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.


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.”


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.


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.


G Johnson

Gay Johnson, CEO

Alcohol Free Holidays for Baby and Me

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

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

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

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

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

Stress management 

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

Holiday socializing 

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

Support from others 

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

Spread the word 

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

This post was written by:

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

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

Female Urinary Incontinence: To Be Expected with Age?

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

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

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

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

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

Types of Urinary Incontinence

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

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

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


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

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

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

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

Stress Incontinence

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

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

Urge Incontinence

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

Final Thoughts for Providers

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

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

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

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

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

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

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

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

We will focus on four efforts:

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

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

If you are interested in learning more about how you can get involved, please email info@NPWH.org.

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

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

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

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

G Johnson

Gay Johnson, CEO

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

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

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

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

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

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

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

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

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

What WHNP’s Need to Know

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

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

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

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

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

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

My Best Resources

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

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

Another great resource is www.breastcancer.org

My Own Personal Insights

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

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

Optimizing Breastfeeding

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

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

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

Start the Conversation in the Antepartum Period

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

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

What we can do and say:

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

Teach practice of milk expression

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

What we can do and say:

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

Postpartum Period

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

What we can do and say:

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

Consider these steps immediately after your patient gives birth:

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

Consider these steps prior to patient discharge:

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

Think About Your Own Views of Breastfeeding as You Counsel Patients

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

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

Understand Reasons Why Moms Discontinue Breastfeeding Early

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

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

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