounds, it fits inside a pocket (hence the name). The device enables healthcare providers to zoom and capture images by pressing a button with their thumb. Images taken with the Pocket Colposcope are transmitted instantly to a smartphone, tablet or laptop.

Read more at Duke Global Health Institute

Promise of PARP Inhibitors for BRCA1/BRCA2 Cancers

For patients with triple-negative breast cancer and BRCA1/BRCA2 mutations, current treatment options may at times be limited; currently, there are no specific treatments for BRCA1/BRCA2-mutated cancers that address the genetic defects seen in these cancers. However, there is growing interest in the use of Poly (ADP-ribose) polymerase (PARP) inhibitors in this setting.

Promise of PARP inhibition in BRCA-mutated disease

“In patients with BRCA1/BRCA2 mutations, PARP inhibitors are one of the most promising treatments to be tested recently in clinical trials,” says Jame Abraham, MD, Director of Cleveland Clinic Cancer Center’s Medical Breast Oncology Program and Co-Director of the Comprehensive Breast Cancer Program.

PARP inhibitors interfere with base excision repair and therefore DNA repair, to effect death of tumor cells. PARP inhibitors can be highly lethal to tumor cells in patients who already have impaired DNA repair from BRCA mutation, Dr. Abraham says.

Although triple-negative breast cancer can be sporadic, these cancers share traits that involve DNA repair defects with those occurring in BRCA-mutated carriers. Eighty percent of hereditary BRCA-mutated cancers share the triple-negative breast cancer phenotype. The prevalence of BRCA1 and BRCA2 mutations in triple-negative breast cancer ranges from 4 to 14.3 percent, and an additional 27 to 37 percent have somatic inactivation of BRCA1.

As a class, PARP inhibitors can cause profound damage to cancer cells in breast cancers that involve DNA repair pathway defects. A number of PARP inhibitors are undergoing clinical development, but none is yet FDA-approved for breast cancer.

OlympiAD and OlympiA: Clinical trial experience with olaparib

Cleveland Clinic is currently participating in two phase III clinical trials evaluating olaparib as a treatment for metastatic breast cancer as well as for stage II/III BRCA1/BRCA2, HER2-negative and triple-negative disease.

OlympiAD, the phase III trial on olaparib in metastatic breast cancer is ongoing but no longer recruiting participants and results are expected soon. In the meantime, Cleveland Clinic is enrolling patients in the OlympiA study, a phase III trial with olaparib as an adjuvant treatment for earlier-stage breast cancers with DNA repair defects — that is, in women with stage II and stage III breast cancer who have completed local treatment and neoadjuvant or adjuvant chemotherapy.

“We have enough evidence from metastatic breast cancer trials to know that olaparib is active in stage IV breast cancer. So now we want to see what kind of benefit stage II/III breast cancer patients will derive from use of olaparib,” Dr. Abraham says.

Olaparib was the first PARP inhibitor approved by both the FDA and the European Medicines Agency for patients with BRCA1/2 mutant ovarian cancer. In 2014, the FDA approved olaparib for patients with germline BRCA-mutated ovarian cancer who have undergone three or more lines of chemotherapy. The treatment was approved along with the BRACAnalysis CDx, a companion diagnostic test.

Read more at Cleveland Clinic

USPSTF: Jury Still Out on Pelvic Exams for Most Gynecologic Conditions

There is insufficient evidence to recommend for or against pelvic exams for most gynecologic conditions among asymptomatic women of reproductive age, said the U.S. Preventive Services Task Force.

Other than cervical cancer, gonorrhea and chlamydia, which have been addressed in separate recommendation statements, the USPSTF cited “insufficient evidence” to assess the balance of benefits and harms of these screenings in asymptomatic, non-pregnant women 18 years of age and older, who are not at increased risk of any specific gynecologic condition.

Notably, the authors reported that they were only able to find “limited evidence” on the accuracy of these examinations to detect ovarian cancer, bacterial vaginosis, genital herpes, and trichomoniasis — with very few studies on screening for other gynecologic conditions with pelvic examination alone.

This final recommendation (I statement) was published on the USPSTF site and simultaneously in the Journal of the American Medical AssociationIt affirms a draft statement issued last June, with a clarification that the USPST is not recommending against screening, and that it did not consider costs in its review.

The Task Force found inadequate evidence of benefits or harms in routine screening, citing only a few studies that reported false-positive rates for ovarian cancer (ranging from 1.2% to 8.6%), and rates of surgery for patients with abnormal findings (ranging from 5% to 36%). No studies quantified the amount of anxiety associated with these examinations, they noted.

separate editorial in JAMA Internal Medicine singled out the high false-positive rates with ovarian cancer screening and suggested the associated harms may be “substantial.” George F. Sawaya, MD, of the University of California San Francisco, characterized pelvic exams as a “ritual,” citing a survey of U.S. ob/gyns where over 85% said they performed bi-manual examination even among patients who had undergone a total hysterectomy, including the removal of both tubes and ovaries.

Read more at MedPage Today

Less-Invasive Fibroid Treatment May Be ‘Under-Used’

A minimally invasive procedure for uterine fibroids may be “under-used” in U.S. hospitals, compared with surgery, a new study suggests.

The study looked at a national sample of hospitals and found that fewer fibroid patients are undergoing hysterectomy — surgical removal of the uterus.

But hysterectomy remains much more common compared with a less-invasive procedure called embolization.

Fibroids are non-cancerous growths in the wall of the uterus that are usually harmless. But when they cause problems — such as persistent pain and heavy menstrual bleeding — treatment may be necessary.

For women with severe symptoms, the go-to has traditionally been hysterectomy, or sometimes surgery to remove the fibroids only.

There are other options, though. One is embolization, which involves injecting tiny particles into the small uterine arteries supplying the fibroids. The particles block the fibroids’ supply of nutrients and cause them to shrink.

Embolization has been a widely accepted treatment for 10 to 15 years, said Dr. Prasoon Mohan, lead researcher on the new study.

Yet, his team found, it still lags far behind hysterectomy. From 2012 through 2013, hysterectomies were performed 65 times more often than embolization at U.S. hospitals.

When embolization was done, it was usually at a large medical center. Few women treated at smaller or rural hospitals had the procedure, the study found.

That points to a discrepancy in women’s access to the treatment, said Mohan, an assistant professor of interventional radiology at the University of Miami.

How often “should” embolization be done? There’s no way to define that, but Mohan said it seems clear that it’s not offered often enough.

“I think it’s definitely under-used, considering it’s minimally invasive, has a shorter hospital stay and is less expensive,” he said.

Read more at Medline Plus

Incontinence may reflect body fat, not just weight

Being overweight or obese is an established risk factor for urinary incontinence, but a recent study indicates that body composition may also play a role. A multicenter team of researchers examined data from 1,475 women enrolled in the Health, Aging, and Body Composition Study. The participants ranged in age from 70 to 79 at the beginning of the study.

The research team looked at body mass index (BMI), percentage of body fat, and the frequency and type of incontinence episodes among participants over three years. They found that both stress incontinence—episodes of spilled urine during exercise—and urge incontinence—sudden, uncontrollable urination—were twice as common in women with the highest BMIs or greatest proportion of body fat compared with those in the lowest categories. Women who lost grip strength—an indication of reduced muscle mass—also had increased episodes of stress incontinence. However, overweight women who reduced either their BMI or their body fat by 5% were less likely than women who didn’t lose weight or shed fat to experience new or persistent stress incontinence. The study was published online Dec. 5, 2016, by the Journal of the American Geriatrics Society.

These findings suggest that while weight loss alone may help alleviate both forms of incontinence, activities that increase muscle mass may be especially helpful for women with stress incontinence.

via Harvard Health Publications

Inside Knowledge: Get the Facts About Gynecologic Cancer

The Inside Knowledge campaign raises awareness of the five main types of gynecologic cancer: cervical, ovarian, uterine, vaginal, and vulvar. Inside Knowledge encourages women to pay attention to their bodies, so they can recognize any warning signs and seek medical care.

New television and radio public service announcements in English and Spanish feature actress Cote de Pablo, talking about her own cervical cancer scare, and sharing advice for other women. And check out the new posters telling Cote’s story, as well as our Behind-the-Scenes videos from filming!

Inside Knowledge also has new TV and radio PSAs that highlight gynecologic cancer symptoms. The PSAs encourage women to learn the symptoms, and pay attention to what their bodies are telling them.

Inside Knowledge has resources for women, and for health care providers and organizations to share with their patients and communities.

Read more and access the resources here at the CDC’s website

CMV virus is way more common than Zika. But expectant mothers don’t know their babies are at risk.

WHEAT RIDGE — When Megan Wiedel was pregnant with her second child, she did just as her doctor told her to.

No raw fish. No soft cheeses. No lunch meat.

All along, a much bigger risk — one that her doctor never told her about — loomed.

So, unaware, when Wiedel’s first daughter sniffled, she held her. When Wiedel herself caught a cold in the second trimester, she shrugged it off. And when her second daughter, Anna, was born — at only 5 pounds, full term — and then failed the newborn hearing test, Wiedel and her husband tried not to worry as the pediatrician ordered more tests.

Two weeks later, the results came back. Anna would be deaf for the rest of her life. She might never be able to walk or even hold her head up. It was because she had a virus called CMV.

Wiedel hung up the phone and thought to herself: Why had she never heard about CMV?

“When you talk about it, it seems like it’s really rare,” Wiedel said. “But it’s not. A lot of kids have CMV.”

“That’s the hardest piece for me is that this is a preventable, prevalent, quiet disease.”

But, now, a small community of mothers and medical workers are trying to make CMV awareness a little less quiet.

Cytomegalovirus, or CMV, is the most common nongenetic cause of childhood deafness in the country. Every year, approximately 30,000 babies are born in the United States infected with CMV, and as many as 8,000 of those children suffer lifetime consequences from the disease — which can also include blindness, cognitive delays and microcephaly. As many as 400 infants die every year from CMV, according to the National CMV Foundation.
It is vastly more common than the Zika virus, which prompted alarm last summer for its potential to cause birth defects. But, while Congress invested $1.1 billion in fighting Zika, funding for CMV lags behind, and numerous studies show that as many as 85 percent of expectant mothers have no idea what CMV is. The American College of Obstetricians and Gynecologists does not advise doctors to talk to expectant mothers about CMV — despite the fact that it is an easily spread virus that is present in nearly every elementary school and day care center in the country.

At Children’s Hospital Colorado, physician assistant Shannon Hughes has developed an outpatient clinic for kids dealing with the aftereffects of CMV. The clinic has served about 40 kids in the past two years. Nearly all of the parents she meets had never heard of CMV before finding out that it would forever alter their children’s lives.

“Obviously, that has a big impact on them emotionally that they think they did something wrong and should have prevented it,” she said.

Neonatal nurse practitioner Erin Mestas, who also works at Children’s as well as at Poudre Valley Hospital, is also trying to raise awareness among both mothers and health care workers about CMV.

“There needs to be more education about CMV risk reduction,” Mestas said. “I think childbearing women need to be more educated.”

In some ways, CMV’s ubiquity accounts for its invisibility.

Most adults have been exposed to CMV at some point in their lifetimes, meaning they have antibodies to fight off a new CMV infection. For women with CMV antibodies, then, being exposed to the virus while pregnant is usually no big deal.

Read more at The Denver Post


10 Women Who Shaped and Advanced Women’s Health

In honor of Women’s History Month, Healthy Women put the spotlight on 10 women (but there are so many more!) who made important contributions to prioritizing women’s health.

1. Clara Barton, nurse/educator (1821–1912) 
Barton founded the American Red Cross in 1881. Since then, the organization has provided much-needed relief for the vulnerable in America—and abroad. Barton identified her calling while nursing wounded soldiers and searching for missing ones during the Civil War.

2. Elizabeth Blackwell, MD, author, educator (1821–1910)
In 1849, Blackwell became the very first woman to earn an MD degree from an American medical school. She was inspired to break barriers because her female friend wanted to see a female doctor. Now, half of medical school graduates are females.

3. Margaret Sanger, women’s rights activist (1879–1966)
Sanger’s research led to the discovery of a pill to prevent pregnancy, and she coined “birth control.” She founded the American Birth Control League, which is now known as Planned Parenthood. Sanger advocated for reproductive rights after caring for women who attempted self-induced abortions and suffered from poorly performed illegal ones.

4. Rebecca Lee Crumpler, MD (1831-1895)
In 1864, Crumpler became the first African-American woman to receive an MD degree. Her book, Book of Medical Discourses, was one of the first publications about medicine by an African American. In post-Civil War Richmond, Va., she cared for freed slaves who would not have otherwise had access to medical care.

5. Ina May Gaskin, MA, CPM (1940-)
Often described as “the mother of authentic midwifery,” Gaskin advocated for natural and home birth at a time when childbirth was seen as a medical problem. Her efforts empowered women to gain control of their bodies and have a say in how they wanted to deliver their babies.

6. Catherine Switzer, author, television commentator and marathon runner (1947-)
Switzer was the first woman to enter and run the Boston Marathon in 1967. She was able to enter because she didn’t use her full name, but when the race director saw a woman running, he tried to physically remove her from the race. Switzer stayed the course, finished and went on to advocate for the women’s marathon to be added to the Olympics.

7. Jane Fonda, actress (1937-) 
Fonda revolutionized women’s fitness in the ’80s and ’90s when she released her workout videos—donning leotards and legwarmers, of course! Her first tape, released in 1982, is the best-selling home workout video of all time.

8. Michelle Obama, U.S. First Lady, lawyer (1964-)
First Lady Michelle Obama turned children’s healthy eating and physical activity into a national conversation. She started a vegetable garden at the White House in 2009 and launched the Let’s Move campaign in 2010. From doing the dougie to competing in fitness competitions against Jimmy Fallon, Mrs. Obama has made healthy living fun—for kids and adults.

9. Nancy Brinker, founder and chair of global strategy of Susan G. Komen (1946-)
Susan G. Komen is widely known now for its global efforts to fight breast cancer. But Brinker founded the organization in 1982 when the disease was not discussed. She named the organization in honor of her sister who lost her battle to breast cancer in 1980.

10. Melinda Gates, business leader, philanthropist (1964-)
As cochair of the Bill and Melinda Gates Foundation, Melinda Gates has advocated for prioritizing women’s and children’s health around the world. The Gates Foundation invests in maternal and child health, family planning and nutrition programs in developing countries. In the United States, Melinda Gates has become a strong voice in reducing the gender gap.

These are just a small, but mighty, group of women who have fought for women’s health priorities, and we’re thrilled to celebrate them.

via Healthy Women


The Pap smear: groundbreaking, lifesaving — and obsolete?

Pap tests are one of the most familiar — and successful — cancer screening tests ever invented. Since their introduction in the 1950s, cervical cancer deaths in the US have fallen by more than 60 percent.

But now, a growing number of scientists say, the Pap may be past its prime.

In its place, they are calling for a simple test, one that’s already routinely used as a second-line test around the world: screening for human papillomavirus (HPV).

When the Pap was invented, no one knew what caused cervical cancer. But in the years since, we’ve come to understand that HPV causes almost all cases of cervical cancer, and vaccinating against the virus can essentially obliterate it.

So, testing for HPV would be an upstream way of testing for cervical cancer risk — allowing for earlier detection, cost savings, and even opening the door for at-home testing.

There are signs it’s catching on. Last year, the Netherlands wholesale switched from Pap tests to HPV tests, and Australia is set to follow in its footsteps this year. The journal Preventive Medicine devoted an entire issue to HPV testing in February. Clinical trials of at-home HPV testing are underway across the US, Europe, and Canada.

But some physicians fear the test isn’t good enough to replace the monolithic Pap smear — or feel that, even if it is, we shouldn’t fix what isn’t broken.

At Home Testing in Appalachia

Proponents of HPV self-testing say its biggest appeal is in expanding the reach of cancer screenings, both to impoverished areas abroad, and also to women closer to home.

A trial underway now looks to test that idea in a woefully underserved region of the US — Appalachia.

“Cervical cancer really is such a cancer of disparities,” said Emma McKim Mitchell, the lead investigator for the trial. In Appalachian Virginia, those disparities are glaring. The state overall has some of the lowest rates of cervical cancer in the country — but women living in its Appalachian counties are diagnosed with cervical cancer about 13 percent more often than women elsewhere in the state, according to the Appalachia Community Cancer Network.

The women in the study get information about screening and a take-home kit with a long swab and instructions. They insert the swab like a tampon to collect vaginal and cervical cells, put that into an included test tube, and then mail the sample to the lab. There, technicians, instead of looking for precancerous cells as in a Pap test, look for the DNA of the dozen or so carcinogenic HPVs.

A positive HPV test would, in turn, trigger another HPV test the next year. That’s due to the fact that about 90 percent of HPV infections clear on their own.

Two positive tests would then bring women into the clinic.

Read more at STAT NEWS

Epidemiology of Adnexal Tumors

The determination of the precise frequency of adnexal masses is impossible as some adnexal tumors go undiagnosed. A variety of age groups need to be considered while estimating the clinical significance of adnexal masses.

Children to adolescents
Nearly 80% of ovarian cysts in girls under 9 years are malignant and those are mostly germ cell tumors.

About half of the adnexal neoplasms in adolescent girls are mature cystic teratomas or dermoid cysts. Women who have a Y chromosome-carrying gonad stand a 25% chance of developing a cancerous growth.

Overall, about 10% of ovarian cancers were found to be hereditary. Patients with a family history of a non-polyposis colorectal cancer syndrome or breast-ovarian cancer syndrome were at an increased risk for developing cancerous tumors.

Endometriosis, though not common in adolescence, may be present in about half of women who have a painful mass. In adolescent women who are sexually active, tubo-ovarian abscess must be considered as a possible cause of an adnexal mass.

Most adnexal masses in reproductive age women are benign cysts. Only 10% of masses are malignant. The rate of malignancy is low in patients aged under 30.

About 25% of adnexal growths are endometriomas, 33% are mature cystic teratomas, and the rest are functional cysts or serous or mucinous cystadenomas.

No matter what the age group is, physicians must take into account the possibility of structural deformities and uterine masses. Also, in all premenopausal women, pregnancy-related adnexal masses such as ectopic pregnancy, corpus luteum cysts, theca lutein cysts, and luteomas should be considered.

Research findings
A research conducted by the Duke Evidence-based Practice Center on a contract with the Agency for Healthcare Research and Quality found that ovarian cancer is the leading cause of death from gynecologic malignancies in the US. The annual incidence of ovarian cancer was over 25,000 with an annual mortality of about 14,000.

Read more at News-medical.net

Common Virus Tied to Diabetes, Heart Disease in Women Under 50

A type of herpes virus that infects about half of the U.S. population has been associated with risk factors for Type 2 diabetes and heart disease in normal-weight women aged 20 to 49, according to a new UC San Francisco-led study.

A research team, headed by first author Shannon Fleck-Derderian, MPH, of the UCSF Department of Pediatrics, and senior author Janet Wojcicki, PhD, MPH, associate professor of pediatrics and epidemiology at UCSF, found that women of normal weight who were infected with cytomegalovirus (CMV), which typically causes no evident symptoms, were more likely to have metabolic syndrome. This condition includes risk factors such as excess abdominal fat, unhealthy cholesterol and blood fat levels, high blood pressure and elevated blood glucose.

In contrast, women infected with CMV who also had extreme obesity – defined as a body mass index (BMI) of at least 40 – were unexpectedly less likely to have metabolic syndrome than women with extreme obesity who were not infected with CMV.

The study appears Feb. 23, 2017, in the journal Obesity.

Weight Predicts Metabolic Syndrome in CMV+ Women

“The likelihood that women infected with CMV will have metabolic syndrome varies dramatically, depending on the presence, absence and severity of obesity,” Fleck-Derderian said. The UCSF research team did not find these same associations between CMV and metabolic syndrome in the men included in the study.

Scientific evidence indicates that metabolic syndrome may be triggered by long-acting, low-intensity inflammation. But while studies have implicated obesity in chronic inflammation, a large minority of individuals with obesity do not develop metabolic syndrome, and many normal-weight individuals do, leading researchers to search for additional drivers of chronic inflammation that also may influence risk for developing metabolic syndrome.

Read more at ScienceBlog

New Agents, Combinations Showing Durable Benefit in Triple-Negative Breast Cancer

The triple-negative breast cancer (TNBC) pipeline is transforming, experts say, with the potential additions of immunotherapy and PARP inhibitors. These agents are being explored both as monotherapy and in combination regimens with standard chemotherapy options.

At the 2016 San Antonio Breast Cancer Symposium, treatment with pembrolizumab (Keytruda) continued to show a consistent durable benefit with an additional year of follow-up for heavily pretreated patients with recurrent PD-L1–positive TNBC, according to findings from the phase Ib KEYNOTE-012 trial.

At a median follow-up of 10.7 months, the median progression-free survival (PFS) was 1.9 months (95% CI, 1.6-5.5), and the 12-month PFS rate was 17.8%. The median overall survival (OS) was 11.3 months (95% CI, 5.3-18.2), and the 12-month OS rate was 47.1%.

In a recent interview, Joyce A. O’Shaughnessy, MD, chair of Breast Cancer Research at Baylor-Sammons Cancer Center, Texas Oncology, addressed some of the key issues in breast cancer treatment and shared insights on where TNBC treatment is headed based on recent research findings.

Read more at Oncology Nursing News

Bone densitometry: Performance, interpretation, and clinical application

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


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

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

• Height, 62 inches; weight, 110 lb;

• Hyperextensible joints;

• Small bone structure;

• Tandem gait excellent; and

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

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

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

• Height, 62 inches; weight, 120 lb;

• Flexibility normal;

• Small bone structure;

• Slight limp from hip fracture;

• Tandem gait done with some difficulty; and

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

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

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

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

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

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

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


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

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

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

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

Osteoporosis workup

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

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

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

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

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


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

Nutritional and nonpharmacologic interventions

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

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


The AACE and NOF strongly recommend pharmacotherapy for persons with:

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

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

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

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

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

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


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

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


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


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

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


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


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

Monitoring treatment response

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

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

Duration of pharmacologic treatment

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

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


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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Satisfaction, acceptability high with vaginal estradiol softgel capsules

Postmenopausal women with vulvar and vaginal atrophy reported high satisfaction and acceptability with vaginal estradiol softgel capsules compared with previously used therapies to treat their symptoms, study data show.

“[Vulvar and vaginal atrophy] is a chronic condition associated with genitourinary syndrome of menopause and affects 50% to 70% of postmenopausal women,” Sheryl A. Kingsberg, PhD, division chief, obstetrics and gynecology behavioral medicine, UH Cleveland Medical Center and professor of obstetrics and gynecology and psychiatry, Case Western Reserve University School of Medicine, told Endocrine Today. “Symptoms include pain with sexual activity, dryness and discomfort. Despite safe and effective prescription therapies, [vulvar and vaginal atrophy] remained under-treated. The availability of a new applicator-free delivery system may be one step to increasing discussion of [vulvar and vaginal atrophy] and treatments between women and [health care providers].”

Read more at Healio

NPs are a new lifeline for opioid addicts

WASHINGTON—Doctors working on the front lines of the nation’s heroin epidemic may be getting some fresh troops starting in 2017—battle-ready health professionals such as Danielle Eddings.

Eddings is a nurse practitioner in Springfield, Mo., eager to take advantage of a new federal law that will allow nurse practitioners and physician assistants to administer a highly effective anti-addiction medication called buprenorphine. Right now, only physicians can prescribe that drug, and they are limited to treating 275 patients per year.

That means a tide of patients get turned away every day at the Ozarks Community Hospital’s Northside Clinic where Eddings works, because the only doctor in the practice has hit his patient cap.

“There’s a dire need,” said Eddings, a psychiatric mental health nurse practitioner at the clinic. “There’s tons of people who can’t get treatment because it’s so limited.”

Congress approved a sweeping bill to address the opioid crisis earlier this year. That measure, now law, included a provision allowing certain non-physicians to treat addicts with buprenorphine.

Last week, federal health officials paved the way for that to take effect—detailing 24 hours of required training for nurse practitioners and physician assistants to complete before they can begin prescribing buprenorphine and similar medications. Buprenorphine is classified as a Schedule III narcotic, and it works by blocking opioid receptors in the brain and minimizing withdrawal symptoms.

It’s part of a treatment regimen called medication-assisted therapy, or MAT, and it’s been proven highly successful. Given in combination with behavioral therapy and other counseling, 70 to 80 percent of patients become stable.

Some doctors worry that allowing non-physicians to treat addicts with the medication will lower the quality of treatment and increase street access to another powerful drug with potential for misuse. But even those who express such concerns say the scope of the opioid crisis requires this expansion.

“We’re in the middle of an unprecedented epidemic,” said Dr. Arturo Taca, a St. Louis psychiatrist and president of the Midwest Society of Addiction Medicine. “There’s a lack of providers and a lack of experts in the field” to treat a growing number of patients suffering from addiction.

Taca said there are only about 30 addiction specialists practicing in Missouri, while the opioid problem in the state has risen rapidly. From 1999 to 2014, opioid-related death rates in Missouri have increased 7.6 times for women and 3.8 times for men, according to the state Department of Mental Health. More than 1,000 Missourians died in 2014 from opioid overdoses.

The trend is playing out across the country, where the nation’s approximately 5,000 addiction specialists struggling to respond, said Stuart Gitlow, past president of the American Society of Addiction Medicine and a Rhode Island physician.

Trying to get more doctors into the field won’t work, Gitlow said, because it’s more difficult and less profitable than other specialties. “So one of the decisions was ‘Okay, let’s go with PAs and NPs and see if that helps’,” he said.

While these are highly qualified professionals, Gitlow noted that they do not have same years-long medical training as doctors have and may have little to no addiction education.

Feds prosecute pain-clinic workers as drug dealers
“Imagine if we don’t have enough plumbers and as a result, I’m bringing in electricians to work on my sink,” he said. “We’re kind of sitting on pins and needles waiting to see how this will all work out.”

He and others say there’s no question the new rule will tap a vast new pool of providers for addiction treatment. There are about 220,000 licensed nurse practitioners in the U.S. and 110,000 physician assistants—and many of those folks are already lining up for the 24 hours of training.

Under the new rule, PAs and NPs will be able to treat 30 patients annually with buprenorphine starting in 2017 and then up to 100 patients each year after that.

“The interest is extremely high,” said Josanne K. Pagel, president of the American Academy of PAs and executive director of PAs at the Cleveland Clinic Health System.

Pagel noted that PAs already regularly see patients suffering from addiction but were limited in their ability to help them.

“We felt that our hands were tied,” she said. “PAs just need the tools to be able to treat them.”

Since passage of the addiction law, Pagel said, she’s been besieged with emails and phone calls from PAs eager to sign up for the training, which will focus on opioid detoxification, patient assessment, and the pharmacology of buprenorphine.

“I think it’s going to move the needle in combating this crisis,” Pagel said. “It’s going to make a difference.”

Eddings agreed and said she plans to complete the coursework in early January, so she can start seeing patients in Springfield.

Her boss, Dr. Salvador Ceniceros, said that could help cut the clinic’s approximately 75-person waiting list in half. But, he added, it’s still not enough.

“It will help, there’s no doubt,” he said. But he said it’s not unusual for his clinic to get 20 calls a day from new patients seeking treatment, and they need other care besides buprenorphine—including scarce counseling or therapy services.

“The numbers are just … you have no idea,” Ceniceros said.

via USA Today

Medical Therapy for Uterine Fibroids

Medical Therapy for Uterine Fibroids Draws Nearer as Phase 2 Trial Brings Promising Results

Women with large uterine fibroids suffer with many quality-of-life issues, including limitations on work, travel, hobbies and sexuality. Unfortunately, our treatment options are primarily surgical ‒ hysterectomy or myomectomy. There is a real need for medical options to help these patients, and Cleveland Clinic recently participated in a Phase 2 placebo-controlled dose-related trial (ASTEROID 1) to investigate the progesterone receptor modulator vilaprisan (Bayer Pharma AG) for this purpose. The study was sponsored by Bayer Pharma AG. Continue reading »

Irregular Sleep During Menopause May be Hard for Older Women’s Hearts

The sleep woes that many women suffer during menopause may be more than a nuisance: New research suggests a link between lost sleep and an increase in risk factors for heart disease and stroke.

When loss of sleep was measured both objectively and subjectively, the researchers found it correlated with a higher risk of plaque buildup in blood vessels and a thickening of artery walls. Continue reading »

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

Lack of knowledge about human papilloma virus (HPV) has been cited as a barrier vaccination uptake. This study examines the effectiveness of two types of education on women’s intentions to become vaccinated against HPV.

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

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

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


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

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

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


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

Risk factors for HPV

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

HPV vaccine attitudes and perceived barriers

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

HPV vaccine intentions

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

Knowledge scores

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


Impact on knowledge

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

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

Impact on HPV vaccination intentions

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

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


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

Clinical implications

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

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

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


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

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

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

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


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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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