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.

April is Sexual Assault Awareness Month

The below was written by Heidi Fantasia PhD, RN, WHNP-BC. Dr. Fantasia is an Associate Professor at the Solomont School of Nursing, University of Massachusetts – Lowell, and a member of the NPWH Board of Directors

April is Sexual Assault Awareness Month. While this is the 18th year we have recognized this public health issue, there is still work to be done to overcome the shame and stigma that plagues victims of sexual assault. This annual recognition serves two purposes, to raise public awareness about sexual assault, sexual harassment, and abuse, and to provide education, resources, and potential solutions for prevention.

A Common Experience

It is estimated that between 25% and 50% of women will experience an attempted or completed sexual assault during their lifetime. Those rates could even be higher when you consider that many sexual assaults are never disclosed or reported, often times because it was perpetrated by someone who is known to the victim. Sexual assault can be defined in many different ways, but broadly it refers to sexual activity in which consent wasn’t obtained or wasn’t freely given. This includes sexual activity or contact that was unwanted, coerced or occurred after intimidation or threats of harm. Although both women and men can be victims of sexual assault, women have the highest rates.

The Role of a Provider

It is always an individual’s decision whether to disclose an assault. But health care providers play an important role in creating a safe space where people feel supported when talking about uncomfortable topics that they may have never discussed anyone else.

Ask the Questions

Asking simple questions such as “Have you ever been forced to have sex when you didn’t want to”, “Have you ever experienced physical or sexual violence from a partner” and “Are you currently afraid of someone” helps start a conversation. These questions can be modified for any practice setting and asked in person or incorporated as part of the patient history. Letting individuals know that these are routine questions asked of everyone will help reduce stigma and reduce the chance that women feel singled out due to factors such as age, race, ethnicity, sexual behaviors, sexual orientation, and gender identification.

Believe Women and Assure Nonjudgement

Individuals who have experienced assault, whether it was attempted or completed, can experience a range of emotions, including fear of not being believed, shame, embarrassment, and self-blame. They may be worried that others will judge their behavior or relationships. Discussing sexual assault allows for open and honest conversations about consent, coercion, and healthy relationships. The most important way health care providers can help those who have experienced sexual assault is believing their account and listening to their most immediate concern.

Offer Timely Resources

If the assault occurred recently (typically within the past 5-7 days), individuals can be directed to a hospital or center with a sexual assault program that provides forensic evidence collection. This evidence will be used if they decide to move forward with legal proceedings. It is important to make sure those who have experienced sexual assault understand the decision to press charges is completely theirs, and having evidence collected does not mean they have to go down this road now.

If the assault occurred outside of this time frame or if the individual doesn’t want to have this done, the office visit should focus on what they identify as most important. This may include concerns about pregnancy, sexually transmitted infections, or emotional issues such as fear, anxiety, and depression. Providers can offer outside resources for additional support such as individual and group counseling, liaisons with law enforcement, and legal assistance.

Providers Create Change

Increasing awareness of sexual assault as a prevalent public health issue will help decrease victim blaming and normalize conversations about best strategies for prevention. Whether a woman is coming in for an annual checkup or seeking help after a sexual assault, our work as clinicians can help lift the veil of secrecy so that more women can get the care they need.

Black Maternal Health Week: Voice and Visibility for Black Maternal Health

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. 

The Black Maternal Health Crisis

We are in the midst of a black maternal health crisis. According to the U.S. Centers for Disease Control and Prevention (CDC):

  • Black women have 3 to 4 times higher rates of death from pregnancy or childbirth-related causes compared to white women.1
  • Black women are more likely than white women to experience complications from maternal morbidities during pregnancy.1
    • Morbidities may include infections, mental health issues, obesity, diabetes, pre-eclampsia, and cardiovascular conditions.2
    • Morbidities may not result in death. However, they do have the ability to affect one’s quality of life.3

These alarming statistics urge us to take action and increase awareness about black maternal health.

As health care providers, more specifically women’s health nurse practitioners, we will likely cross paths with black mothers at some point in our careers. NPs, more than other providers, serve urban areas and rural communities where needs are greatest. It is essential that we see, hear, validate and advocate for this population of women.

Taking Action

A resolution recognizing “Black Maternal Health Week” was introduced in the Senate in 2018 by Senator Kamala Harris (D-CA) as an effort to bring national attention to maternal health care crisis in the black community and the importance of reducing the rate of maternal mortality and morbidity among black women.4 The nation now observes Black Maternal Health Week each year from April 11th -April 17th.

During this awareness week across the United States, campaigns and activities are led by the Black Mamas Matter Alliance to amplify the voices of black mothers and center the values and traditions of the reproductive and birth justice movements.5

Resources for Providers

There are many resources available to assist with the care and advocacy for this population. In 2018, Black Mamas Matter Alliance published a Black Paper entitled Setting the Standard for Holistic Care of and for Black Women.6

Critical Components of Setting the Standard for Holistic Care of and for Black Women include: 6

  • Addressing gaps and ensuring continuity of care
  • Affordable and accessible health care
  • Confidentiality
  • Safe and trauma-informed care
  • Care that centers black women and their families
  • Care that is patient-centered and patient-led
  • Culturally congruent and competent care

An additional resource available is Black Mamas Matter Toolkit. This toolkit was released by the Center for Reproductive Rights in partnership with members of Black Mamas Matter Alliance in 2016.7 It serves as a valuable resource for advocates who have an interest in the health and the well-being of black women and girls.7

Critical Components of Black Mamas Matter Toolkit include:7

  • Human rights-based approach to maternal health
  • Identifying the rights of pregnant and birthing parents
  • Information on the corresponding role of government to ensure safe and respectful maternal health care for all

How Providers Can Help

Black Maternal Health Week provides a forum to create awareness and solutions for health disparities affecting the black maternal population. During the week of Black Maternal Health and throughout your career as a health care provider, please challenge yourself to engage and deepen the national conversation about black maternal health in the United States.8 Consider contributing in areas of community-driven policy, research, and care solutions for this population.8 Black women deserve safe and healthy pregnancies and maternal health care.9  Together, we have the power to ensure they receive it.

References

  1. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. Pregnancy-Related Deaths. Available at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm. Accessed April 8, 2019
  2. CDC Foundation. Report from Maternal Mortality Review Committees. A View Into Their Critical Role. Available at https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf Accessed April 8, 2019
  3. Koblinsky M, Chowdhury M, Moran A, Ronsmans C. Maternal Morbidity and Disability and Their Consequences: Neglected Agenda in Maternal Health. Journal of Health, Population and Nutrition. 2012;30(2). doi:10.3329/jhpn.v30i2.11294
  4. Related Bills – S.Res.459 – 115th Congress (2017-2018): A resolution recognizing “Black Maternal Health Week” to bring national attention to the maternal health care crisis in the Black community and the importance of reducing the rate of maternal mortality and morbidity among Black women. Congress.gov. https://www.congress.gov/bill/115th-congress/senate-resolution/459/related-bills. Published 2019. Accessed April 9, 2019.
  5. Black Maternal Health Week. Apha.org. https://www.apha.org/events-and-meetings/apha-calendar/2019/black-maternal-health-week. Published 2019. Accessed April 9, 2019.
  6. Muse S. Setting the Standard for Holistic Care of and for Black Women. Blackmamasmatter.org. http://blackmamasmatter.org/wp-content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf. Published 2019. Accessed April 9, 2019.
  7. Toolkits – Black Mamas Matter Alliance. Black Mamas Matter Alliance. https://blackmamasmatter.org/resources/toolkits/. Published 2019. Accessed April 9, 2019.
  8. Black Maternal Health Week – Black Mamas Matter Alliance. Black Mamas Matter Alliance. https://blackmamasmatter.org/bmhw/. Published 2019. Accessed April 9, 2019.
  9. Black Women’s Maternal Health:. Nationalpartnership.org. http://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html. Published 2019. Accessed April 9, 2019.

Endometriosis Awareness Month

The following was written by NPWH Board of Directors Chair Aimee Chism Holland, DNP, WHNP-BC, FNP-C, FAANP, and April Love, MSN, RN, RNC-OB, CNE 

Have you ever looked at the statistics for endometriosis? They are most impressive in all the wrong ways. One in every 10 women of reproductive age is likely to experience endometriosis. Endometriosis occurs when the uterine lining grows outside of the uterus, and can lead to adhesion formation. As a result, scar tissue causes painful, sometimes debilitating, menstrual cramps. The number of ‘implants’ and depth of invasion create varying degrees of symptomatology and led to a spectrum within the disease ranging from asymptomatic to debilitating. While many women significantly struggle to find answers for why they experience such intense pain, menstrual irregularity, and infertility, surprisingly, most are unaware of their symptomatic connection to endometriosis.

We recently stumbled across an endometriosis “success” story from one of our co-workers that deserves to be shared. Our co-worker is young, enthusiastic, and undeniably bright. She has her PhD degree in nursing and has been an RN for many years. She is also a dedicated gym-goer who seems to have an unlimited energy supply. A self-proclaimed “lucky one,” Dr. Bray was diagnosed with endometriosis at a reasonably young age and started receiving treatment as a teenager. She is lucky because according to the North American Endometriosis Association Survey (NAEAS), there is a nine-year delay between the time a woman seeks help and is diagnosed with endometriosis.

The delay is often related to the navigation process. It takes time, patience, and diligence to make this diagnosis. Open communication with your healthcare provider is an extremely important initial step. Second, the healthcare provider has the challenging job of connecting the reported symptoms to endometriosis. Then, there needs to be a willingness to explore endometriosis as a diagnosis. To officially diagnose a patient with endometriosis, a laparoscopy procedure is required, allowing a gynecologist to view and remove endometrial adhesions.

After diagnosis, the patient and provider work together to form a plan that provides optimal quality of life and also keeps in mind the individual’s long-term needs and goals, which may include pregnancy. Because women usually experience the symptoms and complications of endometriosis during their child-bearing years, the implications of treatment on fertility and pregnancy can be uncertain. While there are treatment options available, including medications and/or surgical procedures, to help mediate pain and other symptoms, those solutions can negatively impact fertility, the health of a potential pregnancy, or in other cases prevent a patient from being able to carry a child.

For Dr. Bray, she has had success managing her endometriosis with Lupron (leuprolide acetate), a chemotherapy drug. Lupron shuts down the pituitary gland’s production of estrogen, thus creating a medical menopause and effectively “starving” the endometrial lesions on the uterus. The results include a relief of pain and other associated symptoms commonly experienced by individuals diagnosed with endometriosis. Sounds great, right? Actually, despite the growing popularity of Lupron for endometriosis symptom management, the National Institute of Health (NIH) and the Occupational Safety and Health Administration (OSHA) classify Lupron as a “hazardous drug” associated with major fetal anomalies when used in pregnancy. Therefore, it is essential that women understand the importance of a reliable contraception method while using it.

One win in this battle is the growing number of conversations in recent years seen on television and social media encouraging women to tell their healthcare providers about their symptoms. This healthy dialogue empowers women to speak up and speak out about their experience with endometriosis to support earlier diagnosis and symptom management. However, there is still a lot of work to be done to educate the general public.

How do we ensure faster diagnosis to improve quality of life and, if a patient priority, minimize potential reproductive complications? What treatment best reduces the chronic pain women suffer? We do not have all the answers yet, but we can advocate for everyone with endometriosis by bringing awareness and encouraging compassion for those who endure this condition every day.

Endometriosis is more than “just a bad period,” and it deserves to be explored and acknowledged. We encourage everyone reading this blog to take that next step toward awareness. Talk openly with family, friends, and co-workers about endometriosis. Most importantly, remind women to routinely make an annual appointment for a well-woman visit and to share signs and symptoms of concern with their healthcare providers.