National Nurse Practitioner Week: Shedding Light on the Important Role of Women’s Health Nurse Practitioners

The following was written by Shawana Moore, DNP, MSN, CRNP, WHNP-BC. Dr. Moore is an Assistant Professor and Women’s Health-Gender Related Nurse Practitioner Program Director at Jefferson University, as well as an NPWH Board Member. 

November 10th-16th, 2019, we celebrate nurse practitioners (NPs) throughout our nation for their extraordinary contribution to society. NPs care for individuals throughout the lifespan, lead healthcare systems, advocate for health policies, educate communities, and transform the way healthcare is delivered.

Statistics on Nurse Practitioners

  • 270,000 practice in the United States1
  • 1% have graduate degrees2
  • Hold prescriptive privileges, including controlled substances, in all 50 states and the District of Columbia3

Specialty Areas Available for Nurse Practitioners

There are multiple speciality areas in which nurse practitioners can obtain their primary certification. These include:

  • Women’s Health Nurse Practitioner
  • Neonatal Nurse Practitioner
  • Primary Care Pediatric Nurse Practitioner
  • Acute Care Pediatric Nurse Practitioner
  • Adult-Gerontology Nurse Practitioner
  • Adult-Gerontology Acute Care Nurse Practitioner
  • Family Nurse Practitioner
  • Psychiatric Mental Health Nurse Practitioner

Women’s Health Nurse Practitioners

Women’s health nurse practitioners (WHNPs) specialize in the care of women and make up 2.7% of NPs.3 According to a survey completed by the American Association of Nurse Practitioners in 2018, most WHNPs work as part of a private practice obstetrics and gynecology group.3 WHNPs practice in inpatient and outpatient settings, treating individuals throughout their lifespan and caring for their sexual and reproductive health care needs with a comprehensive and holistic approach.

Practice Settings Include:

  • Urogynecology Clinics
  • Gynecology-Oncology Clinics
  • Primary Care Clinics
  • Obstetric Triage Units
  • Breast Health Centers
  • Obstetric and Gynecology Outpatient Clinics
  • Postpartum Units
  • Reproductive Endocrinology & Infertility Offices
  • Maternal-Fetal Medicine Clinics
  • Sexual Health Practices
  • Women’s Correctional Facilities
  • Family Planning Clinics or Health Centers

Areas of Care Include:

  • Well-women care
  • Adolescent health
  • Contraceptive counseling
  • Transgender health
  • Pregnancy testing
  • Infertility treatment
  • Sexual Health
  • Male reproductive and sexual health
  • Menopausal health
  • Sexually transmitted infection treatment
  • Screening for general health problems
  • Breast health
  • Gynecological cancers

Resources

Facts about the women’s health nurse practitioner can be found on Nurse Practitioner & Women’s Health Nurse Practitioner Practice Facts website provided by the National Association of Nurse Practitioners in Women’s Health. Additionally, WHNP Guidelines for Practice and Education – 7th Edition, provides information on the role of women’s health nurse practitioners, practice guidelines and competencies of practices.

During this special week, let us take time to recognize the significance of nurse practitioners and the role of women’s health nurse practitioners in improving the lives of women everywhere.

 

References

  1. AANP National Nurse Practitioner Database, 2019.
  2. American Association of Colleges of Nursing (AACN). (2019). 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington DC: AACN.
  3. 2018 AANP National Nurse Practitioner Sample Survey.

Preconception Care for Women Living with Diabetes

Brandee Newsom, APRN, BC-ADM, CDE, works in Perinatal Diabetes Management at the High Risk Pregnancy Center in Las Vegas, NV. She recently presented on gestational diabetes at our 2019 Annual Conference. She shares the below for World Diabetes Day.

Today is World Diabetes Day, and as practitioners who care for women, it’s critical that we understand how this condition impacts our patients -especially when it comes to pregnancy. Diabetes can be managed before and during pregnancy to mitigate the risks to our pregnant patients and improve their long-term health. I offer this overview of screening and diagnosis, risk reduction, and the latest developments so we can provide quality care to our patients with diabetes and those at risk for diabetes.

By the Numbers

People living with diabetes are 2-4 times more likely to develop and die from heart disease or stroke. These risks are greater in women than men. Women with diabetes who become pregnant have a 10-20% chance of developing preeclampsia in addition to other adverse outcomes.

Screening and Diagnosis

If a woman is at risk for diabetes, she should be screened and counseled regarding risks. This includes women with the following risk factors:

  • Overweight/obese
  • Family history of diabetes
  • High blood pressure
  • High cholesterol
  • PCOS
  • Ethnicities including Native American, Asian, African American, Hispanic, or Pacific Islander
  • History of gestational diabetes or macrosomic fetus
  • History of cardiovascular disease

Criteria for the diagnosis of diabetes:

  • Fasting plasma glucose ≥126 mg/dL (fasting is defined as no caloric intake for at least 8 hours)*
  • 2-h PG ≥200 mg/dL during 75-gram glucose tolerance test*
  • A1C ≥ 6.5%*
  • Random plasma glucose ≥200 mg/dL, with classic symptoms of hyperglycemia or hyperglycemic crisis

(* In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.)

Any woman with diabetes should be counseled if they are planning a pregnancy within the year. Referring to an MFM specialist for a prepregnancy consultation can be helpful in this regard especially if the patient has additional risk factors.

Reducing Risk for Mother and Baby

In optimizing the health of the mom, fetus and neonate, the two key modifiable risk factors are BMI and blood sugar levels. In this regard:

  • Prior to pregnancy their A1C should be less than 6.0%, their fasting blood sugar should be <95 and 2 hours after meals should be < 120.
  • For optimal risk reduction, they should try and achieve a normal BMI prior to conception.
  • Excellent nutrition and a moderate amount of exercise are imperative for improving health, especially for women with diabetes planning a pregnancy. Referrals to a certified diabetes educator (CDE), a Registered Dietitian (RD/RDN), or a Diabetes Program that is recognized by the ADA/AADE can help.
  • They should have screening for any diabetes related complications such as heart disease, hypertension, or thyroid disease.
  • They should be up to date on their eye and dental exams as well as their vaccinations.
  • Since these patients have an increased risk of neural tube defects, they should be taking folic acid at least 3 months prior to conception and through the first trimester.

New Developments

The link between diabetes and cardiovascular disease has been well established. Even gestational diabetes and future risk of cardiovascular disease has been well studied. Interestingly, a retrospective study published in the Lancet in March 2019 shows that the risk of cardiovascular disease extends into the non-diagnostic range for glucola results. It showed that for each 1 mmol/L increment in the glucose challenge test result was associated with a 13% higher risk of cardiovascular disease after adjustment for age, ethnicity, income, and rurality. This relationship persisted after excluding women with gestational diabetes.

Helpful Resources

ACOG committee opinion on Prepregnancy Counseling

ACOG FAQ handout for patients Healthy Pregnancy for Women with Diabetes

The Provider’s Role in Domestic Violence Awareness

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

Every October, we recognize Domestic Violence Awareness. Since 1981, this month has been used to promote awareness, support victims, and advocate for a world with less physical, sexual, and emotional violence. The Violence Against Women Act was passed in 1994 and there has been much progress toward providing services for victims of violence and also holding perpetrators responsible for their actions.


What is domestic violence?

Domestic violence, also known as intimate partner violence, is a broad term that can include many different types of actions. Abusive behavior is used as a way to control a partner, and control is a central component of the relationship. These behaviors can include things such as control of finances, limiting outside relationships, isolation from family and friends, verbal threats or intimidation, stalking, coerced sexual encounters, control over reproduction, and physical violence. Although violence can occur in any relationship and can be committed by both men and women, the most common scenario is a male perpetrating violence toward a female partner.


How common is domestic violence?

It is estimated that 1 in 4 women will experience some type of intimate partner violence during their lifetime and this number may even be higher due to underreporting. Although all women could potentially be exposed to violence in a relationship, younger women between the ages of 18 and 24 are at greatest risk. Relationship violence, combined with a gun in the home, increases the risk of homicide by 500%. Intimate partner violence accounts for 15% of all violent crimes.


Why do women stay in abusive relationships?

Leaving an abusive relationship can be extremely dangerous for the woman. They often face blame for staying and disbelief that violence occurs when they don’t end the relationship. When the abuser senses that he or she is losing control over their partner, the violence can escalate and the risk for lethality increases. If there are dependent children, then leaving becomes even more complex because not only does the woman need to consider her own safety but the also the safety of her children. The process of leaving can be lengthy, and often women have experienced economic control and isolation as part of the abuse. Therefore, they may lack the financial resources and social capital necessary to support themselves and their children independently and safely.


What can health care providers do?

Screen for Intimate Partner Violence

One of the most important things health care providers can do is screen women for intimate partner violence when they present for care. Due to fear, stigma, concern about being believed, and shame, women may be reluctant to initiate a conversation with their provider. Asking women directly if they have experienced violence increases disclosure rates and allows for identification of women who need services and support. Direct questions such as “Have you ever experienced physical, sexual, or emotional violence or threats from a partner?”, “Are you currently afraid of someone?” and “Do you feel safe in your relationship and at home?” are examples of questions that are clear and concise. Letting women know that these questions are asked of everyone prevents women from feeling singled out or targeted due to any sociodemographic factor. These questions also convey that the topic is important and allows for dialogue about safety and physical and emotional health.

Discuss Healthy Relationships

Another important role for health care providers is to discuss healthy relationships, especially with adolescent women who might be starting to navigate dating and romantic partnerships. Inquiring about the nature of the relationship with open-ended questions such as “Tell me about your partner” or “Are you happy in your relationship?” provides an opportunity to gain insight into behaviors that might indicate abuse or the potential for abuse. Adolescent women may perceive constant messages, wanting to know where they are and who they are with, and displays of jealousy as care and concern and not controlling behavior.

Direct Patients to Support Services

All health care providers should be prepared to offer support and assistance to women who disclose violence. It’s important to have a current list of support services in the geographical area, including law enforcement contacts, shelters, safe houses, counseling, and legal aid (especially pro bono). Women may want to end a relationship but need time to arrange housing, finances, transportation and other necessary items. Performing a lethality assessment and helping women to craft a safety plan is essential, especially if there are guns or other weapons in the home.

 

Although awareness of intimate partner and domestic violence has increased steadily, there is still much more progress to be made. Continued efforts to recognize relationship violence as a prevalent public health issue will help decrease victim blaming and normalize conversations about best strategies for prevention.

Don’t Let Breast Cancer Awareness Fade After October

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

October is Breast Cancer Awareness Month – an opportunity for us all to focus on breast cancer and its impact on those affected by the disease in our community. Even though we’re nearing the end of the month and the pink ribbons are being put away, we cannot let our dedication to educating patients fade.  Here’s a refresher on the breast cancer risks, symptoms, and screening guidelines that all WHNPs should be familiar with in order to support our patients.

Breast Cancer Statistics

First, let’s talk about who is affected by breast cancer:

  • Advancements in breast cancer screening and treatment has improved survival rates dramatically since 1989. According to the American Cancer Society an estimated 268,000 women will be diagnosed with invasive breast cancer, and 62,930 women will receive a diagnosis of noninvasive breast cancer in 2019. ACS reports over 3.1 million breast cancer survivors in the United States.
  • About 1 in 8 U.S. women (about 12%) will develop invasive breast cancer during her lifetime.
  • A man’s lifetime risk of breast cancer is about 1 in 883. Approximately 2,670 new cases of invasive breast cancer are expected to be diagnosed in men during 2019.
  • For women, breast cancer death rates are higher than those for any other cancer, besides lung in the U.S.
  • African American women under the age of 45 are more commonly diagnosed with breast cancer than white women.
  • A woman’s risk of developing breast cancer doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer.
  • About 5-10% of breast cancers can be linked to gene mutations inherited from one’s mother or father.
  • The most significant risk factors for breast cancer are gender (being female) and age (growing older).

Risk Factors  

We know a lot about what factors can influence a patient’s risk of breast cancer:

Age: The risk of breast cancer increases with age. At 20 years, the probability of developing invasive breast cancer in the next 10 years is .06%, or 1 in 1,732. This means that 1,732 women in this age group can expect to develop breast cancer. Age 70, the probability of developing invasive breast cancer in the next 10 years is 3.84%, or 1 in 26.

Family history of breast cancer: Up to 10% of breast cancers are due to specific mutation in single genes that are passed down in a family. Multi-gene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at-risk patients and their families. Genes associated with hereditary breast cancer includes the following that could potentially be included in a multi-gene test: BRCA1, BRCA2, ATM, BARD1, CHEK2, PALB2, TP53, PTEN, STK11, and CDH1.

Personal history of breast cancer: Women who have previously been diagnosed with breast cancer are at risk of developing it again, either in the same breast or the other, and is higher than if you never had the disease.

Dense breast tissue: Dense breasts are common, particularly in younger women. Dense breasts are associated with an increased breast cancer risk and may impair detection, however there are currently no recommendations for screening women with dense breasts.

Exposure to estrogen: Estrogen stimulates breast cell growth and exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of the risk factors that are nonmodifiable include: starting menstruation before the age of 12, going through menopause after age 55, and exposure to estrogen in the environment.

Body weight: Women who become overweight or develop obesity after menopause may also have a higher chance of developing breast cancer, possibly due to increased estrogen levels. High sugar intake may also be a factor.

Alcohol consumption: A higher rate of regular alcohol consumption appears to play a role in breast cancer development.

Radiation exposure: Prior exposure to high-dose therapeutic chest irradiation at age 10-30 years may increase the risk of developing breast cancer later in life.


Symptoms

It’s critical that patients know and regularly look for these symptoms, and that they know to talk to us if they experience any:

  • new lump or lumpiness, especially if it’s only in one breast
  • a change in the size or shape of your breast
  • a change to the nipple, such as crusting, ulcer, redness or inversion
  • a nipple discharge that occurs without squeezing
  • a change in the skin of your breast such as redness or dimpling
  • an unusual pain that doesn’t go away.
  • peeling, flaking, or scaling of the skin on the breast or nipple

Finally, providers need to know the difference in screening guidelines for women with average breast cancer risk, and women whose risk is above average:

Screening Guidelines for Women at Average Breast Cancer Risk

(no symptoms of breast cancer, no history of breast cancer or atypia, no family history of breast cancer, no suggestion of a hereditary cancer syndrome, and no history of mantle radiation)

  • Women between the ages of 25 and 40 should have an annual clinical breast examination.
  • Women 40 and older should have an annual mammogram in addition to an annual clinical breast examination.
  • Ultrasound may be recommended for women with dense breast tissue.
  • All women should consider performing a monthly self-breast exam beginning at age 20 and become familiar with their breasts so they are better able to notice changes.


Screening Guidelines for Women at Above-Average Breast Cancer Risk

  • A clinical breast exam every six months starting no later than ten years before the age of the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • An annual mammogram starting no later than ten years before the age of the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • Possible supplemental imaging (for example, with ultrasound) for women with dense breast tissue.
  • Possibly alternating between a breast MRI and a mammogram every six months, as determined by your provider.

 

We have made so many advancements in screening for and treating this cancer. As providers, we need to keep up the fight, stay vigilant, and support our patients with the best care we can provide.

September is Fetal Alcohol Spectrum Disorders Awareness Month

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

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

Call to Action

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

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

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

The Facts

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

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

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

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

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

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

Fetal Development Chart 

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

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

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

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

References:

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

Ovarian Cancer Awareness Month

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

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

Risk Factors

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

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

Symptoms

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

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

Screening

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

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

Treatment Options

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

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

Recent Advancements in Screening

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

Continued Support for Preventive Effects of OCP

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

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

Breastfeeding and Personal Experience

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

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

What WHNP’s Need to Know

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

Information to discuss includes:

Benefits to Mothers:

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

Benefits to Babies – Decreased Risk Factors of:

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

Societal Benefits

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

Know What to Ask and Who Can Help

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

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

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

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

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

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


First-hand Experience from a Working/Breastfeeding Mom

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

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

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

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

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

References

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

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

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

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

Symptoms

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

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

Hepatitis A

Method of Transmission

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

Individuals at Risk

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

Acute Versus Chronic

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

Diagnosis

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

Treatment

Supportive care

Prevention

Hepatitis A is preventable. Prevention measures include the following:

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

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

Hepatitis B

Method of Transmission

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

Individuals at Risk

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

Acute Versus Chronic

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

Diagnosis

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

Treatment

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

Prevention

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

Hepatitis C

Method of Transmission

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

Individuals at Risk

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

Statistics

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

Acute Versus Chronic

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

Diagnosis

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

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

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

Treatment

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

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

Prevention

There is no vaccination for HCV infection.

Additional Resources and Tools

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

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

Guidelines for management of HCV

References

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

Partnerships in Women’s Health – NPWH and PCORI

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

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

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

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

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

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

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

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

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

ADDITIONAL INFORMATION: BOlder Women’s Health Coalition

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

The coalition’s four supporting pillars are:  

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

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

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

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

Susan Rawlins, MS, APRN, WHNP-BC

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

National Cancer Survivor’s Day

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

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

Who Exactly are Cancer Survivors?

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

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

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

A Cancer Survivor’s Journey

There are three phases of cancer survivorship:

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

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

Caring for Cancer Survivors

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

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

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