Systemic Lupus Erythematosus (SLE) Awareness Month

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

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


What is Lupus?

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


How common is Lupus?

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


How does Lupus affect pregnancy and contraceptives?

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

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

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

What are other health concerns for women with Lupus?

Menstrual Problems

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

Osteoporosis

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

Heart Disease

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

Renal Involvement

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

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

May is Teen Pregnancy Month

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

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

Good news:

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

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

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

Bad news:  

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

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

The Social Cycle

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

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

The Providers Role

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

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

 

Fighting Misinformation

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

We Can Make a Difference

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

An Open Letter to WHNP Students

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

Dear WHNP Students,

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

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

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

Sincerely,

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

NPWH Statement on Abortion Bans

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

As these disturbing events continue to unfold, NPWH re-asserts our mission statement, which values “protecting and promoting a woman’s right to make her own choices regarding her health within the context of her personal, religious, cultural, and family beliefs.”

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

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

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

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

Infertility 101

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

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

Guidance for Women

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

Guidance for Men

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

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

Guidance for Couples

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

What APNs Can Do

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

Ovarian Reserve Testing

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

HSG

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

Semen Analysis 

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

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

April is Sexual Assault Awareness Month

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

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

A Common Experience

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

The Role of a Provider

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

Ask the Questions

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

Believe Women and Assure Nonjudgement

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

Offer Timely Resources

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

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

Providers Create Change

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

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

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

The Black Maternal Health Crisis

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

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

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

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

Taking Action

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

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

Resources for Providers

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

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

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

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

Critical Components of Black Mamas Matter Toolkit include:7

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

How Providers Can Help

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

References

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

Endometriosis Awareness Month

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

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

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

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

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

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

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

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

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

Women’s Heart Health Update 2019

This month’s blog post comes from our very own Lynne T. Braun, PhD, ANP, FAHA, FAANP, FNLA, FPCNA, FAAN. She shares important updates in guidelines for women’s heart health that providers should know.

Heart disease remains the #1 killer of women. We, as providers, know the basics: Women need to be vigilant in reducing their risk for heart and blood vessel disease by practicing Life’s Simple Seven: manage blood pressure, control cholesterol, reduce blood sugar, get active, eat healthfully, lose weight, and never smoke/quit smoking. This Heart Health month, I want to go beyond the basics and talk about the specific interventions women should expect from their healthcare providers if they have a higher risk for heart disease.

I recently had the privilege of serving on the writing committee of the 2018 Multi-Society Guideline on the Management of Blood Cholesterol, which can be found here. My contribution was to synthesize the evidence and write the recommendations on Issues Specific to Women.  I’d like to share some key information about women’s heart health and recommendations from the guideline.

For Women with Heart Disease

I’d like to first address women with known atherosclerotic cardiovascular disease (ASCVD).  These women have had heart attacks or have evidence of plaque in their coronary arteries.  They are considered high risk if measures are not taken to prevent another heart attack or a first heart attack.  A key preventive intervention is “high intensity” statin therapy (atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg).  Statins, although there is a great deal of misinformation on the Internet, are lifesaving medications that have been shown in every randomized clinical trial to prevent heart attacks, strokes, and deaths in men and women who take them.  We know that women derive as much benefit from statins as men.  For those women who have side effects from statins, a lipid specialist can help identify a statin at a dose that a woman can tolerate (there are 7 different statins), or if necessary, can recommend a different medication.

For Women with Elevated Cholesterol

Another high-risk group of women are those with severely elevated cholesterol levels.  Women with LDL cholesterol of 190 mg/dL or higher, and especially if they have a family history of early ASCVD (male first degree relative before age 55 years, female first degree relative before age 65 years), this typically means an inherited form of high cholesterol called familial hypercholesterolemia.  The guideline recommends “high-intensity” statin therapy to lower LDL cholesterol to less than 100 mg/dL.  Sometimes additional cholesterol-lowering medications are required.

For Women with Other Traditional Risk Factors

For women who do not have known ASCVD but may have traditional risk factors (high blood pressure, high cholesterol, diabetes, cigarette smoking, obesity, physically inactive) or who desire a heart health evaluation, this is what you should expect:

  1. If 40 years of age or older, estimation of 10-year risk for a heart attack or stroke using a risk calculator. A percent is obtained that indicates risk in the next 10 years. For example, if after entering age, sex, blood pressure, cholesterol level, presence of diabetes, smoking status, your 10-year risk is 5%, this means that if there were 100 women who were just like (had the same risk factors), 5 of the 100 women are estimated to have a heart attack or stroke in the next 10 years.  If the calculated 10-year risk is 7.5% of higher, the clinician may discuss starting statin therapy to reduce a woman’s risk.
  2. For younger women (ages 20-40 years), the same risk calculator is used to calculate lifetime risk for having ASCVD.
  3. In the guideline we added “risk enhancing factors” that are not part of the 10-year risk estimation but need to be taken into consideration to evaluate risk. In other words, calculating a woman’s 10-year risk is the starting point, and the clinician should then discuss if a woman has any risk enhancing factors that tailor her risk assessment.  A woman’s 10-year risk estimation may be quite low, but if she has risk enhancing factors, her risk may be much higher.  Examples of risk enhancing factors are: family history of early heart disease (male first degree relative before age 55 years, female first degree relative before age 65 years), persistently elevated LDL cholesterol of 160 mg/dL or greater, chronic kidney disease, metabolic syndrome, inflammatory diseases such as rheumatoid arthritis, certain high-risk ethnicities such as South Asian, and conditions specific to women, such as pregnancy-associated complications (preeclampsia) and premature menopause (before age 40 years).  These conditions increase a woman’s risk for future ASCVD, and in fact, having preeclampsia during pregnancy carries at least twice the risk of ASCVD and stroke compared with a woman who didn’t have this complication.  Therefore, although a woman’s 10-year risk is calculated as low, the presence of risk enhancing factors may cause a clinician to recommend statin treatment sooner rather than later to reduce a woman’s overall risk.
  4. The guideline reinforces the need for a clinician-patient discussion of risk assessment and how to best manage risk. This discussion should include the potential benefit of lifestyle therapy (heart-healthy diet, regular exercise, and weight loss if necessary), the potential benefit of statin medication and potential risks, cost of treatment, and the woman’s thoughts and preferences.  Even if the 10-year estimated risk is high (7.5% or above), a prescription for a statin should not be ordered without first having a clinician-patient discussion through which a woman’s questions are thoroughly answered.

For Women Who Are Pregnant or May Become Pregnant

Guideline recommendations specific to women include:

  • Clinicians should perform a risk assessment and conduct a thorough menstrual and pregnancy history. They should note that pregnancy-associated complications and premature menopause increase a woman’s risk for ASCVD and consider these in treatment recommendations.
  • Clinicians should counsel all sexually active women of childbearing age who are treated with a statin to use a reliable form of contraception. Statins are contraindicated when a woman is pregnant.
  • In women who are treated with statin therapy and plan to become pregnant, the statin should be stopped 1-2 months before pregnancy is attempted and restarted after breastfeeding is complete. If a woman becomes pregnant while on statin therapy, the statin medication should be stopped as soon as pregnancy is discovered.  The clinician and patient should discuss other ways to manage high cholesterol during pregnancy.

A most important point to remember is that healthy lifestyle is the cornerstone of prevention of heart disease and must start early in life.  Even if drug treatment is ultimately required to lower cholesterol or to reduce ASCVD risk, making healthy lifestyle changes remains critical.  As my colleague tells all of his patients: Eat less, make healthy food choices, and move more.

Meet Our New Board MEmbers

Welcome to the new NPWH Board Members! These four champions of women’s health officially joined the Board on January 1, 2019, and look forward to serving you over the upcoming years.

gorham

Rachel Gorham, MSN, WHNP-BC, AGN-BC

Ms. Gorham is an Advanced Practice Registered Nurse with 6 years of clinical experience. She is double board certified and hold national certifications as a Women’s Health Nurse Practitioner and in Advanced Genetics Nursing. Her expertise is in breast cancer risk assessment, hereditary cancer syndromes, cancer genetics, managing and developing high risk breast centers, and cancer prevention. She has provided her expertise on two national position statements for NPWH which include Hereditary Breast and Ovarian Cancer Risk Assessment and Care of Men with Breast Cancer: The Role of WHNPs Specializing in Breast Care. Rachel is a National Key Note Speaker for Merck and Myriad Genetics. Rachel also has a passion for improving the lives of homeless women in her community. She is the founder of a non-profit organization for homeless women in Washington State called The Healing Hands Project. Rachel’s philosophy on care: “The human spirit is composed of strength and resilience. I strive to focus on prevention and wellness. I truly believe that if you listen to your patients, they will always tell you their diagnosis. Women deserve to feel empowered in their healthcare decisions.”

fantasia

Heidi Fantasia, PhD, RN, WHNP-BC

Dr. Fantasia is an associate professor in the Zuckerberg College of Health Sciences, Solomont School of Nursing at University of Massachusetts Lowell and a board certified women’s health nurse practitioner. Her clinical practice has primarily been in public health providing sexual and reproductive health to underserved women and men. Her research interests include the intersection of violence and the reproductive health of women, including violence screening, women’s experiences of violence, and issues surrounding sexual consent and coercion. Dr. Fantasia is on the editorial advisory board for the Journal of Obstetric, Gynecologic, and Neonatal Nursing and the author of over 60 publications, including peer-reviewed manuscripts, books, and book chapters that focus on women’s health throughout the lifespan. Dr. Fantasia received a BSN from Salem State College and MS and PhD from Boston College. She completed a postdoctoral fellowship at Boston College prior to joining the faculty at the University of Massachusetts.

shawana s. moore

Shawana S. Moore, DNP, MSN, CRNP, WHNP-BC

Dr. Moore earned a Bachelors’ of Science degree with a concentration in Biology from Wilberforce University. She earned a second Bachelors’ of Science in Nursing (BSN), Masters’ of Science in Nursing (MSN) with a specialty in women’s health, and Doctor of Nursing Practice (DNP) degrees from Thomas Jefferson University. She is an alum of the National League of Nursing LEAD Institute and Jefferson Leadership Academy. Dr. Moore is a board-certified women’s health nurse practitioner. She currently serves as an Assistant Professor and the Director of the Women’s Health- Gender Related Nurse Practitioner Program at Thomas Jefferson University, Jefferson College of Nursing. As the Director of the Women’s Health Nurse Practitioner Program, Dr. Moore is responsible for educating the next generation of women’s health nurse practitioners entering into clinical practice. Additionally, she has a passion for providing women’s and reproductive health care to underserved populations. She actively maintains clinical practice by serving as a women’s health nurse practitioner at health care organizations in Pennsylvania and New Jersey. Some of her research interests include women’s health, transgender care, adolescent empowerment, preconception counseling, contraception, maternal obesity and telehealth in the women’s health care setting. She presents on these topics locally and nationally.

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Sandi Tenfelde, PhD, RN, APN

Dr. Tenfelde is an Associate Professor and the Director of the Women’s Health Nurse Practitioner program at Loyola University Chicago, Marcella Niehoff School of Nursing.  She is a certified yoga instructor with a focus on pelvic floor health.  As a Women’s Health Nurse Practitioner, she is interested in health promoting activities that allow individuals to be actively engaged in maintaining their own health and direct participation of the management of symptoms.  The goal of Dr. Tenfelde’s program of research is to explore and test interventions to reduce symptom burden for women with pelvic floor disorders.  She studies yoga as a mind/body therapy to help reduce symptoms of urinary incontinence and improve Quality of Life and how post-partum physical changes impact sexual function.  Dr. Tenfelde completed the Sexual Health Counseling program at the University of Michigan in Ann Arbor in 2015.  She has worked clinically in a sexual health clinic and currently works in a Federally Qualified Health Center as a Women’s Health NP. In 2014, she received the New Investigator Award from the Midwest Nursing Research Society to fund her research.

To learn more about the NPWH Board of Directors, please click here.

2018 and Beyond at NPWH

We hope you had a healthy and productive 2018! As the year winds down, I wanted to share some highlights of this past year and major initiatives we’ll be working on in 2019.

We’re Developing New Patient Education Tools

  • We shared the first look at our exciting women-patient focused digital resource,  H.E.R Hub (Health. Education. Resources). It features short videos, easy-to-use handouts, and perspectives from leading WHNP experts on a variety of women’s health conditions, like bacterial vaginosis and STD’s, and general healthy women advice, like to what to expect at a pelvic exam, getting pregnant, and menopause. We have been populating the portal with content all year and are still working to build it out with future funding that will enable us to officially launch in 2019!

We Continue to Provide Leading and Unique Clinical Education Resources

  • Close to 150 of you joined us in Phoenix for our 5th annual Women’s Sexual Health Course for NPs. Save the Date: The 2019 WSHC will be held May 30-June 2, 2019 in Orlando, FL. Keep an eye out for more information and registration opening in February 2019. Read more about the 2018 course here.
  • The 21st Annual Premier Women’s Healthcare Conference was our largest yet, with almost 1,000 people joining us in San Antonio! Click here to read a recap, including details on our Inspirations in Women’s Health Award winners. Save the Date: please plan to join us for next year’s conference in Savannah, GA, October 16-19, 2019.

We’re Growing in Number 

  • Almost 800 new members joined us in 2018! Welcome to NPWH. We encourage you to add your practice to our “Find an NP” database on the NPWH website. Adding your information to the database will not only help your practice grow, it will also help those seeking health care services to find excellent care. We are also always looking for submissions to our new Member Spotlight If you would like to nominate yourself or another member to be featured, please let us know.

We’re Building a (b)Older Women’s Health Coalition so Women Can Be Healthy At Any Age

  • We convened leaders from healthcare, research, government, consumer, and advocacy organizations for our second annual Healthy At Any Age Summit in April. There, we began to catalogue the interconnected web of issues facing aging women and laid the groundwork for the (b)Older Women’s Health Coalition.
  • We met again in November to discuss how the Coalition would work and what topics it would prioritize first. The Coalition, consisting of members from a variety of organizations that touch the health and wellbeing of older women in some way, will work with policymakers, clinicians, researchers, and the general public to advocate for improved policies for women’s health as they age, better research, and strengthened clinical education and resources to treat older women. To read more about the Coalition and its goals, please click here.

We’re Advocating for Smart Policies

  • When the USPSTF issued recommendations that removed co-testing for cervical cancer, we responded with a website and campaign that set the record straight on why co-testing is the best choice for protecting women. We were thrilled that the USPSTF’s final recommendations retained co-testing as the preferred method for cervical cancer screening. Click here to read a statement from NPWH and other women’s health organizations. We will be launching an updated version of our website, testforcervicalcancer.org, in January.
  • Our Director of Policy, Sue Kendig, represents NPWH on a variety of coalitions, including the Council for Patient Safety in Women’s Health Care and the Alliance for Innovation in Maternal Health. These collaborative efforts target reducing maternal mortality and improving patient safety in all aspects of women’s health care. Sue also represents NPWH on the Advisory panel charged with overseeing the Women’s Preventive Services Initiative (WPSI).  NPWH is one of four partners and the only nursing organization in this ACOG led initiative, funded by HRSA, charged with identifying the gaps in women’s preventive services not covered by the IOM and USPSTF recommendations. In 2017 – 2018, WPSI issued recommendations regarding postpartum screening for gestational diabetes, and urinary incontinence screening.
  • NPWH, along with ACNM and AWHONN, partnered with the University of Alaska to work on an exciting CDC-funded effort to reach over 30,000 women’s health nurses on preventing alcohol-exposed pregnancies. Susan Rawlins, our Director of Education and Beth Kelsey, our Director of Publications, represents NPWH in this effort and traveled to Atlanta to meet with our fellow partners. Susan is also the NPWH liaison for ACOG’s Committee on Gynecologic Practice.
  • Gay Johnson, Chief Executive Officer, along with a small group of other national organizational leaders, participated in a private meeting with Scott Gottlieb, Commissioner of the FDA on November 19, 2018. The meeting was to hear Mr. Gottlieb’s priorities and their relationship to the unique needs of women’s health.  We shared with him how vital the office of Women’s Health is in research, policy and outreach.
  • Most recently, Jacki Witt, Immediate Past Board Chair, and Jamille Nagtalon-Ramos, Secretary, represented NPWH at the new ACOG initiative on Maternal Mental Health. The group of provider organizations and industry partners are working together to develop tools to improve maternal mental health.

We appreciate your support this year and look forward to working together again in 2019. Thank you for your continued support of women’s health.

Sincerely,

G Johnson

Gay Johnson, CEO