Alcohol Free Holidays for Baby and Me

Reprinted with permission from Healthy Nurse, Healthy Nation, American Nurses Association.

It’s the holiday season. Time for family, friend, and co-worker get-togethers. Time for shopping wrapping, and giving gifts. Time for holiday traditions. Maybe there will be some traveling.  For many people, alcohol is a part of the holidays…a cup of eggnog at the company party, a glass of wine to relax after a long day of shopping, a new year’s toast with a glass of champagne. For some people, alcohol is used to relieve stress and although the holidays are hopefully enjoyable, they can also be stressful.

But wait…what if you are pregnant or could be pregnant? What if a close friend or family member is pregnant? We want to share some very important facts regarding alcohol use and pregnancy that many people, even nurses, may not know. Alcohol is a teratogen with the potential to disrupt fetal development throughout an entire pregnancy. Fetal alcohol exposure can cause a range of lifelong physical, behavioral, and intellectual disabilities known as fetal alcohol spectrum disorders (FASDs). Disabilities may manifest as developmental delays and impairments affecting attention, learning, memory, self-regulation, and social/adaptive skills. FASDs can be prevented when women abstain from alcohol throughout their entire pregnancy.

The American College of Nurse-MidwivesAmerican College of Obstetricians and Gynecologists American Academy of PediatricsAssociation of Women’s Health, Obstetric, and Neonatal NursesCDC, and National Association of Nurse Practitioners in Women’s Health, among other professional health associations, all agree there is no known safe amount, no safe time, and no safe type of alcohol use during pregnancy because we cannot predict how any mother/baby pair will react to the teratogen.

So, if you or someone for whom you care are or might be pregnant, here are a few tips to plan for an alcohol-free holiday season.

Stress management 

You just had a somewhat stressful day of shopping. The stores were crowded, you couldn’t find the perfect gift for that special someone, and your feet hurt. Now you are home and want to relax. Don’t reach for the wine glass and bottle of wine. Instead, take a relaxing bath with candles and soft music. Or curl up with a good book and a cup of hot chocolate. Watch a fun holiday movie – How the Grinch Stole Christmas, Elf, A Rugrats Chanukah, A Rugrats Kwanzaa, A Wonderful Life.  Are your feet still hurting? Get a foot massage.  Revisit last December’s Healthy Nurse/Healthy Nation blog – Overcome Holiday Overwhelm for more tips on stress management during this holiday season.

Holiday socializing 

It’s time for that New Year’s Eve party with special friends. You know that cocktails and champagne are traditionally included in the celebration. How do you ring in the new year? Plan ahead. Share some mocktail (non-alcoholic cocktail) recipes  with the host of the party. Bring a bottle of non-alcoholic champagne with you. Drink your non-alcoholic beverages in wine, cocktail, or champagne glasses. Volunteer to be the designated driver.

Support from others 

Get support from your significant other, friends, and family. You may want to share with them what you know about FASDs. The September 2018 blog September is FASD Awareness Month – Fetal Alcohol What? provides facts and helpful resources. Seek professional help if needed. If you are pregnant or trying to get pregnant and cannot stop drinking, get help. Contact your healthcare provider, a local Alcoholics Anonymous, or local behavioral health treatment facility.

Spread the word 

Together we can make a difference if we all spread the word that FASDs can be prevented by not drinking alcohol during pregnancy. Have a frank discussion not only with your patients, but also  your daughters, sisters, friends, spouses, nieces, granddaughters– any loved one who is or might be pregnant. Tell them alcohol is a teratogen and there is no known safe amount, no safe time, and no safe type of alcohol use during pregnancy. Help them have an alcohol-free pregnancy.

This post was written by:

  • Beth Kelsey, EdD, APRN, WHNP-BC, FAANP, Director of Publications, National Association of Nurse Practitioners in Women’s Health
  • Elaine Germano, CNM, DrPH, FACNM, Special Projects Technical Advisor, American College of Nurse-Midwives
  • Marilyn Pierce-Bulger, APRN Owner/Manager, FASDx Services, LLC and Board of Directors member, Alaska Center for FASDs, Anchorage, AK.
  • Susan Rawlins, MS, WHNP-BC, Director of Education, National Association of Nurse Practitioners in Women’s Health
  • Catherine Ruhl, MS, CNM, Director, Women’s Health Programs, Association of Women’s Health, Obstetric and Neonatal Nurses

    With the support of the Collaborative for Alcohol Free Pregnancy: Partnering for Practice Change, the University of Alaska Center for Behavioral Health Research and Services.

Female Urinary Incontinence: To Be Expected with Age?

This post is co-authored by Brooke Faught, DNP, WHNP-BC, NCMP, IF, and Brandy Hood, MD

Urinary incontinence impacts women’s lives and wellbeing in more ways than the obvious, including contributing to social isolation, falls, and hip fractures. It is also a tremendous financial burden on patients and on the nation, with an estimated annual cost of $66 billion in the United States.

Yet despite the personal and societal costs, even discussing incontinence with patients often means overcoming stigma. Patients often fail to divulge their experience with urinary incontinence unless specifically questioned. And when they do, they often couch it defensively and tentatively.  Clinicians often hear, “Oh yeah, I leak a little when I run, but I’ve had two babies. That’s normal, right?” Or, “I always have to pee as soon as I put my key in the door and sometimes I don’t make it.”

While urinary incontinence is fairly common, it is not a normal symptom that patients should be afraid to discuss or tolerate. As providers, we need to ensure our patients understand that and know that we can help.

In this post, we’ll discuss tools for evaluation and treatment that providers should know.

Types of Urinary Incontinence

First, let’s understand the types and causes of urinary incontinence. The most common types are stress and urge.

  • Stress incontinence occurs when a defect in the supportive tissue of the urethra and/or pelvic floor allows urine to pass through the urethral sphincters due to heightened abdominal pressures often caused from jumping, laughing, sneezing, coughing, and vomiting.
  • Urge incontinence occurs due to overactivity of the detrusor muscle of the bladder that causes an increase in intravesical pressure. During a detrusor contraction, urine in a full bladder either expels out of the urethra or refluxes back up into the kidneys. While more noticeable, urinary incontinence is less concerning than reflux.

Other less common types of urinary incontinence include functional and overflow incontinence. Although outside the scope of this blog post, patients with urinary incontinence should also be screened for fecal incontinence.


Providers need to conduct thorough evaluations for urinary incontinence. That means asking questions about:

  • frequency of symptoms
  • exacerbating factors
  • volume of leakage
  • number of pads used each day
  • hematuria
  • dysuria
  • urinary frequency
  • nocturia
  • enuresis
  • symptom impact
  • risk factors, including:
    • past pregnancies
    • number of vaginal deliveries
    • vulvovaginal and pelvic surgeries
    • menopausal status, neurologic conditions
    • history of recurrent UTIs

Voiding Diaries: A 24-48 voiding diary is a great evaluation tool because it allows for the comparison of fluid input/output and also provides objective data when evaluating treatment efficacy.

Exam: A full pelvic floor examination aids the health care provider in understanding important urogenital factors that may be associated with a patient’s symptoms including pelvic floor tone and strength, prolapse, urethral hypermobility, and vulvovaginal tissue atrophy. The provider should perform a digital and speculum exam. Patients should also be examined in the supine and standing positions.  Urodynamics provides additional details about patients’ symptoms of incontinence and should be considered in cases where patients report mixed urinary incontinence (more than one type of incontinence) or when they do not respond to conventional therapy such as behavioral modifications, pelvic floor physical therapy and/or oral medications.

Stress Incontinence

Many patients report onset of stress incontinence during pregnancy and after vaginal deliveries, although nulliparous status and lack of previous vaginal deliveries does not preclude the patient from experiencing stress incontinence. Genetics also plays a big role in a woman’s potential for experiencing stress incontinence.

Weight loss may help patients reduce stress incontinence. In some cases, continence pessaries provide enough support at the urethral neck to prevent stress incontinence. I also often recommend pelvic floor physical therapy as a first line treatment approach for women reporting stress incontinence unless they have severe urethral hypermobility (identified on exam) and/or intrinsic sphincter deficiency (identified on urodynamics). In the latter cases, women often require surgical intervention.

Urge Incontinence

If patients fail conservative interventions including at least two oral anticholinergic meds and/or a β3 -adrenergic agonist, they are candidates for third-line therapies including neuromodulation and intravesical Botulinum Type-A toxin. Tibial nerve stimulation offers patients a non-invasive treatment option for urgency and urge urinary incontinence, although patients must come into the medical clinic for twelve weekly 30-minute sessions. Sacroneuromodulation involves the surgical placement of a small implant that functions at the pudendal nerve complex. The length of the battery life depends upon multiple variables of each individual patient. Intravesical Botulinum Type-A toxin is injected directly into the bladder mucosa with the assistance of the cystoscope. The effects of this therapy may last up to 6 months although upwards of 5% of recipients experience transient urinary retention.

Final Thoughts for Providers

Urinary incontinence is not just a nuisance that should be ignored or tolerated, but rather a health condition with significant personal and economic impacts. Health care providers who care for women should screen for urinary incontinence and offer treatment and/or an appropriate referral(s) when identified. It is our responsibility to bring conversations about incontinence out of the shadows, and ensure our patients get the care they need and the quality of life they deserve.

Fall 2018 Healthy at Any Age and Older Women’s Health Coalition

As women’s health nurse practitioners, we work with women across their lifespans, from adolescence to advanced age. Our experience with such a wide range of ages has shown us that it’s the aging population that is often neglected.

The population of aging women is soaring and this generation of women approaches aging differently than their mothers and grandmothers did.

  • Between 2005 and 2015, the number of women aged 65 and older more than tripled to 26 million.
  • The number of older women will double by 2030 and continue to rise.
  • By 2030, about one in five Americans of both sexes will be older than 65, with women outnumbering men.
  • There are more women in the workforce after 65 and there are higher expectations for how to live well in retirement.

These older women are also facing more challenges, which include poverty, caregiving burdens, and stigmas around sexuality, mental health, addiction, and disability.

That’s why, for the last two years, NPWH has been convening leaders from a variety of organizations that touch the lives of women and aging populations to determine how to harness our work to make the whole larger than the sum of the parts. We recently gathered  at a “Healthy at Any Age” /Older Women’s Health Coalition planning meeting in early November to continue our efforts from a spring meeting where we began to lay the groundwork for an Older Women’s Health Coalition that will work with policymakers, clinicians, researchers and the general public on issues facing aging women.

Diverse leaders rolled up their sleeves to review the suggested goals, structure, and agenda for how a new coalition that will focus on advancing the health interests of older women.

We will focus on four efforts:

  • Advocating for federal legislative and regulatory policies – including federal funding for health research and services —  that benefit older women.
  • Promoting greater public education about the holistic needs of older women – particularly in physical and mental health care and breakdown stigmas and stereotypes
  • Strengthening the knowledge of the clinical community about how to treat and engage with older women patients and their families/caregivers
  • Promoting additional research into medical therapies that will improve older women’s health and wellness

As a next step, we are continuing to refine priorities for the coalition and are excited to dive into research on a report to be released next year. We also want to open up the conversation to others who care about aging women.

If you are interested in learning more about how you can get involved, please email

Looking Back at the 21st Annual Premier Women’s Healthcare Conference

Thank you so much to everyone who attended the 21st Annual Premier Women’s Healthcare Conference last month! This was our biggest conference yet – between attendees, speakers, and exhibitors, we welcomed almost 1,000 champions of women’s health to San Antonio. For those who missed it – or those who want to relive it – I wanted to take the time to share some highlights:

  • Our educational sessions are always a highlight of the conference and we hope you enjoyed the plenaries, breakout sessions, and workshops. As always, all sessions will be uploaded to the NPWH website so you can watch any session you might have missed. Look for an email with more information in December.
  • Our Student Leadership Program returned this year, allowing 11 WHNP students from around the country the chance to attend the conference and gain invaluable experience. It was such fun to see these future leaders at work, and we look forward to them being a part of NPWH for years to come. We encourage everyone to share this opportunity with any students they know next year.
  • We also brought back our Inspirations in Women’s Health Awards! Congratulations to the following winners and leaders in the field:
    • Marcia Clevesy, DNP, WHNP-BC (Practice): In addition to her work as an associate professor at the University of Las Vegas, Dr. Clevesy volunteers weekly at the Nevada Obstetrical Charity Clinic, a nonprofit organization providing obstetrical and gynecologic care services at reduced fees for uninsured women. She recently implemented a QI project that improved postpartum depression screening detection and rates at the clinic.
    • Nalo Hamilton, PhD, MSN, APRN-BC (Research): Dr. Hamilton is both a biological researcher and a practicing WHNP. Her unique background in biochemistry and molecular biology, combined with her clinical expertise as a WHNP, enables her to investigate questions related to women’s health. Her current research focuses on the identification of biological markers for screening and therapeutic treatment of triple-negative breast cancer.
    • Allyssa Harris, PhD, RN, WHNP-BC (Policy): Dr. Harris is the WHNP program director at Boston College. She is also a mentor for Boston College’s Keys to Inclusive Leadership Program, which helps to prepare nurses from disadvantaged backgrounds to enter the nursing workforce.
    • Anne Moore, DNP, WHNP, ANP, FAANP (Education): Moore was instrumental in developing the WHNP program at Vanderbilt University, serving a total of 22 years as both an instructor and program director. She is currently the senior medical science liaison at AMAG Pharmaceuticals.
  • We consistently heard from exhibitors that they loved the engagement and excitement they receive from our attendees! We hope you enjoyed talking with them and learning about new products and treatments. This was our biggest exhibit hall to date, and we look forward to expanding even more next year!

Click here to view more highlights from the conference. Thank you all for your continued support, and we look forward to seeing you in Savannah, Georgia, October 16-19, 2019!

G Johnson

Gay Johnson, CEO

My Breast Cancer Story (and What My Fellow Nurse Practitioners Can Learn From It)

In honor of Breast Cancer Awareness Month, former NPWH Board of Directors member Carola Bruflat shares her experience with breast cancer and suggestions for WHNPs with breast cancer patients.

After an 18-year career as a women’s health practitioner, I retired from clinical practice in December 2016. Two months later, on Valentine’s Day, I received a breast cancer diagnosis. What I’ve learned since then may be helpful to those in my profession.

My first phone call after being diagnosed was from the nurse navigator at a large medical center where my husband and I had received care for years. The medical center’s Breast Cancer Clinic answered many questions, but I still felt I needed a second opinion. After all, this was life changing. So, I called one of the physicians at my practice, who became my guide through the process. I am eternally grateful to her.

The breast surgeon was my next stop. She made me feel at ease immediately, drawing diagrams to illustrate the entire process. Together, we chose a partial mastectomy, and the surgery went very smoothly. My margins were clear, and I had no lymph node involvement.

For follow-up, I chose aggressive partial breast radiation. My radiation oncologist had helped to develop this technique and offered a lot of data about side- and long-term effects. But I was not ready for the overwhelming fatigue that resulted, and I also developed oral thrush from using Bactrim and Flovent at the same time. That’s my first lesson for my colleagues: always look at that medication list!

The final part of my cancer journey was to the medical oncologist. I wanted to avoid chemotherapy if possible, and the oncologist reassured me that my choice was valid. Together, we decided on aromatase inhibitor (Aromasin) treatment daily for five years with no chemotherapy. It was a great day when I got that news!

Recently, I had my first mammogram (all-clear), and my first survivorship meeting with the oncology office. I hope my experiences will benefit your patients as we observe Breast Cancer Awareness Month 2018!

Here are some other observations from one who’s “been there”:

What WHNP’s Need to Know

Know and follow the current guidelines for breast cancer screening and risk assessment: Work with your patients to develop individualized plans for screening based on their age, health status, risk assessment and personalized values, and encourage them to take active roles in monitoring their own breast health.

Get a thorough genetic history and update at each visit: As nurse practitioners we are ideally placed to identify families that may have an inherited predisposition to cancer. (My sister developed breast cancer around age 60.) Taking a brief family history can easily become a part of routine health assessments.

Get to know your local breast cancer community and refer patients often to them: Local support groups can be a very important live resource, in addition to websites, message boards, education workshops, counseling programs and online communities.

Listen to your patients: Megan Childers, a nurse practitioner from Vanderbilt University, offers valuable tips here on how to talk to patients with a new diagnosis. They include:

  • Sitting down when you talk.
  • Using simple language.
  • Covering the most important information slowly.
  • Staying positive, calm, personable and empathetic.

Read what is in the everyday press about cancer treatment and new research: Since your patients will surely do so, it’s important to give them good internet sources—those with informative and factual information and stories of hope and reassurance—to look at. I recommend and to both patients and practitioners.

My Best Resources

Practitioners may be interested in the results of the TAILORx trial, released in June 2018, finding that most women with early breast cancer do not benefit from chemotherapy.

Please also take a look at this article from The Journal for Nurse Practitioners, April 2018, on managing cancer survivorship issues.

Another great resource is

My Own Personal Insights

  • My mammogram saved my life as I could not feel the lump, nor could anyone else.
  • When you get your diagnosis, learn all you can about breast cancer from reliable on-line sources. It helps you formulate your questions for your first visits, including what your wishes for treatment are.
  • Find your support system – girl friends, spouse/partner, medical partner (my boss), and the nurse navigators. I did not do this very well.   It was so unexpected for me, I found it hard to talk about initially with anyone outside my immediate family.
  • Always get a second opinion – this is cancer after all.
  • Find a medical team you are comfortable with. One of the benefits of being in health care is that as nurses we have the best contacts for care.
  • Choose a healthy lifestyle – be active, eat a healthy/Mediterranean diet, no smoking, limit alcohol, manage stress and other chronic illnesses.
  • Utilize your local support systems and health and wellness programs.

Yes, I am a member of the “1 in 8” club, but I am a breast cancer survivor.

Optimizing Breastfeeding

Outgoing NPWH Board of Directors Secretary Jamille Nagtalon-Ramos, EdD, MSN, WHNP, IBCLC, and Nicole Chaney, MSN, CNM, shares their tips on optimizing breastfeeding below.

WHNPs play a very important role educating and supporting pregnant women and new mothers about breastfeeding. There are many things we can do in both the critical antepartum and postpartum periods to help the mother-baby pair optimize the breastfeeding experience.

As an inpatient WHNP and an International Board Certified Lactation Consultant® (IBCLC®) here’s my guidance for clinicians. Please feel free to share your tips, as well.

Start the Conversation in the Antepartum Period

We should start providing breastfeeding education as early as possible in the pregnancy, according to the “Ten Steps to Successful Breastfeeding” guidelines from the World Health Organization and the United Nations Children’s Fund’s Baby-Friendly Hospital Initiative.

Women are interested in learning about how to best care for themselves and their babies in this period and research shows this is when mothers make their decisions about how to feed their infants. In fact, a mother’s determination to breastfeed during the prenatal period is a strong predictor of successful breastfeeding.

What we can do and say:

  • Find out what’s important to a pregnant patient
  • In my practice, I have found that getting to know my patient and opening up a conversation about what they value and what they fear helps me focus my counseling, For example women with a family history of breast cancer are very interested to know that breastfeeding is thought to decrease the incidence of breast cancer later in life.
  • It’s important to try to identify early on any breastfeeding barriers patients anticipate. You can document those and provide resources to address them at the outset. Then, revisit these barriers periodically throughout the pregnancy.
  • Use open ended questions – as a way of eliciting more comprehensive responses– versus closed questions about feeding options.
  • For example, ask the patient “What would you like to learn about breastfeeding?” rather than “Do you have any questions about breastfeeding?”.
  • Offer a strong statement of breastfeeding support to help influence a woman, while still supporting her personal choice to breastfeed, formula feed, or do both,
  • We can say things like, ”At this practice, we recommend breastfeeding exclusively for the first six months for various health reasons for the baby and for you, the mom.” Organizations like American Academy of Pediatrics recommend it, and I personally recommend breastfeeding,

Teach practice of milk expression

Immediate postpartum can be such a blur (especially with a c/s, pain, anxiety) and can be a tough time for many new moms to learn new things, acquire new skills, and believe that their bodies are capable of making milk to nourish their babies. This is why it’s important to help patients get comfortable with their bodies in the weeks and months before they deliver.

What we can do and say:

  • teach hand expression of milk antenatally. Although not evidenced based, I and other WHNP’s encourage our pregnant patients to practice beginning around 38-39 weeks if they’d like .
  • Most women are comfortable practicing in the shower, but anywhere they are comfortable would work. If they happen to express some milk, they could save it, but you can remind them that most people don’t have milk yet, and that not having expressible milk now has no significance on their body’s ability to make milk after the baby is born.
  • show them the Stanford video
  • encourage women to look in the mirror every day, and tell themselves their body is magical and will make a lot of milk for their baby.

Postpartum Period

In the immediate postpartum period, WHNP’s continue to have a vital role in helping optimize breastfeeding.

What we can do and say:

  • approach each postpartum patient as someone who will be a successful breastfeeding mother unless the patient tells us otherwise.
  • If the patient states that she has decided to formula-feed or to supplement her breastfeeding with formula, I offer the same eager support for her choices.
  • Depending upon the breastfeeding culture of your facility, and your prior knowledge of the patient history, consider asking the brief question, “Did anyone discuss the benefits of breastfeeding with you?”
  • coordinate with the nurses and lactation consultants in your unit on how to work as a team in providing the best possible support for our patients who are open to learning more about breastfeeding

Consider these steps immediately after your patient gives birth:

  • Encourage early (immediate) and unlimited skin-to-skin contact on the mother’s chest, uninterrupted for the first, golden hour
  • Early latching and suckling ??
  • Foster an environment that supports baby-led feeding instead of scheduled feedings.
    • For example, scheduling procedures such as baths, vaccinations, hearing testing around the infant’s feedings and not the other way around.
  • Provide hands-on assistance in helping position the infant especially for the first feeds
  • Teach parents about feeding cues
  • Educate and reassure about expected amounts of inputs – frequency and duration of feedings – and outputs – number of wet diapers.
  • Facilitate obtaining a breast pump through their insurance or rental of the breast pump
  • Educate on breast pump use
  • Educate women who choose to supplement with formula on the types of formula and the preparation of formula
  • Provide culturally-sensitive care for women who desire to breastfeed

Consider these steps prior to patient discharge:

  • Refer women to lactation groups within their community prior to discharge
  • Provide follow-up and telephone support

Think About Your Own Views of Breastfeeding as You Counsel Patients

It is also important for WHNP’s to examine their own personal biases for or against breastfeeding, as well as personal assumptions about cultural, racial, or ethnic influence on a woman’s breastfeeding decisions.

  • consider taking an implicit bias/racism in healthcare training course – because breastfeeding is steeped in historical context, and a person’s own implicit bias can influence their counseling,

Understand Reasons Why Moms Discontinue Breastfeeding Early

As WHNP’s it’s important for us to recognize why nearly 60% of women discontinue breastfeeding at six months and 35% stop at 1 year  – despite the fact that the American Academy of Pediatrics (AAP) recommends that infants be exclusively breastfed for about the first 6 months with continued breastfeeding alongside introduction of appropriate complementary foods for 1 year or longer. (Centers for Disease Control and Prevention, 2018).

Know these major factors that mothers identified as to why they discontinued breastfeeding early:

  • Lack of family support
  • Cultural beliefs and practices
  • Unsupportive hospital practices and policies
  • Concurrent medications while breastfeeding
  • Latching issues

Let’s Focus on Brain Health

This post is written by Jill Lesser, President of WomenAgainstAlzheimer’s

September 21 marks the seventh annual World Alzheimer’s Day – a prime opportunity to talk about where we’ve come from, where we currently stand, and where we must direct our focus for the future of those living with Alzheimer’s.

Arguably, the most significant hurdle we must address immediately is a society-wide lack of awareness for Alzheimer’s and dementia. And we’re starting with women. This disease touches everyone but it targets females. Alzheimer’s is not gender neutral. It affects women far more than me – both as people living with the disease and those that take one the role of caregiver.

Two out of every three people suffering from Alzheimer’s is a woman. And according to one survey, just 27% of women realize they are more susceptible to the disease simple because of their gender. More than two thirds of women wrongly believe that symptoms don’t start to appear until age 60. And nearly half wrongly think that Alzheimer’s is strictly genetic.

Given the scale of this disease, these numbers are particularly alarming.

We recently teamed up with HealthyWomen and participated in the WomenTalk survey to learn more about women’s attitudes towards brain health.  There was good news and bad.

The survey found that just 29% of women say they discuss the topic occasionally, and a mere 8% say they talk about it regularly.

Fewer than one in five say they’ve taken steps to protect the health of their parents, and just three in ten say they’ve taken steps to protect the brain health of their children.

That’s the bad news.

The good news is that, nearly two-thirds of women say they are worried about the health and performance of their brains. And more than two thirds are interested in learning more about the subject.

In other words, most women want to know more, and would take action if they knew what they could do.

Health data show that women over age 60 are twice as likely to develop Alzheimer’s than breast cancer. They are also far more likely to end up taking care of parents living with the disease. Women, in fact, comprise two-thirds of voluntary caregivers. For many women today, the challenge of caring for a loved one is doubled because many are trying to raise children while tending to their parents’ full-time care needs. As someone who has lived this, I can tell you that the stress can be relentless. And, as numerous studies show, caregiver’s health almost always suffers as well.

There are a number of things we can do now to see progress.

  • We need to set an example for the ones we love and get moving. Studies show that regular physical activity is good for the brain. Yet only 23% of Americans meet the national minimum physical activity guidelines. Women have the power to influence each other and their loved ones to live healthier lives and the best way to do so is to lead by example.

  • We need to start spending time educating women about the risks they face. While doing so, we need to raise awareness of the steps that women can take to improve their brains. And it’s more than just brain games and a healthy diet. Start from square one and check in on your brains at the next checkup. Get to know your baseline and start measuring changes as they happen, before memory becomes a concern.


  • We must advocate for a healthcare system that works for women. The public health community, led by women, has done a masterful job of raising awareness for women’s health issues such as heart disease and breast cancer. But these changes have only come when women demanded them. It’s time we come together and advocate for women’s health across the lifespan – applying the same level of dedication and enthusiasm to making women aware of the need to focus on their brains.


Everyone wishes for a cure for Alzheimer’s. And one day – hopefully one day soon – the cure will be discovered. Until then, we need to do everything we can to raise women’s awareness of their own risks, and what they can do to minimize them.

As a society, we need to not only direct more resources at Alzheimer’s. We need to make sure that the money we spend on research, health care, support services, and education targets the women who disproportionately carry the burden of Alzheimer’s.

On this, the 7th World Alzheimer’s Day, we need to recognize that this fight is as much about social justice for women, as it is about treatments and a cure for this relentless disease.

Preconception Diet and Supplementation

By Randee Masicola, DNP, APRN-CNP, WHNP-BC and member of the NPWH Board of Directors

Are you giving evidence-based information to your patients who are planning a pregnancy or who could become pregnant about diet that includes supplements to consider and foods to avoid?

What are the most critical things to tell them when your time with patients is limited?  What are some resources you can give them as they walk out the door?

It is particularly important to discuss food safety with all women who could become pregnant as many women do not seek care prenatal care until they are well into their first trimester.

Overall Diet: How to Eat Healthy

It is crucial that women who could become pregnant are educated on the safety of their food choices and the required nutrients needed to improve chances of a healthy pregnancy outcome.  Education starts with explaining the basics of daily fruit and vegetables and limiting high fat choices. Include background on the five food groups, healthy portion sizes, as well as any insight gathered form a 24-hour diet recall. Discuss replacing fast food with healthy convenient options to help patients make better choices within their own lifestyle.

Resource:, the federally funded campaign, is a great place to start

Fish – What to Eat and What to Avoid

It is important to talk with women about the benefits and risks of fish in their diet. Fish is an excellent source of low fat protein and can be help in the growth and development of the fetus.  It contains Omega-3 fatty acids which have proven to be essential for healthy fetal brain development. But women need to be counseled on the safe levels of methyl mercury in fish and warned about potential risks during pregnancy. A variety of birth defects have been linked to high levels of mercury in a pregnant woman’s diet.

  • Mercury can be found in many bottom-dwelling fish including king maceral, shark, and orange roughy.
  • Canned tuna fish has a very low mercury content and is safe but is recommend no more than 2-3 times a week. Albacore tuna has a higher mercury content.
  • Raw fish like sushi, as well as all raw and undercooked meats, should not be ingested due to the risk of parasites or bacteria.

A fabulous resource on Education of safe fish options and quantities, as well as up-to-date information for providers and patients is available on the FDA website ( 

Dairy: What to Avoid

Share with your patients the value of calcium in milk and cheese, but recommend they avoid unpasteurized milk and soft cheeses including Brie, Feta, Camembert, Roquefort, and even Queso due to the risk of E coli, Listeria, and/or Salmonella contamination.

Vitamins and Minerals: When Supplements Are Needed

Folic Acid

All women who could become pregnant need to take a multivitamin with at least 400mcg of folic acid. The United States Preventative Service Task Force (USPSTF) reaffirmed its 2009 recommendation in 2017 that all women who are planning or capable of pregnancy should be recommended to take a daily supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid and received its highest recommendation (USPSTF, 2017).

Folic acid supplementation should be started at least one month prior to conception. It can significantly reduce the risks of neural tube defects, like spina bifida and anencephaly (USPSTF, 2017).

Women with a history of having a child with a neural tube defect are encouraged to take 4-5mg of folic acid daily prior to conceiving which has shown to decrease risk of defects in following pregnancies (Toriello, 2011).


The recommended daily iron allowance for reproductive age women is 27mg of iron a day (ACOG, 2015). Most women will get this in their daily diet without supplementation. However, the growing blood supply of the placenta and fetus and the increased oxygenation needs of mother and the fetus result in a woman’s need for 50% more iron while pregnant. (ACOG, 2015).  The fetus uses the mothers iron stores for growth and development, commonly leaving the mother depleted.

Women already at risk or who have been identified as anemic should be counseled on appropriate iron supplementation and foods high in iron to include in their daily diet.

Red meats, spinach and raisins are common foods high in iron which is better absorbed when consumed with vitamin C rich foods like citrus fruits and tomato sauce.


Let your patients know that most women can increase calcium in their diet without supplementation. Supplementation of calcium is only recommended to achieve a daily uptake of 1000 mg/day in pregnant women, and if supplements are required, patients should be instructed to only take 500mg at a time at breakfast and again at dinner to increase absorption.

Calcium is an essential element for embryo growth. It is responsible for building strong bones and teeth for the fetus

Maintaining appropriate consumption can decrease risk of preeclampsia, preterm birth and low birth weight (Hofmeyr, 2010). The best source of calcium is through diet and can usually be achieved with dairy products and other foods rich in calcium; for example, calcium-fortified orange juice and cereals, sardines, green beans and sunflower seeds.

Liquids: How to Stay Hydrated

Hydration is essential for general health, however, women who could become pregnant should be advised about what beverages to avoid.

  • 6-8 glasses of water should be recommended a day.
  • Caffeine and artificial sweeteners, unfortunately, have limited evidence, so many national organizations give a blanket statement to limit or drink these beverages in moderation, recommending only 1-2 cups a day.
  • Alcohol should be completely avoided as it is a known teratogen.
  • Soda, due to the high sugar calorie count, should also be discussed and alternatives provided.

Preconception education goes beyond counseling women who are planning a pregnancy to include all women who could become pregnant. Evidence-based information about nutritional needs is an important component of this education that can occur at any office visit. This information is critical to improve health prior to pregnancy and to promote healthy pregnancies and pregnancy outcomes.

WHNPs can utilize available evidence-based web sites and written resources to streamline the information provided within the limited time we have with each patient.



American College of Obstetricians and Gynecologists. The importance of preconception care in the continuum of women’s health care. ACOG Committee Opinion No. 313, September 2005. Obstet Gynecol. 2005;106:665–6. (Reaffirmed 2017)

Hofmeyr GJLawrie TAAtallah ANDuley L. (2010). Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD001059.

Toriello, H. V. (2011).  Policy and Practice Guideline Committee of the American College of Medical Genetics.  Policy statement on folic acid and neural tube defects.  Genet Med. 2011;13(6):593-596.

United States Preventative Services Task Force (2017). Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183-189

Reflecting on the Women’s Sexual Health Course for NPs

NPWH and the International Society for the Study of Women’s Sexual Health (ISSWSH) hosted the fifth annual Women’s Sexual Health Course for NPs in June. Samantha Tojino, NP-C, FNP, DNP-s, first attended the course in 2013 and returned this year as a faculty member. She reflects on this year’s program and the need to have a course specifically focused on women’s sexual health.

Q: Why is the Women’s Sexual Health Course so important?

Before NPWH and ISSWSH developed the Sexual Health Course, there were no post-graduate education or training programs designed to keep nurse practitioners up to date on the latest practices and standards of care in women’s sexual health. Sexual health is critical to overall health and wellness throughout a woman’s life – from sexual debut and STD prevention through the childbearing years and continuing on through menopause and beyond. Unfortunately, few educational programs spend adequate time on this essential topic.

Q: Who can benefit from the Sexual Health Course?

NPs are the ideal practitioners to address sexual health needs. With their ability to have intimate conversations with patients about sometimes taboo and difficult subjects and their clinical experience with women of all ages, NPs offer a knowledgeable and caring approach to sexual health. But the Sexual Health Course isn’t just for women’s health NPs. It is a valuable complement for all nurse practitioners who deal with women’s health, including FNP, AGNPs, and CNMs.

Q: What’s unique about the instruction offered by the Women’s Sexual Health Course?

The Sexual Health Course was created by NPs recognized as sexual health experts for NPs wanting to enhance their competence in women’s sexual health. With input from both NPs and physicians, the course focuses on the knowledge and skills advanced practice nurses can include in daily practice to enhance women’s sexual health as well as specialty knowledge geared to identifying and treating women with sexual dysfunction.  The course includes content on hormone therapy specifically geared to nurse practitioner management of sexual function and dysfunction as well as training in detailed vulvar, vaginal, and pelvic examination. The vulvoscopy workshop provides a hands-on approach for providers, enabling them to evaluate epithelial dermatologic conditions during the vaginal exam. Participants are guided by experts in the field.

Q: Has interest in the Sexual Health Course changed over the years?

Yes, course offerings – and the number of participants – have grown significantly since 2013. As our program grows, more providers are taking advantage of this opportunity to better serve our patients.

Q: What were the key takeaways for participants this year?

  1. Women’s sexual health is a complex subject! Nurse practitioner education and experience lead to better patient outcomes.
  2. Sexual health is a basic human right and a vital component of overall lifelong wellness.
  3. Female sexual dysfunction can affect quality of life for a woman and her partner – but nurse practitioners can help.
  4. With the knowledge gained from this course, nurse practitioners are more confident in their ability to address, diagnose, and treat their patients’ sexual health concerns.

Spotlight on Caregivers

U.S. longevity trends are thrusting more women into caregiving roles. NPWH recently led discussions at two national summits on women’s health spotlighting how women’s health advocates must be and are increasingly focused on the roles and needs of women caregivers. For too long, caregiving has been a social and health challenge in the shadows, but as more of us age and take on the role of caregiver, there are many things to know.

Diana Drake, DNP, MSN, APRN, WHNP-BC, reflects on these efforts to put caregiving needs front and center, and shares caregiving trends health care providers should know.

Did you know? The numbers tell us we need many hands on deck and thoughtful planning.

  • The U.S. 65-and-older population is projected to nearly double over the next three decades, ballooning from 48 million, to 88 million by 2050.
  • The nation’s first wave of Baby Boomers will turn 85 twelve years from now in 2030.
  • 85 –year olds are twice as likely as 75-year-olds to need help getting through the day.
  • Increased longevity has already resulted in more than 34 million “informal” caregivers to support our aging population.
  • Family caregivers have been described as America’s other Social Security. The nation’s healthcare system would go broke if it had to pay for their work, valued at $470 billion a year in free care.2

Who are these caregivers? Many of them are our patients

  • The average caregiver is female, 49 years old and providing care for her mother that is the equivalent of a part-time job.2
  • Compared with other demographic groups, women, along with low-income workers and minorities, are more likely to reduce their work hours or leave the workforce because of their caregiving role.2
  • Female caregivers are less likely than male caregivers to see health care providers for their own preventive healthcare needs.
  • Female caregivers face increased risks for::
    • Depression and anxiety
    • A weak immune system
    • Obesity
    • Chronic disease (including heart disease)
    • Problems with short-term memory or paying attention

NPWH is pushing the issue front and center.

Through our leadership role in two coalitions, NPWH is helping drive national conversations around caregiving to increase awareness of, and support for, the female caregiver.

Coalition for Women’s Health Equity

More than three hundred women from across the country met in Washington, DC, for the Women’s Health Empowerment Summit, hosted in May by the Coalition for Women’s Health Equity.3 The summit spotlighted actions to address inequities that endanger women’s health and safety. As a member of the steering committee, NPWH helped organize a panel on Caregiving Across the Lifespan. Panel members explored the burdens and opportunities of caregiving and considered legislation to require the government to develop strategies that recognize and support family caregivers.

As a panel member, I was honored to speak as both a nurse practitioner who provides healthcare to many caregivers, and also as the daughter of two 96-year-old parents living in partially assisted care. I spoke directly to the impact of the female caregiver and the invisibility of the issue. With the profound impact that being a caregiver has on these women’s health, I also addressed the need for all health care providers to determine the caregiver status of their patients. The panel encouraged all caregivers in the room to lead by example, and to discuss their caregiver roles with their HCPs at health visits.

Healthy at Any Age Coalition

At NPWH’s second Healthy at Any Age Summit, we laid the groundwork for a coalition and began outlining the National Older Women’s Health Agenda. This agenda must include women caregivers and the adverse impact of long-term neglect of their own health.4 As we unite diverse sectors, share resources, and create strategies to advance the health and well-being of older women, NPWH will continue to draw attention to the vital role of caregivers and how to best meet their needs.

More conversations about caregiving must happen in living rooms, communities, government offices – and exam rooms. Let us know how you approach your patients to assess how caregiving may be impacting their physical health and psychological well-being.

Diana M. Drake is Clinical Associate Professor and Specialty Coordinator of the DNP WHNP Program at the University of Minnesota School of Nursing and Program Director for Integrative Women’s Health at the Women’s Health Specialists Clinic, both in Minneapolis. She is Chair of the NPWH Policy Committee and Chair Elect of the NPWH Board of Directors.


  1. United States Census Bureau. U.S. Population Aging Slower than Other Countries, Census Bureau Reports. March 28, 2016. gov/newsroom/press-releases/2016/cb16-54.html
  2. AARP Public Policy Institute. Understanding the Impact of Family Caregiving on Work. October 2012. org/content/dam/aarp/research/public_policy_institute/ltc/2012/understanding-impact-family-caregiving-work-AARP-ppi-ltc.pdf
  3. Coalition for Women’s Health Equity website. org/advocate/coalition-for-womens-health.html
  4. American Heart Association. Caregivers: Be Realistic, Think Positive. Last reviewed June 2017. org/HEARTORG/Support/Caregivers-Be-Realistic-Think-Positive_UCM_301771_Article.jsp#.WzlnWi2ZNhE