September is Fetal Alcohol Spectrum Disorders Awareness Month

The below is written by NPWH Director of Publications, Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

As nurse practitioners providing healthcare for women, we have the opportunity to be leaders and champions in a campaign to prevent alcohol use during pregnancy and fetal alcohol spectrum disorders (FASDs). Our patients trust us to provide client-centered care that includes providing facts, being respectful of their individual needs and concerns, and supporting them in making informed decisions that will promote healthy pregnancy outcomes. Sometimes the conversations we have with patients about alcohol use during pregnancy are easy, sometimes they are difficult. As nurse practitioners we are equipped to have the conversation whether easy or difficult.

Call to Action

According to CDC data, only 17 percent of pregnant women reported that their healthcare provider talked with them about alcohol use. We have to do better. Our role must go beyond individual patient care. Educate colleagues, offer to speak at community events on the topic of preventing alcohol use during pregnancy, and, if you teach NP students be sure they have the knowledge and skills to also be leaders and champions.

Let’s start by agreeing to set the record straight regarding the mixed messages women may receive from family, friends, and even other healthcare providers about whether it is safe to drink alcohol during pregnancy. There is no safe time, no safe amount, and no safe type of alcohol to drink during pregnancy.

Alcohol is a known teratogen that readily crosses the placenta. When a developing baby is exposed to alcohol it can lead to permanent conditions known as FASDs. A range of developmental, cognitive, and behavioral problems can occur, appear at any time during childhood, and last a lifetime. We don’t have a crystal ball to know who might be affected and how seriously. Genetics, environment, and other exposures may all contribute to outcomes. Every pregnancy is different so alcohol exposure can affect each developing baby differently even in the same woman.

The Facts

  • About 1 in 9 pregnant women reported drinking alcohol in the past 30 days and one third of pregnant women who reported consuming alcohol engaged in binge drinking.1
  • Drinking alcohol while pregnant can cause miscarriage, stillbirth, premature birth, and FASDs.
  • Alcohol-exposed pregnancies are a leading cause of preventable birth defects and neurodevelopmental abnormalities in the United States.
  • Based on National Institutes of Health-funded community studies, experts estimate that the full range of FASDs in the United States might number as high as 1 to 5 per 100 school children.2

There is no safe time to drink during pregnancy — Prenatal alcohol exposure at any time during pregnancy can cause developmental problems. Brain development occurs throughout gestation. Because alcohol exposure affects the developing baby through a variety of mechanisms and impacts different body systems, timing of the exposure can influence some of the potential effects. You can use a fetal development chart to facilitate discussion with your patients about developmental timing. The chart can help you to make the point that while it is best to stop drinking prior to becoming pregnant, it is never too late in pregnancy to stop drinking and lessen potential effects. The fetal development chart can also be used when you provide preconception counseling. Approximately half of pregnancies are unplanned, so women could potentially be drinking alcohol before they realize they are pregnant.

There is no safe amount of alcohol to drink during pregnancy – No amount of alcohol is currently deemed safe during pregnancy. This is true for most known teratogens. We don’t know a dose threshold for teratogenic effects. We do know that because alcohol readily crosses the placenta, a developing baby can be exposed to the same level of alcohol as the mother.

There is no safe type of alcohol to drink during pregnancy – all types of alcohol can be equally harmful to the developing fetus, including all wines and beer.

Are you ready to answer the call to action? Here are some useful resources.

The CDC and Collaborative for Alcohol-Free Pregnancy
Mother’s Womb: Baby’s First Environment Graphic

Fetal Development Chart 

Free online continuing education courses for healthcare providers on the prevention, identification, and management of FASDs

University of Pittsburgh School of Nursing
Fetal Alcohol Spectrum Disorders Toolkit for Nurse Champions

NPWH
Optimizing Preconception Health: Preventing Unexpected Teratogen Exposure in Reproductive Age Women is a series of seven taped webinars on different aspects of this topic.

The National Organization on Fetal Alcohol Syndrome (NOFAS) provides fact sheets, videos, and other resources for professionals and individuals impacted by FASDs.

References:

  1. Denny CH, Acero CS, Naimi Ts, Kim SY. Consumption of alcohol beverages and binge drinking among pregnant women aged 18-44 years – United States, 2015-2017. MMWR. 2019; 68:365-368.
  2. May PA, Chambers CD, Kalberg WO, et al. Prevalence of fetal alcohol spectrum disorders in 4 US communities. Journal of American Medical Association. 2018;319(5):474–482.

Ovarian Cancer Awareness Month

The below is written by Rachel Gorham, MSN, WHNP-BC, AGN-BC. Ms. Gorham is on the NPWH Board of Directors. 

Ovarian cancer is said to be a “silent killer,” but it’s a whisper that needs to be heard. The American Cancer Society estimates in 2019, 22,530 women will be diagnosed and approximately 13,980 will die from ovarian cancer. It ranks fifth in cancer deaths among women. As providers, we have an opportunity during Ovarian Cancer Awareness Month to help patients to better understand this gynecological cancer. I’d like to provide this overview of the basics we should all be well-versed in, and also let you know about some of the promising developments in screening and prevention.

Risk Factors

Ovarian cancer typically develops in older women. About half of women are 63 years or older at the time of diagnosis. This cancer develops more commonly in white women than African American women. Factors that can elevate a woman’s risk of developing ovarian cancer include:

  • Age: Risk increases with age, and typically develops after menopause.
  • Personal or family historyof breast cancer, ovarian cancer, uterine cancer, or colorectal cancer.
  • Hormone therapy, particularly for more than five years of estrogen-only therapy.
  • Inherited cancer syndromes, including BRCA gene mutations, hereditary nonpolyposis colorectal cancer (also known as HNPCC or Lynch syndrome), Peutz-Jeghers syndrome and MUTYH-associated polyposis.
  • Reproductive history:Women who had their first child after the age of 35 or who have never given birth.
  • Endometriosis is a condition in which uterine lining grows outside of the uterus.

Symptoms

Women who develop ovarian cancer generally have a poor outcome, with a survival rate of less than 35% over five years. Women who have ovarian cancer often present with advanced disease and staging, which is the most critical factor affecting disease outcome. Most have had symptoms for an extended period before the presentation, which often leads to delays between presentation and treatment. Ovarian cancer symptoms include:

  • Pelvic, abdominal or back pain
  • Bloating
  • Loss of appetite or feeling full quickly
  • Changes in bowel or bladder function, such as constipation, urinary frequency, or urinary urgency
  • Menstrual changes
  • Pain during sex
  • Fatigue

Screening

Currently, there are no societal guidelines that recommend routine screening for ovarian cancer since screenings have not shown to decrease mortality. Patients may require increased monitoring if found to be high-risk of developing ovarian cancer, which includes:

  • Family history and/or personal history of breast or ovarian cancer
  • Inherited pathogenic variant, such as BRCA gene mutations and Lynch syndrome
  • History of infertility or use of assisted reproductive therapies
  • Hormone replacement therapy
  • Endometriosis

Treatment Options

Surgery is the standard treatment option for patients with ovarian cancer, including:

  • Cytoreductive (debulking) surgeries, whichremove as much tumor as possible from the pelvic and abdominal areas. This can improve outcomes and reduce cancer recurrence.
  • Coordination with other surgical specialties such as urology, thoracic, hepatobiliary, and neurosurgeons, who can remove secondary tumors in other parts of the body.
  • Fertility-sparing surgeryfor early-stage germ cell or stromal tumors confined to one ovary, which can preserve the patient’s ability to have children.
  • HIPEC(heated intraoperative peritoneal chemotherapy), a procedure in which cancer-fighting drugs are circulated into the abdominal cavity immediately after surgery. This therapy of direct heated chemotherapy can help kill more cancer cells than chemotherapy given orally or intravenously.
  • Inherited cancer syndromesfor patients who are high-risk for developing ovarian cancer (such as BRCA gene mutation carriers), can undergo a risk-reducing surgery such as a bilateral salpingo-oophorectomy.

Recent Advancements in Screening

A good deal of the current research in ovarian cancer is focused on screening and early detection, as early diagnosis is key to a positive prognosis. Recent advancements in this area include a promising test from Queens University Belfast which may allow clinicians to diagnose patients up to two years sooner than current tests allow. 

Continued Support for Preventive Effects of OCP

In the last few years, we’ve continued to see evidence that oral contraceptives decrease both ovarian and endometrial cancer risk. Risk reduction is correlated with duration of use. Studies have shown up to 50% reduction in ovarian cancer seen with 15 years of OCP. Furthermore, this risk reduction carries over beyond the general population to higher risk groups, such as BRCA carriers and those with Lynch syndrome BRIP1RAD51C, or RAD51D mutations. The degree of risk reduction with 1 year of use has been estimated at 33-80% for BRCA1 and 58-63% for BRCA2 carriers.  Providers should consider recommending OCP use for all woman with increased risk factors for epithelial ovarian cancer.

There is plenty of work to be done when it comes to advancing screening, prevention, and treatment for ovarian cancer. But every day, Nurse Practitioners and other providers who care for women can work with patients to identify risks, catch symptoms early, and provide support throughout treatment.

Breastfeeding and Personal Experience

Written by NPWH Board Member Tamera G. Borchardt, Lt Col, USAF, NC, DNP, WHNP-BC, and Amanda J. Anderson, Maj, USAF, NC, MS, ACNS-BC

August was officially declared National Breastfeeding Month in 2011 by the United States Breastfeeding Committee. Every year, groups including the World Health Organization, UNICEF, La Leche League, MomsRising, and a host of others promote the benefits of breastfeeding and encourage women to breastfeed throughout their child’s first six months. Thanks to these efforts, far more information, tools, and resources about breastfeeding are available, and advocacy is better than ever. WHNPs have a key role to play in supporting women as they consider breastfeeding.

What WHNP’s Need to Know

WHNPs are often the first-line providers for new pregnancies, fertility, and conception counseling. It’s crucial to have an early discussion about the benefits of breastfeeding so that mothers have time to research, take classes, ask questions, and make an educated decision about what’s best for her and her baby. WHNPs have the knowledge and experience to make this conversation as comforting and informative as any other about women’s health concerns.

Information to discuss includes:

Benefits to Mothers:

  • Recover faster from delivery; fewer complications; fewer maternal deaths
  • Decreased risk factors for breast and ovarian cancer
  • Decreased risk factors for Type 2 diabetes

Benefits to Babies – Decreased Risk Factors of:

  • Asthma
  • Obesity
  • Ear Infections
  • Eczema
  • Diarrhea and vomiting
  • Respiratory Infections
  • Sudden Infant Death syndrome (SIDS)
  • Type 2 diabetes

Societal Benefits

  • Decreased childhood hunger/world hunger
  • Decreased sick time and lost wages
  • Environmentally friendly (decreasing cans, bottles, and trash created with bottle feeding)

Know What to Ask and Who Can Help

In just a brief conversation with your patient, you can work together to figure out what resources she has access to and how they can help to make nursing go smoothly. It’s good to keep a list of these resources in your facility or area, including lactation consultants, breastfeeding classes, WIC services, local La Leche league, and/or new parent support programs. It’s also important to know whether your clinic can assist with breast pumps and other equipment.

Here are some questions you can ask to help your patient make a plan:

  • To what extent does your insurance cover pumps and equipment?
  • Where would be best to pump when you’re back at work? Does your workplace have a designated breast pumping room?
  • Are you planning to take maternity leave after delivery? This can help with bonding and developing a breastfeeding routine.

If your patient is a working mother, she may need time to get comfortable with a breast pump.

Laura Atkinson, a lactation consultant at Wright Patterson AFB, says breastfeeding success can be dependent on the provider reengaging with mom at her follow-up post-partum visit, and then again after she returns to work. These are good times to check in and talk about any difficulties or barriers to breastfeeding they might be experiencing, and to help your patient with a plan to address them so they can continue to breastfeed, if possible. Keep in mind that it’s unwise to order or suggest a breast pump at the first sign of difficulty – sometimes all it takes is adjusting positions while breastfeeding to dramatically improve the experience for a mother.

The number one reason why mothers often give up breastfeeding after facing difficulties is a lack of support from a healthcare provider. WHNPs are in an excellent position to make a difference for these women by reassuring patients that they can be successful with the right knowledge, support from family, and plenty of patience. It’s important to remind patients that breastfeeding is a learned technique – being unable to breastfeed effortlessly the first time is not a weakness. And while the evidence does suggest breastfeeding is best, we need to listen and support our patients with whatever feeding decision they make.


First-hand Experience from a Working/Breastfeeding Mom

To wrap up this blog, Active Duty Air Force Nurse Major Amanda Anderson shares her personal experience with breastfeeding and the uniqueness she experienced with each birth.

I have been able to breastfeed both of my children until they were 10 months (baby #1) and 6 months (baby #2). Both of those experiences were completely different. With my first baby we were discharged from the hospital with little to no education about how to breastfeed and what to expect. I had this idea that breastfeeding would just “happen” and that my baby and I would have this symbiotic, natural experience. However, upon discharge we were not successful, and wound up back in the hospital – she had jaundice. Her bilirubin levels had increased to a critical level.  When asked about her feeding habits, I naively responded that she was on the breast “all the time” so I thought she was getting exactly what she needed.

Looking back on that experience, I underestimated the work that goes into establishing that special bond with your child. After my baby received the medical treatment she needed and nutrition (pumped breastmilk and formula) I was able to reinitiate the breastfeeding relationship and successfully breastfed her until she was 10 months old.

My experience with my second child was very different.  She was a healthy baby and we had a successful latch within the first hour of life. However, after about another hour of life her clinical picture worsened.  She started to have an increase in respirations, her oxygen sats dropped, and she was becoming more lethargic and “floppy”. She was transported to the local children’s hospital to receive proper medical care and non-invasive oxygen therapy. We were in the NICU for a week, with a diagnosis of Transient Tachypnea of the Newborn and eventually jaundice. During those first few days of life, we were unable to establish that breastfeeding relationship because of her respiratory compromise. Thankfully, with the help of a lactation consultant and my support system, I was able to pump on a regular basis and provide her with the nutrition she needed. We also supplemented with formula until my breast milk came in. She received her feeds through an OG tube, and we began breastfeeding when she no longer required oxygen. We were successful for 6 months.

The intent of sharing my experiences with breastfeeding is to show that the relationship can look different between a mother and their child and that is okay. We are all trying our best to give our babies what they need: nutrition. Whether that’s exclusively breastfeeding, breastfeeding with supplementing, formula, exclusively pumping, whatever… it’s fine. Everyone’s story is different and so is their breastfeeding relationship.

References

  1. The General Surgeons Call to Action to Support Breastfeeding 2011. Available at https://www.cdc.gov/breastfeeding/resources/calltoaction.htm;. Accessed Aug 15, 2019
  2. National Breastfeeding Month 2019. Available at http://www.usbreastfeeding.org/nbm19;. Accessed Aug 12, 2019.
  3. World Breastfeeding Week 2019. Available at https://www.who.int/news-room/events/detail/2019/08/01/default-calendar/world-breastfeeding-week-2019;. Accessed Aug 12, 2019.
  4. Making the decision to breastfeed. Available at https://www.womenshealth.gov/breastfeeding/making-decision-breastfeed;. Accessed Aug 12, 2019.

World Hepatitis Day: Taking Action to Prevent, Test for and Treat

The below was written by  Shawana S. Moore, DNP, MSN, CRNP, WHNP-BC. Dr. Moore is Assistant Professor and WHNP Program Director at Jefferson University. She is also on the NPWH Board of Directors. 

July 28th is World Hepatitis Day – the optimal time to refresh our knowledge on Hepatitis to better care for communities. Hepatitis is defined as the inflammation of the liver, most often caused by a virus. Millions of people throughout the world are affected by viral Hepatitis and it accounts for more than one million deaths per year.1The five types of viral Hepatitis are A, B, C, D and E with the most common types being A, B and C. Let’s review the most current evidence regarding screening, risk factors, treatment and prevention recommendation for the three most common viral Hepatitis.

Symptoms

The symptoms for all three types of hepatitis are the same, but may vary in severity and duration.

  • Fatigue
  • Decreasedappetite
  • Stomach pain
  • Nausea
  • Jaundice
  • Joint pain
  • Dark urine
  • Diarrhea

Hepatitis A

Method of Transmission

  • Person to person through fecal-oral route
  • Consumption of contaminated food or water

Individuals at Risk

  • Men who have sex with men
  • Persons with clotting factors disorders
  • Injection drug users
  • Travelers to countries with high to intermediate incidences of Hepatitis A
  • Persons in close contact with someone who has Hepatitis A
  • Persons working with primates

Acute Versus Chronic

Hepatitis A is self-limiting and does not result in chronic infection.1

Diagnosis

Diagnosis of Hepatitis A is based ona positive serum test for antibodies to HAV (anti-HAV) IgM and can be made 2 weeks before the onset of symptoms to about 6 months afterwards. A positive total anti-HAV result and a negative IgM anti-HAV result indicate past infection or vaccination and immunity. The presence of serum IgM anti-HAV usually indicates current or recent infection and does not distinguish between immunity from infection and vaccination.3

Treatment

Supportive care

Prevention

Hepatitis A is preventable. Prevention measures include the following:

  • Vaccinations
  • Immunoglobulin (IG)
  • Food and water precautions
  • Good hygiene and sanitation

There are two monovalent Hepatitis A vaccines available in the United States given in 2-doses, approved for individuals 12 months of age and older. These vaccinations are safe to provide during pregnancy. 3

Hepatitis B

Method of Transmission

  • Person to person through bodily fluids
  • Percutaneous puncture from instrument with infected blood

Individuals at Risk

  • Men who have sex with men
  • Babies born to infected mothers
  • Sex partners of infected persons
  • Men who have sex with men
  • Injection drug users
  • Household contacts or sexual partners of known persons with chronic HBV infection
  • Health care and public safety workers at risk for occupational exposure to blood or blood-contaminated body fluids
  • Patients receiving hemodialysis

Acute Versus Chronic

Hepatitis B can be acute or chronic.  Approximately, 95% of adults recover completely from HBV infection and do not become chronically infected.5

Diagnosis

Diagnosis of Hepatitis B is based onserology test for HepatitisB surface antigen (HBsAg), Hepatitis B surface antibody (anti-HBs), IgM antibody to Hepatitis B core antigen (IgM anti-HBc) and total Hepatitis B core antibody (anti-HBc). A positive HBsAg, positive total anti-HBc, positive IgM anti-HBc and negative total anti-HBc indicate an acute HBV infection. Chronic HBV infection is determined by a positive HBsAg, positive total anti-HBc, and negative total anti-HBc.4

Treatment

The treatment for an acute HBV infection is supportive care. Antiviral medications are available to treat chronic HBV. The American Association for the Study of Liver Diseases (AASLD) Practice guidelines  provide guidance for proper treatment of chronic HBV infection. It is important to note that individuals with chronic HBV infection will require regular monitoring to prevent liver damage and or hepatocellular carcinoma.4

Prevention

Hepatitis B is preventable through a 3 dose vaccination given over 6 months. These vaccinations are safe to provide during pregnancy and lactation.4

Hepatitis C

Method of Transmission

  • Person to person through blood
  • Percutaneous puncture from instrument with infected blood

Individuals at Risk

  • Injection drug users (current and former)
  • Recipients of blood transfusions or solid organ transplants prior to July 1992 or clotting factor concentrates before 1987
  • Patients receiving chronic hemodialysis
    • Health care workers after needle sticks involving HCV-positive blood
  • Recipients of blood or organs from a donor who tested HCV-positive
  • People with HIV infection
  • Infants born to HCV-positive mothers

Statistics

It is estimated that 2.4 million individuals are living with HCV.

Acute Versus Chronic

Hepatitis C can be acute or chronic with approximately 75-85% of those infected developing chronic HCV.Chronic HCV infection places individuals at risk for developing cirrhosis. 6

Diagnosis

The following are blood tests performed to test for HCV infection:

  • Screening tests for antibody to HCV (anti-HCV)
  • Qualitative tests to detect presence or absence of virus (HCV RNA polymerase chain reaction [PCR])
  • Quantitative tests to detect amount (titer) of virus (HCV RNA PCR)

The CDC created a quick Reference Card for HCV Resultsto assist with interpretation of results.

Treatment

New guidelines advise against treatment for acute HCV infection. However,it is recommended that individuals are followed and monitor closely. There are several FDA Approved Treatments for HCVavailable.6WIth 8-12 weeks of oral therapy, over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype.7 A huge barrier to achieving this outcome is cost. A 12 week course of drug therapy for HCV can range from $55,000-95,000. The following companies and organization may provide assistance with paying the cost for treatment:

Additionally the following pharmaceutical companies may provide support for drug coverage:

Prevention

There is no vaccination for HCV infection.

Additional Resources and Tools

The CDC Guidelines and Recommendations  provides update to date resources for healthcare providers related to viral Hepatitis.

Additionally, the CDC created The ABCs of Hepatitis Fact Sheetas a quick reference for information related to statistics, transmission, risk factors, clinical features, screening, testing and vaccination recommendations for HAV, HBV and HCV.

Guidelines for management of HCV

References

  1. Center for Disease Control and Prevention. Vital Hepatitis. Available at https://www.cdc.gov/Hepatitis/index.htm <https://www.cdc.gov/Hepatitis/index.htm&gt; . Accessed July 21, 2019.
  2. Center for Disease Control and Prevention. Viral Hepatitis A. Available at https://www.cdc.gov/Hepatitis/hav/index.htm <https://www.cdc.gov/Hepatitis/hav/index.htm&gt; . Accessed July 21, 2019.
  3. Center for Disease Contro and Prevention. Travels Health Hepatitis A. Available at https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/Hepatitis-a <https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/Hepatitis-a&gt; . Accessed July 21, 2019
  4. Center for Disease Control and Prevention. Hepatitis B. Available at https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm#b1 <https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm%23b1&gt; . Accessed July 23, 2019.
  5. Fattovich G, Bortolotti F, Donato F. Natural history of chronic Hepatitis B: special emphasis on disease progression and prognostic factors. J Hepatol. 2008;48(2):335-52.
  6. Center for Disease Control and Prevention Viral Hepatitis C. Available at https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm#overview <https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm%23overview&gt; . Accessed July 22, 2019.
  7. American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA). Recommendations for testing, management, and treating Hepatitis C. HCV testing and linkage to care. Available at https://www.hcvguidelines.orgexternalicon. Accessed July 23, 2019.

Partnerships in Women’s Health – NPWH and PCORI

As a professional membership organization for women’s health nurse practitioners (WHNPs), the National Association of Nurse Practitioners in Women’s Health (NPWH) is a leading voice for courageous conversations about women’s health. NPWH champions state-of-the-science health care that holistically addresses the unique needs of women across their lifetimes. We elevate the health issues others overlook and compel attention to women’s health from providers, policymakers, and researchers.

The Patient-Centered Outcomes Research Institute (PCORI) is a nonprofit organization authorized by Congress to fund comparative clinical effectiveness research (CER). The studies PCORI funds are designed to produce reliable, useful information that will help patients, family caregivers, clinicians, employers, insurers, policy makers, and others make better-informed health and healthcare decisions.

CER compares two or more available healthcare options to determine what works best for which patients, under what circumstances. PCORI supports patient-centered outcomes research, which is CER that focuses not only on traditional clinical outcomes but also on the needs, preferences, and outcomes most important to patients and those who care for them.

NPWH is pleased to have ongoing opportunities to partner with PCORI as we work toward meeting shared goals regarding women’s health. NPWH and PCORI recognize that women have unique and sometimes complex healthcare needs that have not been fully addressed in the clinical and research arenas. PCORI has funded 61 comparative effectiveness research (CER) studies targeting conditions that specifically or more often affect women. A few examples illustrate the wide array of topics addressed in these studies: personalizing breast cancer screening, improving outcomes for low-income mothers with depression, treatment options for fibroids. The findings of these CER studies provide clinicians and patients with reliable information for shared decision making about treatment options.

A study recently funded by PCORI, Moms in Recovery (MORE): Defining Optimal Care for Pregnant Women and Infants, will be closely followed by NPWH as it focuses on the comparison of outcomes for women receiving prenatal care in practices providing medication-assisted treatment (MAT) with those receiving care in practices that refer MAT to specialty care. NPWH recognizes the immense significance of opioid use disorder (OUD) for pregnant and postpartum women and their infants. WHNPs are on the forefront to identify, support, and provide appropriate referrals and collaborative care for pregnant and postpartum women with OUD. At our 22nd Annual NPWH Premier Women’s Healthcare Conference in October, we are partnering with the American College of Obstetricians and Gynecologists to provide the American Society of Addiction Medicine’s Treatment of OUDs Course as a four-hour workshop, along with a four-hour online education component specifically designed for women’s healthcare providers. As well, previous NPWH conferences, journal articles and our 2016 position statement: Prevention and Management of Opioid Misuse and Opioid Use Disorder Among Women Across the Lifespan demonstrate our dedication to preparing WHNPs to meet the challenges of the opioid epidemic.

This June we represented NPWH at the PCORI-AHRQ Stakeholder Workshop on Improving Care for Women with Urinary Incontinence (UI) held in Washington DC. This one-day workshop brought together healthcare providers and organizations to explore the feasibility of developing a dissemination and implementation project aimed at improving the diagnosis and treatment of UI among women. The key findings from the systematic review on nonsurgical interventions for UI for women published by PCORI and AHRQ provided an evidence-based focus.

PCORI is a valued member of the NPWH-led BOlder Women’s Health Coalition (see below) with a goal to bring together leaders in policy, research, healthcare, and public and clinical education to promote healthy aging for women.

NPWH, through its broad educational strategies and ability to engage nurse practitioners providing women’s healthcare, disseminates and promotes implementation in practice of best evidence. NPWH has significant potential as a membership organization of nurse practitioners providing women’s healthcare to participate with PCORI and other partners in the study of outcomes from dissemination and implementation strategies as relates to improving women’s health.

To learn more about the NPWH activities and initiatives, visit our website at www.npwh.org,where you will find information on upcoming meetings, collaborative initiatives, educational opportunities, and a Well Woman Visit App.

ADDITIONAL INFORMATION: BOlder Women’s Health Coalition

NPWH believes this generation of aging women deserves our most innovative vision and actions to address their healthcare needs, advance their quality of life, and support their ongoing contributions to a better society. NPWH is the lead organization for the BOlder Women’s Health Coalition bringing together cross-sector leaders in health, aging, and clinical arenas to identify opportunities for collaboration and synergy. The goal is to work with healthcare, public policy, research, business, and nonprofit service to secure high-quality health for older women. We are focusing on the needs and unique challenges of aging women and innovating solutions to promote healthy aging.

The coalition’s four supporting pillars are:  

  • Policy:Advocating for legislative and regulatory policies that benefit older women
  • Clinical Education:Strengthening the knowledge of health care providers on prevention, diagnostics, and holistic treatments of older women
  • Public Education:Providing aging women and their families with the information they need to be healthy as they age and to remove the undermining stigma and stereotypes of aging
  • Research:Promoting approaches to research that will improve older women’s health and wellness

More than 25 coalition partners, including PCORI, are working to unite diverse sectors, share resources, and create strategies that advance the health and well-being of older American women for decades to come.

About the Authors
Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

Beth Kelsey is a certified WHNP. She teaches the women’s health course for family nurse practitioner students at Ball State University in Muncie, Indiana. Kelsey is the director of publications for NPWH and the editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs, the official journal of NPWH. She is the co-editor of Midwifery & Women’s Health Nurse Practitioner Certification Review Guide, 4th ed.

Susan Rawlins, MS, APRN, WHNP-BC

A women’s health nurse practitioner, Rawlins received her bachelor’s and master’s degrees in nursing from Texas Women’s University and her certificate as a women’s health nurse practitioner from the University of Texas, Southwestern Medical Center at Dallas. She is currently the director of professional development at the National Association of Nurse Practitioners in Women’s Health; serves on the editorial advisory board of Women’s Healthcare: A Clinical Journal for NPs, the official journal of NPWH; and is the co-director of the 2018 WHNP Certification Exam Review Course & Women’s Health Update. During her career, Rawlins has had the opportunity to combine the roles of educator, researcher, and clinician.

National Cancer Survivor’s Day

This blog is written by NPWH Board Member Rachel Gorham, MSN, WHNP-BC, AGN-BC

It was April 2016, when I heard the words, “You have cervical cancer.” I remember finding out the news before heading into a busy day of clinic and seeing my own patients. I quietly walked into my office, closed the door, and broke down. I remember drying my tears, saying a prayer, and from that moment on I never looked back. I was a mother to my only child, Makenzie, and knew what I had to do in order to win the battle ahead of me. I underwent a surgical intervention the following week and required no adjuvant therapy.  May marks my three-year anniversary of celebrating cancer survivorship.

Who Exactly are Cancer Survivors?

Experts from the American Cancer Society and the National Cancer Institute defines a cancer survivor as any individual who has been diagnosed with cancer and remains alive and well. This includes patients who are currently undergoing treatment, as well as those who have finished treatment and are considered cancer-free.

As of January 1, 2014, there are 6,876,600 men and 7,607,230 women who survived cancer. The numbers were based on the Cancer Treatment & Survivorship Facts & Figures 2014-2015 report, which is a collaboration between the American Cancer Society and the National Cancer Institute. Current statistics report that 64% of all cancer survivors have lived at least five years since their diagnosis. That includes the 15% of people who lived at least twenty years since their cancer diagnosis. Nearly half (46%) of cancer survivors are 70 years of age or older.

There are over 15 million cancer survivors in America. National Cancer Survivor’s Day is meant to be cherished around the world on the second day of June. This is a day for reflection and celebration. Whether you are a cancer survivor yourself, supportive family member, or beloved friend to someone who has recently been diagnosed, today provides us with courage and strength to overcome.

A Cancer Survivor’s Journey

There are three phases of cancer survivorship:

  1. Acute survivorship starts at the time a patient is diagnosed with cancer and goes through the end of treatment. The main goal of this phase is cancer treatment.
  2. Extended survivorship starts at the end of cancer treatment and advances through the upcoming months. The main effects of cancer and treatment is the focus during this phase.
  3. Permanent survivorship is the last phase which encompasses years passed since the end of cancer treatment. There is typically less of a chance that the cancer will recur during this phase.

The long-term effects of cancer and treatment is the focus. As patients transition between phases, so do their needs. The patient’s physical, emotional, and psychological needs must be met at each individual phase in order to provide holistic care.

Caring for Cancer Survivors

Long-term cancer survivorship focuses on health, wellness, and the prevention of cancer recurrence. Accomplishing this goal includes a team of medical oncologists, nurse practitioners, nurse navigators, social workers, registered dietitians, and support staff. Providing cancer survivorship care consists of four activities: disease surveillance, recognition of the signs and symptoms of disease recurrence, adhering to the recommended healthcare maintenance, and education on long-term effects from cancer treatment.

The 2005 Institute of Medicine (IOM) report “From Cancer Patient to Cancer Survivor: Lost in Transition” recommends that every cancer survivor receives a survivorship care plan. The goal of this plan is to educate and guide patients through long-term cancer survivorship. The care plan provides specific details on the patient’s diagnosis, treatment, and potential long-term sequelae. The survivorship care plan also addresses recommended follow-ups, adherence to treatment, physical examination, goals of cancer survivorship, and diagnostic testing schedules. The care plan provides a means of communication between all members of the patient’s healthcare team.

As medical research continues to improve survival statistics and the number of cancer survivors grow, its increasingly important to understand the psychological and medical needs of cancer survivorship. Clinicians who care for cancer survivors have the power to help their patients achieve an optimal quality of life.

Systemic Lupus Erythematosus (SLE) Awareness Month

Guest blog by Jennifer Parker Kurkowski, NP and instructor at Baylor College of Medicine

May is Systemic Lupus Erythematosus (SLE) Awareness Month. Building awareness and knowledge of this disease is important for providers who care for women, as it primarily affects women of reproductive age. Here is a brief overview of SLE and the considerations for patients managing the condition.


What is Lupus?

SLE is a chronic autoimmune disease that can affect multiple systems throughout the body,  including blood, kidneys, lungs, nervous system, serous membranes, joints, and skin. The cause of SLE is multifactorial and can include genetic, hormonal, immunologic, and environmental factors. Patients may present with a wide array of symptoms, signs, and laboratory findings. The disease is characterized by periods of remissions and relapses including a variable prognosis.


How common is Lupus?

The reported prevalence of SLE in the United States is 20 to 150 cases per 100,000. The Lupus Foundation estimates 1.5 million Americans have lupus. The female to male preponderance varies with age, emphasizing the estrogen effect. The ratio climbs as high as 15:1 in women of childbearing years. For this reason, it’s important that all providers who care for women in this population are familiar and capable of counseling patients with SLE.


How does Lupus affect pregnancy and contraceptives?

Contraceptive and preconception counseling are important for patients with SLE because it is a disease that is typically diagnosed in women of reproductive age. Here are a few things providers and patients should understand about SLE, pregnancy, or pregnancy prevention:

  • Current research indicates fertility is not altered by the disease, but many medications used to treat SLE have potential teratogenic effects of which the patients should be made aware.
  • Patients with SLE have an increased risk of pregnancy complications, including preterm labor, unplanned cesarean delivery, fetal growth restriction, preeclampsia, eclampsia, thrombosis, infection and transfusion. Also, patients with antiphospholipid antibodies (APL) can be at increased risk for adverse outcomes including pregnancy loss and thrombosis.
  • Possible fetal complications include miscarriage, stillbirth, growth restriction, neonatal lupus and premature birth.
  • Prior to conception, a woman’s SLE should be in good control or inactive for a 6-month period. Active SLE at the time of conception is linked to negative outcomes for mother and child.

Despite the maternal and fetal risks associated with SLE, many patients do not use an effective contraceptive method. The current Center for Disease Control and Prevention (CDC) medical eligibility for contraceptive use provides guidance among different patient populations. The ideal method of birth control for women with SLE depends on their APL status.

What are other health concerns for women with Lupus?

Menstrual Problems

  • Menstrual irregularities can be common in patients with SLE, including heavy menstrual bleeding in those with thrombocytopenia.
  • Premature ovarian failure is a concern in patients receiving alkylating agents such as Cyclophosphamide (CYC). CYC is typically used in severe cases of SLE with renal or central nervous system involvement. This risk is dependent on the patient age at time of exposure and cumulative dose of CYC. It is less in women who received CYC at age 25 or younger and have a cumulative dose of less than 10 grams. Women receiving CYC must be counseled about the importance of avoiding pregnancy. The risk for teratogenicity is greatest if exposure occurs in the first trimester.

Osteoporosis

  • Osteoporosis and osteopenia can be a significant problem in those patients receiving treatment with It is important to be aware of the risk for fractures. Patients should be encouraged to do weight bearing exercises, maintain a healthy weight, and stop smoking. Vitamin D levels should be checked.

Heart Disease

  • Lupus raises the risk of coronary artery disease. This is linked to hypertension and high cholesterol. One study found women with SLE are 50% more likely to have a cardiac event compared to a healthy counterpart.

Renal Involvement

  • Up to half of patients with SLE have some type of renal involvement. Patients with Lupus should have periodic blood pressure checks as well as screening for lupus nephritis.

It is our responsibility as providers to ensure we and our patients understand the nuances of caring for women with Lupus so they can live full and healthy lives.

May is Teen Pregnancy Month

The below is written by Shelagh Larson, DNP, WHNP-BC, NCMP. Dr. Larson is Secretary of the NPWH Board of Directors. 

The month of May might be the time of flowers, butterflies and Mother’s Day.  It is also the month we recognize Teen Pregnancy. Teen pregnancy is a healthcare issue that all providers, parents, teachers, politicians and religious leaders need to come together for.

Good news:

Rates of adolescent pregnancy, birth and abortion in the United States continued to decline and reached historic lows. The teen pregnancy rate is the summation of all live births, abortions, and miscarriages per 1,000 adolescent females in a given year.

  • The rate declined 7% from 2016 to 2017, to 18.8 births per 1,000 females aged 15–19.
  • Birth rates fell 10% for women aged 15–17 years and 6% for women aged 18–19 years.
  • The largest decline in the teen birth rate from 2016 to 2017 was for non-Hispanic Asian females, down 15% to 3.3 births per 1,000.

Although reasons for the declines are not totally clearly understood, evidence suggests these declines are due to teens abstaining from sexual activity, and those that are sexually active, are using more birth control, especially long acting reversible contraceptive (LARCs), than in previous years. Kathryn Kost, lead author of the Guttmacher Institute says, “The available evidence suggests that improved contraceptive use continues to be the primary driver of these declines.” Before you throw a party, let’s see the other side to the story.

Bad news:  

Still, the teen birth rate in the U.S. remains significantly higher than in other developed countries, according to the CDC. The U.S. teen pregnancy rate is substantially higher than in other western industrialized nations, and racial/ethnic and geographic disparities in teen birth rates persist.

  • About 77 percent of teen pregnancies are unintended, undesired, or occurred “too soon”.
  • Not all teen births are first births, either. In 2017, one in six (16.3 percent) births to 15- to 19-year-olds were to females who already had one or more births.
  • Moreover, teen childbearing costs U.S. taxpayers between $9.4 and $28 billion a year through public assistance payments, lost tax revenue, and greater expenditures for public health care, foster care, and criminal justice services.
  • On a positive note, between 1991 and 2015, the teen birth rate dropped 64%, which resulted in $4.4 billion in public savings in 2015 alone.

The Social Cycle

Pregnancy and birth are significant contributors to high school dropout rates among girls. Only about 50% of teen mothers receive a high school diploma by 22 years of age, whereas approximately 90% of women who do not give birth during adolescence graduate from high school. While adolescents that are enrolled in school and engaged in learning (including participating in after-school curriculum/programs, having positive attitudes toward school, and performing well educationally) are less likely than are other adolescents to have or to father a baby. The adolescents with mothers who gave birth as teens and/or whose mothers have only a high school degree are more likely to have a baby before age 20 than are teens whose mothers were older at their birth or who attended at least some college. Having lived with both biological parents at age 14 is associated with a lower risk of a teen birth. At the community level, adolescents who live in wealthier neighborhoods with strong levels of employment are less likely to have or to father a baby than are adolescents in neighborhoods in which income and employment opportunities are more limited. Teenage girls who are pregnant — especially if they don’t have support from their parents — are at risk of not getting adequate prenatal care.

The stigma of out-of-wedlock pregnancy may have diminished; however, the risks of serious health consequences remain for babies born to teen mothers. The infants are more likely to have born preterm, lower birth weights, and to suffer the associated health problems. Children born to adolescents realize particular challenges— more likely to have inferior educational, behavioral, and health outcomes throughout their lives, compared with children born to older parents. These children are also more likely to have lower school achievement and to drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult. This is a perpetuating cycle.

The Providers Role

As a health care provider, you play a critical role in further reducing teen pregnancy rates through the care you provide to your adolescent patients.

  • Ask both male and female adolescent patients about their past and current sexual and reproductive history.
  • Provide confidential, respectful, and culturally appropriate services that meet the needs of teen clients.
  • Discuss not only pregnancy as a risk, but also acquiring STDs.
  • Support those who are not sexually active to continue to wait.
  • Present sexually active teens the importance of always using dual methods—such as an IUD or hormonal method, and a condom—to prevent pregnancy, and STDs including human immunodeficiency virus (HIV).
  • Discuss the full range of contraceptive methods after birth, especially LARCs. Research indicates that effective contraception helps prevent poor birth spacing, thereby reducing the risk of low-weight and/or premature birth. Most states’ Medicaid program cover the cost of contraceptives, especially the LARCs.

 

Fighting Misinformation

Abstinence-only programs are a classic case of “information manipulation”—an attempt to misuse information to influence individual choice. This is why leading medical organizations have taken strong stances against abstinence-only programs. These programs often promote harmful gender stereotypes, and they marginalize and systematically ignore the needs of marginalized groups, including LGBTQ young people. Ultimately, young people have a need and right to complete and accurate information to support their healthy sexual development as adolescents, and throughout their lives.

We Can Make a Difference

We are making a difference in teen pregnancy rates, but our job is not over. Having the power to decide if, when, and under what circumstances to get pregnant and have a child increases young people’s opportunities to be healthy, to complete their education, and to pursue the future they want. But they can’t make that decision if they lack information and access to contraception. It is our calling to make that difference.

An Open Letter to WHNP Students

An open letter to WHNP students by NPWH Chair Elect, Diana Drake DNP, APRN, WHNP-BC and Clinical Associate Professor

Dear WHNP Students,

To the students who graduated this semester in the Class of 2019, and the future graduates in the Class of 2020 and 2021, I strongly urge you to pay very close attention to the current bans, discussions and political debates regarding abortion, contraception and the control of women’s bodies that is happening right now. With all due respect to your individual values and beliefs, please know that the issues at stake will have a direct impact on you career as WHNPs and the young girls and women you are seeing as patients.

The WHNP faculty work hard to instill the values of compassionate individualized care, health care rights, safe choices and equal access. What we teach is based on sound science and it is implemented through models of evidence-based practice. As WHNPs, we follow and align closely with highly regarded national organizations in our specific field that promote and protect the health and wellbeing of girls and women. You can read NPWH’s statement below.

Please read, please stay current and please stay engaged as activists and advocates for women and girls. We are at the frontlines of women’s health care and we have a professional obligation and responsibility to the populations we serve. 

Sincerely,

Diana Drake DNP MSN APRN, WHNP-BC
Clinical Associate Professor, School of Nursing, University of Minnesota

NPWH Statement on Abortion Bans

The National Association of Nurse Practitioners in Women’s Health (NPWH) is alarmed that lawmakers are working to pass new laws banning and restricting abortion access – imposing professional, civil, and criminal penalties on clinicians who provide safe, high-quality abortion care to their patients. We are also troubled and paying close attention to new discussions and political debates regarding contraception and the autonomy of women’s bodies.

As these disturbing events continue to unfold, NPWH re-asserts our mission statement, which values “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.”

Nurse practitioners understand that it is crucial to have the ability to provide women with compassionate, individualized healthcare built on sound science and evidence-based practice. We are committed to offering safe choices and equal access to all women.

The Infertility Evaluation:  What ANPs Can Do Before a Referral to a Specialist

The below was written by Jordan Moore Vaughan. MSN, APRN, WHNP-BC

Infertility doesn’t discriminate. It affects all races, religions, and all socioeconomic backgrounds. This complex diagnosis can affect physical, mental, and financial well-being. It is often overlooked or misunderstood. During this Infertility Awareness Week, I hope to shed some light on this condition as well as some tools we have as providers prior to referring a patient to a specialist.

Infertility 101

The definition of infertility is the inability conceive after one year of regular, unprotected intercourse, or six months if a woman is over the age of 35.  According to the CDC, as many as 10% of women struggle to become pregnant or continue a pregnancy in the United States.

As an advanced practice nurse (APN), you may be the first point of contact for patients in the fertility journey. Before referring them to an infertility specialist, you can provide them with education and guidance on how to maximize fertility.

Guidance for Women

All women of childbearing age should be on a prenatal vitamin with folic acid. They should not be smoking, and should limit their alcohol and caffeine consumption. Women should also maintain a healthy body weight to promote efficient ovulation and optimal health for continuing pregnancy.

Guidance for Men

The guidance for men is similar. They should also be taking a multivitamin. They should not be smoking, and should limit alcohol consumption. Men also need to maintain a healthy body weight.

In addition, men should not be taking any anabolic steroids, as it affects the hormonal balance between the brain and testes, which impacts sperm production.

Guidance for Couples

Education on the timing of intercourse is very important. To increase the chances of pregnancy, couples should have intercourse during the “ fertile window” which is the  5 days leading up to and the day of ovulation.  You should educate your patients on how to monitor ovulation, whether by menstrual calendar, ovulation predictor kits, or evaluation of cervical mucus.

What APNs Can Do

In order for a woman to conceive three components are necessary: Ovulation, a suitable uterine environment, and motile sperm capable of fertilization. Here are three things you can do before initiating a referral:

Ovarian Reserve Testing

Determine if a woman is ovulating either by a detailed history or by testing. Although there is no perfect test, and generally a combination of testing is used to predict chances of pregnancy, AMH (Antimullerian Hormone) is a promising screening tool to predict ovarian reserve. This may be obtained by blood sample at any day of a women’s cycle, whereas a basal FSH (Follicle stimulating hormone) is only reliable on menstrual days 2-4.  In the literature, a level of > 1 ng/ml is generally considered to be normal.

HSG

Tubal disease is a common cause of infertility. You can rule this out prior to referral.  Screening for a history of Chlamydia is particularly important as it is the primary modifiable cause of tubal factor infertility.  Doing an HSG (hysterosalpingogram) is an inexpensive way to determine tubal status. This is done after a woman stops bleeding and prior to ovulation. This can document tubal patency, uterine anomalies, such as a fibroid or polyp, and uterine malformations, such as a septum.

Semen Analysis 

For the male partner, a semen analysis should be considered early in the evaluation. This analysis is the most accurate evaluation of male fertility and can be used as a cost-effective way to quickly exclude male factors as the cause of a couple’s infertility. Collections should be made with 2-5 days of abstinence for optimal results.  Contact your local fertility practice or lab for specific instructions as all centers are different.

The diagnosis of infertility is life altering for many couples, with lasting psychological impact as well.  As an APN you are in a unique position to guide your patients through the fertility journey providing holistic care and addressing both the physical and emotional well-being aspects.  Because of the length and intimacy of the evaluation, patients may feel more comfortable working with you because of the already established a trusting relationship you have before referral to a specialist.  These are some components of the evaluation that you can do in your practice prior that are helpful in the referral process.