The purpose of this course is to provide healthcare professionals with updated information related to issues surrounding women across the lifespan to facilitate thorough and appropriate care.
This course is designed for nurses and other healthcare professionals involved in improving health outcomes for women.
NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers. The course is approved for 15 CE contact hour(s). Activity code: H00021056. Approval Number: 160001848. To claim these CEs, log into your CE Center account at www.ccmcertification.org.
NetCE designates this continuing education activity for 15 ANCC contact hour(s). NetCE designates this continuing education activity for 2 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 18 hours for Alabama nurses. Social workers participating in this intermediate to advanced course will receive 15 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. NetCE is authorized by IACET to offer 1.5 CEU(s) for this program. AACN Synergy CERP Category A.
In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.
The purpose of this course is to provide healthcare professionals with updated information related to issues surrounding women across the lifespan to facilitate thorough and appropriate care.
Upon completion of this course, you should be able to:
- Consider factors that may influence access to and quality of health services for women, including economic, cultural, and demographic issues.
- Review the historical and current context of the inclusion of women in health research.
- Review gender-specific health theories and models.
- Compare and contrast the presentation of sexually transmitted infections in men and women.
- Explain communication skills that foster a non-judgmental attitude regarding sexual activity.
- Identify issues related to gynecological health, including the recommended Pap screening schedules.
- Discuss the risk factors for cervical cancer and the holistic therapeutic plan of care for a woman with gynecologic cancer.
- Define menarche, perimenopause, and menopause, and identify care issues that may arise in these life stages.
- Discuss the risks, benefits, and contraindications for hormone replacement therapy.
- Discuss various health promotion and pharmacologic options for women experiencing menopause.
- Discuss recommendations regarding breast cancer screening.
- Identify the various factors that should be considered when making treatment choices for women with breast cancer.
- Compare and contrast gender differences in women and men with cardiovascular disease.
- Explain the relationship between a balanced diet and exercise to maintain health across the lifespan.
- List the risk factors and treatment and screening guidelines for obesity, diabetes, and heart disease.
- Discuss osteoporosis risk factors and the risks, benefits, and side effects of the common medications used in the treatment of the disease.
- Discuss common mental health issues in women's health, including depression and domestic violence.
- Review culturally specific risk factors and health disparities for women of color.
- Identify complementary therapies, including those that have been effective in various women's health issues, such as cancer, heart disease, and menopause.
- Review health screening guidelines and immunization recommendations for women across the lifespan.
Gayle Roux, PhD, RN, CNS, FNP, received her BSN from University of Nebraska, and her MS and PhD in Nursing from Texas Women's University. She has been employed in various aspects of women's care including childbearing, family planning, and women's health. Currently, she practices as a family nurse practitioner and is faculty at Texas Woman's University. Dr. Roux's area of research is focused on inner strength in women living with chronic health conditions such as breast cancer. She lives in Dallas, Texas, and has two daughters. Dr. Roux enjoys cross-country skiing, traveling, and reading mystery stories.
Contributing faculty, Gayle Roux, PhD, RN, CNS, FNP, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Jane C. Norman, RN, MSN, CNE, PhD
Alice Yick Flanagan, PhD, MSW
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
- WOMEN'S HEALTH AND HEALTH PROMOTION
- SEXUAL AND REPRODUCTIVE HEALTH
- GYNECOLOGIC HEALTH
- GYNECOLOGIC CANCERS
- MENARCHE TO PERIMENOPAUSAL YEARS
- PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS
- BREAST HEALTH AND BREAST CANCER
- CARDIOVASCULAR HEALTH
- EXERCISE AND NUTRITION
- PSYCHOLOGICAL HEALTH
- CULTURAL NEEDS AND HEALTH DISPARITIES OF AFRICAN AMERICAN AND HISPANIC WOMEN
- COMPLEMENTARY THERAPIES
- HEALTH CARE ACROSS A WOMAN'S LIFESPAN
- Works Cited
- Evidence-Based Practice Recommendations Citations
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#93311: Health Issues Distinctive to Women
Health issues distinctive to women encompass all of the dimensions in which a woman interacts with herself and her environment—mind, body, and spirit. This course will include information on healthy lifestyle behaviors, risk factors, and interventions for common health issues in women. Major health promotion issues and treatment in the care of women, including sexual and reproductive health, gynecological cancers, perimenopause and menopause, breast care, heart disease, obesity, diabetes, and psychological health will be highlighted. While men may also experience some of these conditions, the course will focus on distinct aspects for women. Health choices and actions reflect the individual's place in her world, including her cultural, social, and spiritual perspective. These beliefs will form the basis for her actualization of health choices. Nurses and other health professionals are in a position to understand the complexity of women's health beliefs and behaviors and to assume leadership positions in health promotion, primary care, primary prevention, and treatment of women and their families.
Health is a key concept of health care, and it should not be characterized as the absence of illness or a disability. The multiplicity of emotional, spiritual, social, financial, and cultural dimensions to health should also be considered. In addition, a new view of women's health is especially needed because of the great change and expansion from its original focus on reproductive health. Based on the philosophy that patients should control their bodies and make informed choices regarding their health care, the definition of health and health promotion has evolved.
Health promotion is a process that enables people to address cultural, social, and political factors to increase control over and improve their health . It is a transformative process in which the health professional functions as a partner with the patient and her family in education, consciousness raising, and advocacy. This process is characterized by a respect for the patient's autonomy and an acknowledgment of the dynamic relationship between the patient and her environment. The goal of health care is to improve and maintain health. Health is a highly complex professional practice that continues to evolve as scholars, researchers, and practitioners address its many facets . Health promotion choices and actions reflect the individual's cultural, educational, social, and spiritual perspective.
Many of the health problems that plague women today may be avoided or lessened through better health education and community and public health programs. Nurses and other health professionals are in a position to make a difference. Sharing concerns about issues that affect women's health is a prerequisite to making a change in the way nurses and other health professionals practice. The information should also be used as resource material for teaching plans. There is a distinct need for more health education and comprehensive preventive programs to improve access and quality of health care for women of all ages.
The Office on Women's Health (OWH) has noted that women are living longer, facing more chronic conditions by virtue of lifespan, and coming from a variety of cultural backgrounds, necessitating a focus on the health of women across the lifespan to encourage well-being and functional outcomes. Both demographic changes and increasing incidence rates of conditions such as heart disease, diabetes, and breast cancer provide justification for further advancement of health issues facing women. The population increase of aging or elderly women is significant. An estimated 45 million Americans are 65 years of age and older, approximately 55% of whom are women. This percentage of older persons, which now comprises 14% of the population, is expected to grow to almost 84 million by the year 2050, to 21% of the population [3,4,5]. Minority populations are also experiencing unprecedented growth. Nearly 86% of persons 65 years of age or older are non-Hispanic whites. Blacks account for 9% of this population; Hispanics account for 7%; and Asians represent 3%. However, by 2050, this cohort is expected to diversify, with the Hispanic population increasing the most .
One in eight women, or approximately 13%, will develop breast cancer in their lifetime . Aging is a serious risk factor for breast cancer. An estimated 79% of new cases occur in women 50 years of age and older, with the highest incidence rates occurring in women 75 to 79 years of age . The older a woman, the greater her risk of both heart disease and breast cancer. While age is a well-established risk factor for chronic health conditions, research is lacking regarding differences, health needs, and interventions to maximize strengths in women living with these conditions.
As women age and the incidence of breast cancer, heart disease, and osteoporosis increases, nurses and healthcare professionals must recognize that health care impacts the physical, emotional, and spiritual lives of women. The Office of Research on Women's Health (ORWH) at the National Institutes of Health (NIH) has specified research priorities that "advance the understanding of biological sex differences in health and disease at multiple levels, from genes to hormones to complex systems" . Topical research priorities for the ORWH include studies on diseases and conditions that affect women, methodological advances, education and career development of women in science, quality of life, and fostering research collaborations and partnerships to further women's health research .
The U.S. Department of Health and Human Services composed Healthy People 2020 with a global goal to reduce health disparities. This includes a dramatic need for improvements in screening, early diagnosis, and treatment of women of color with conditions such as heart disease, diabetes, and cancer .
Despite the evolution and political strength of the women's health movement, women's health advocacy in the United States does not consistently address experiences specific to women in ethnic, socioeconomic, and aging subgroups. In the past, women were generally excluded from research studies, leaving gaps in the body of knowledge relating to ways women respond and deal with health and illness and creating assumptions that findings were the same for women as for men. Today, the NIH closely monitors the inclusion of women and minorities in research. In addition, extensive studies on women's health issues, such as the Women's Health Initiative (WHI), have provided scientific information previously lacking.
Gender-sensitive care should be the direction for the philosophical and theoretical development of women's health. Overcoming the limitations imposed by the dominant medical model in women's health requires theoretical bases that do not reduce women's health and illness experience into a disease. The gender-sensitive philosophy incorporates explanations of health and empowers women to effectively and adequately deal with their situations. The major components incorporated into the development of gender-sensitive care include:
Gender is a central feature.
Women's own voices and experiences are reflected.
Diversities and complexities are incorporated into women's experiences.
Theorists reflect about underlying androcentric and ethnocentric assumptions.
Sociopolitical contexts and constraints of women's experiences are considered.
Guidelines for practice with specific groups of women are provided.
These criteria have guided the philosophical premise of this course.
Nurses and health professionals have adopted a model of care that views women in a holistic way. The individual woman, her family, and her community cannot really be separated but are treated as one and the same. This philosophy of care provides women with a means to grow and change. Women are confronted with a variety of psychological and physiological stresses over the course of their lifespan. Nurses and other health professionals should offer holistic approaches, support, and advocacy to improve and maintain health. Health concepts include the development of a theory in relation to empowerment, collaboration, stages of change, learning, participation, and equity .
Health care may be viewed as a global term that defines actions intended to promote health. Health promotion includes the complex dimensions of health education, marketing the health message, lifestyle modification, engaging in social and environmental change, and addressing the patient's set of values. Health professionals perform a thorough health history to elicit each woman's definition of these dimensions in relation to her health behaviors and choices. Health care includes both self-management strategies and interventions implemented by healthcare professionals. Therapies to promote and maintain health include both traditional and complementary therapies, which are nontraditional therapies that complement or augment the usual traditional therapies.
It is now recognized that environmental factors and lifestyle patterns are crucial variables in the promotion of individual, family, and public health. This is also true in the development of healthy sexuality, the prevention of sexually transmitted infections (STIs), and the maintenance of reproductive health. Lifestyle-related diseases involve not only diet, smoking, alcohol consumption, and exercise but also emotional relationships and sexuality. Health professionals should never underestimate the importance of sexual health and history in girls and women of all ages. Professional care involves developing competency in conducting a thorough and sensitive health history and assessment of sexual and reproductive health. Health history questions should include the following objective data:
When was your last Pap test? Have you ever had an abnormal Pap? If yes, when and what treatment was performed?
How many pregnancies, term deliveries, preterm deliveries, elective abortions, and miscarriages? If miscarriages, at what gestational age and any known cause? Vaginal births or cesarean? Normal birth or complications? Living children and ages?
Are you sexually active? At what age did you initiate intercourse? With men, women, or both?
How many partners have you had in the last year?
What type of contraceptive(s) do you use? Are you satisfied with this contraceptive?
Do you use condoms? With every sexual encounter?
Are you satisfied with your sexual relationship(s)?
After conducting this health history, the healthcare professional and the patient are better equipped to mutually identify risk factors and discuss sexual behaviors they would like to change. This health history should be conducted at the annual exam with a nurse practitioner or physician or when the patient presents with a sexual health or contraceptive concern. Regular pelvic exams and Pap tests are essential for early detection of various conditions in the reproductive system [11,12].
Although the organisms, transmission, and complications of STIs are known, healthcare professionals have not been able to control these diseases. The incidence of many STIs has increased in the last few decades to 20 million new infections per year . They now result in an estimated $16 billion in direct medical costs annually . The spread of STIs dramatically demonstrates that the social determinants of disease must be addressed. Healthcare professionals should become more informed regarding the pathophysiology and the social ramifications of genital/oral infections and STIs and provide education and anticipatory guidance to patients of all ages at each stage of the lifespan.
STIs are caused by a spectrum of organisms. More than 100 diseases and syndromes are recognized as being sexually transmissible. Although some STIs affect one anatomical area alone, such as the labia or cervix, other organisms ascend the female reproductive tract, where further invasion is possible. These organisms can move upward from the vagina, through the cervical canal, and into the uterus, from which colonization into the fallopian tubes, ovaries, and entire pelvis may occur. Infections such as chlamydia, gonorrhea, syphilis, herpes, and acquired immunodeficiency syndrome (AIDS) can cause serious threats to future reproductive viability as well as to life itself. Other infections are transmitted to or via the oral cavity and facial area.
Each organism requires a unique diagnostic strategy and treatment. There is considerable variation in the symptoms and treatment options. Therefore, the following information is given as a general guide for major STIs for adults in the United States. The information is not intended to be exhaustive, and other textbooks and resources will be needed to describe care in more detail. The Centers for Disease Control and Prevention (CDC) remains the central body of expertise on treatment protocols for STIs [14,15].
It has been said that STIs are biologically sexist. This is because women experience a disproportionate amount of the STI burden and complications, including sterility, perinatal infections, genital tract neoplasm, and death. STIs in women are often asymptomatic, but the silent process is both infectious and damaging. Vertical transmission of the disease in the perinatal period places the fetus at risk for developing illness, congenital anomalies, and developmental disabilities, or may result in fetal death [14,16,17].
Prevention and treatment programs for STIs are common denominators across all racial, ethnic, and economic strata. Sexual behavior choices are not always made in a logical and rational manner. For example, teenage girls may believe condoms are unnecessary because a boyfriend declares his love. Education that conveys factual information and addresses the social context of the patient and partner is necessary. Young teenagers and all patients should be instructed on the use of condoms. When women seek oral contraceptives, they should be reminded that these contraceptives do not prevent STIs. Safer sexual practices that decrease the risk of STIs include limiting sexual partners and always using latex condoms. STIs may also result from rape or sexual assault, which are much more common among women than men (lifetime prevalence: 17.6% and 3%, respectively) .
The most common (new and existing) STIs in the United States are human papillomavirus (HPV; 79.1 million infections), genital herpes simplex virus (HSV-2; 24.1 million infections), trichomoniasis (3.7 million infections), chlamydia (1.5 million infections), human immunodeficiency virus (HIV; 0.9 million infections), hepatitis B (422,000 infections), gonorrhea (270,000 infections), and syphilis (117,000 infections) . These are the STIs that will be discussed in this section. As noted, the CDC treatment guidelines remain the gold standard for information and treatment of STIs .
To date, 120 types of HPV have been isolated from humans, and more than 40 can infect the genital tract . These types have been classified into the relative risk categories of low, intermediate, and high. Low-risk viruses include types 6, 11, 42, 43, and 44. These are rarely associated with cancer of high-grade squamous intraepithelial lesion (HSIL). Visible genital warts are often caused by HPV types 6 and 11. Intermediate-risk types 31, 33, 35, 39, 51, and 52 are infrequently associated with invasive cervical cancer. Types 16, 18, 45, and 58 are high-risk HPV types found in women with HSIL . It is important to remember that the presence of HPV does not always mean that disease will develop. Studies continue to show that only a small proportion of women remain HPV-positive over time. Women at greatest risk for HPV-related cervical disease are those who lack an adequate immune response to HPV exposure and those in whom high-risk HPV infection persists [14,24].
Most HPV infection is not visible, but the most common recognized visible manifestation of HPV is the presence of genital warts . If left untreated, warts may resolve on their own, remain unchanged, or increase in size.
Both patient-applied and provider-applied treatments are available. Factors that influence treatment choices include wart size, number, location, morphology, cost, and convenience. Treatment is not recommended in the absence of warts for subclinical genital HPV, as the lesions typically clear spontaneously . The most effective strategy is the prevention of HPV through immunization. Bivalent, quadrivalent, and 9-valent HPV vaccines are approved for the prevention of HPV-related diseases [14,200]. The immunizations are recommended for girls, boys, and young women and men up to 26 years of age.
Genital HSV is a chronic, lifelong viral infection. Symptoms may occur immediately or as late as a year after contact; in some cases, there are no symptoms at all. If apparent, symptoms include an itching, tingling sensation followed by painful vesicles that appear in clusters [14,21]. Women may be asymptomatic with cervical lesions, and outbreaks may occur in a sporadic manner. Antiviral medications offer relief to most symptomatic patients and are also used to treat recurrent episodes or as daily suppressant therapy. Patients should be treated with an antiviral at the first clinical presentation to reduce the incidence of prolonged or severe symptoms, which can develop even if the initial episode is mild . Acyclovir is the first-line recommended treatment for antiviral and suppressive therapy, followed by valacyclovir or famciclovir. Famciclovir is less effective at reducing viral shedding . Safety in pregnant women has not been established [14,22].
Valacyclovir has been shown to reduce transmission of genital herpes. A 500-mg dose once daily cuts transmission by 50% . Patients taking valacyclovir to suppress transmission should be counseled on the following points [14,19]:
Medication must be taken daily. When the medication is stopped, transmission risk goes back up.
While this drug is an effective assistance, it is not a cure.
The use of condoms during asymptomatic periods with a partner who understands the risks and total abstinence from sex during outbreaks is still necessary.
Infection with Trichomoniasis vaginalis is the most common nonviral STI in the United States, especially among ethnic minority women (prevalence 13% in black women, compared with 1.8% in non-Hispanic white women) . The infectious organism is a protozoan species. The symptoms of trichomoniasis are typically mild or absent in women, but a small percentage of patients will experience a diffuse, foul-smelling, or yellow-green vaginal discharge that may or may not be accompanied by vulvar irritation. All women presenting with abnormal vaginal discharge should be tested for trichomoniasis, but routine screening for the infection in asymptomatic women with low risk is not recommended . Screening should be considered for asymptomatic, high-risk women (e.g., history of STI, multiple sex partners, sex workers, illicit drug users) or women in high-prevalence settings (e.g., correctional facilities, STI clinics). High sensitivity/specificity testing (versus wet-mount microscopy), including nucleic acid amplification testing (NAAT) and the APTIMA T. vaginalis assay (RNA detection), is recommended by the CDC . Other U.S. Food and Drug Administration (FDA)-cleared DNA assays are available and are recommended over wet-mount microscopy, if available . Treatment of trichomoniasis includes a single 2-g oral dose of metronidazole or tinidazole. Alternatively, patients may be prescribed oral metronidazole 500 mg twice per day for 7 days. To reduce the possibility of a disulfiram-like reaction, patients should be instructed to abstain from alcohol until at least 24 hours after completion of metronidazole and 72 hours after tinidazole .
Infection with Chlamydia trachomatis is the most common bacterial STI in the United States, especially among adolescents and young adults [14,18]. Although many women have no symptoms, any of the following may occur one to three weeks after contact :
Frequent, uncomfortable urination
Cervicitis with scant cervical discharge
Lower abdominal pain
Pelvic inflammatory disease (PID)
Chlamydia is also a major cause of nongonococcal urethritis (NGU) and lymphogranuloma venereum (LGV) in men . Diagnosis is frequently made in men as NGU and in women after treatment of a male partner for NGU, or on a routine pregnancy screening in asymptomatic women. Laboratory testing has become more sophisticated, with NAAT used to detect the specific DNA of C. trachomatis, (e.g., polymerase chain reaction tests) . A vaginal swab, either collected by a provider or self-collected in a clinic, is the recommended test for women. Antibiotic treatment (except for in pregnant or lactating women) includes drug protocols of azithromycin, 1 g orally in one dose, or a course of doxycycline, 100 mg orally twice per day for one week. Erythromycin, levofloxacin, and ofloxacin are alternative options [14,19].
Infection with HIV produces a condition that progresses from a latent or asymptomatic state to AIDS. Progression varies from a few months to years. Management of HIV involves a complex team of behavioral, psychosocial, and medical services. Referral to a provider or center specializing in HIV care is recommended .
Hepatitis B is caused by the hepatitis B virus, which produces a symptomatic illness in approximately half of infections and has an onset of six weeks to six months . The infection can be chronic or self-limited, largely depending upon age when acquired; chronic infection develops in approximately 90% of infants, 30% of children, and 2% to 6% of adults. Usual risk factors among female adolescents and adults are history of STIs, injection drug use, unprotected sex, and multiple sex partners, with premastication and poor infection control in healthcare settings being less common identified risk factors .
The diagnosis of hepatitis B relies on serologic testing. Treatment is mainly supportive, but there are FDA-approved drugs that can suppress viral replication and support liver disease remission in patients with chronic infection. Referral to a specialist is recommended. Prevention strategies include hepatitis B immune globulin (for postexposure prophylaxis) and the hepatitis B vaccine. The vaccine is recommended for all children, adolescents, high-risk adults, and any adults who want to have protection from the virus, including unvaccinated STI clinic patients . All pregnant women should be tested for hepatitis B, and those at high-risk should be vaccinated. Pregnant women who are found to be hepatitis B positive should be referred to a specialist and enrolled in a perinatal hepatitis B prevention program .
Most gonorrheal infections among men produce symptoms (e.g., burning on urination, discharge) that cause them to seek treatment, thus preventing complications. However, many women have no symptoms, leading to upper reproductive infection and PID . When symptoms are present, any of the following may occur one to three weeks after contact: pus-like vaginal discharge; lower abdominal pain; painful urination; and urinary frequency. Diagnosis is obtained by culture of the organism from the vagina, cervix, pharynx, or rectum or NAAT of endocervical swabs, vaginal swabs, or urine specimens. Patients infected with gonorrhea are often co-infected with chlamydia and are routinely treated with a regimen effective against both organisms. Treatment recommendations no longer include quinolone, as quinolone-resistant strains of gonorrhea have disseminated throughout the United States. Cephalosporins are the only class of antimicrobials available for treatment of gonorrhea . The preferred regimen for uncomplicated urogenital, rectal, or pharyngeal infection is ceftriaxone 250 mg IM in a single dose (or cefixime 400 mg orally in a single dose) plus 1 g oral azithromycin.
The first-stage symptoms of syphilis appear 10 to 90 days after infection, most often within three weeks, and include rash, flulike symptoms, and a painless genital chancre. Diagnosis is via a blood test and physical examination. Treatment consists of an antibiotic regimen of parenteral penicillin G, 2.4 million units in a single dose. The preparation, dosage, and length of treatment depend on the stage and clinical manifestations of the infection and whether the patient is pregnant [14,20].
Despite the availability of public health information, the discussion of contraception, safer sex, and sexual concerns are complex communication issues. Conflict with religious beliefs, inconvenience, cost, stigma, and responsibility are just a few communication barriers that persist between the woman and the provider. Communication techniques to enhance a frank discussion of sexual health needs should include:
Discuss the woman's experiences of sexual risk behavior.
Challenge myths to help protect women against unsafe sexual demands (e.g., having unprotected sex because "they love each other")
Explore situations with the woman to establish a realistic assessment of her sexual risks.
Demonstrate value to the woman by establishing a rapport and taking time to discuss her situation.
Health professionals should provide women with a teaching plan for perineal hygiene and the prevention of infections. The goal is to prevent infections from organisms, such as Escherichia coli, from causing vaginitis and urethritis [16,22]. Women should be instructed to wash their hands before and after genital contact and after using the restroom. The woman should always wipe the perineum from front to back, not back to front or back and forth, and discard the tissue. This single front to back motion should be used after urination, bowel movement, sex, or menses . Women should also avoid products that may disturb the normal flora of the vagina or cause irritation and allergic reaction of the genital area. If a woman is prone to vaginitis, she should use only white, unscented tissue and unscented pads or tampons [22,25]. Women should not use feminine hygiene sprays or any sprays near the perineum. They should avoid deodorant or scented tampons and pads, and when using tampons, be sure that the string does not slip back to the rectal area. If it does, the tampon should be changed immediately.
Douches are rarely necessary. Douching washes out the normal balance of bacteria in the vagina and puts the woman at risk for developing bacterial vaginosis. Women do not need to douche, unless otherwise instructed by a healthcare provider [16,25,26]. Women should avoid the use of perfumed or flavored douches. Vaginal deodorants, sprays, gels, or powders are not recommended for routine hygiene [25,26].
Women are often at risk for genital infections or vaginitis because of microbial growth in the warm, moist environment of the vagina. Wearing cotton underpants with a cotton crotch, especially under pantyhose, girdles, and exercise suits, can decrease this risk . Cotton pants are best during any exercise activity (e.g., aerobics, jogging, biking). Women should avoid nonabsorbent clothing as much as possible, especially when exercising. Showers are preferable to tub baths. Women prone to vaginitis and urinary tract infections should avoid bubble bath and other bath additives. If a lubricant is necessary during sexual intercourse, an over-the-counter water-soluble vaginal lubricant may be used . Vaseline is not water soluble and is not recommended as a vaginal lubricant. Allowing time for proper sexual arousal is often the only lubrication technique necessary. However, vaginal dryness may occur with perimenopausal changes or when taking certain medications.
Changes in vaginal physiology or a rise in the pH makes women more vulnerable to vaginal infections [22,25]. Caution women that risk factors for reduced vaginal acidity include pregnancy, use of high-estrogen oral contraceptives, antibiotic therapy, and uncontrolled diabetes. Women in these situations should follow the suggested techniques for avoidance in addition to a protocol for care for that specific risk factor. If the woman is taking antibiotics, taking probiotics either from food sources or as supplements may help to prevent vaginal infections. Some women will need prophylactic antifungal therapy in conjunction with antibiotic therapy. If a woman has itching, irritation, burning, sores, or odor, she should be examined to determine the exact cause. There are many different types of vaginal infections, each with different treatments [25,27].
Transmission of organisms to and from sexual partners should be avoided. During any treatment for vaginal infections, the woman should either refrain from sexual contact or ensure the use of a condom. If the woman gets irritations easily, she should check with her partner, as his or her soap or other personal products could be the problem.
Vaginitis can result from a wide number of different organisms. A bacterial infection is often the cause of vaginitis, but candidiasis, or yeast infection, is also very common. Any of these organisms may cause the symptoms of vaginitis, such as burning, itching, and vaginal discharge. Asymptomatic colonization may also occur [14,16,22,28,29].
The incidence of yeast infections may be increasing, in part due to the widespread, often improper use of antimicrobial therapy. Other factors, such as positive HIV status, diabetes, and recent IV drug use, are also believed to contribute to yeast colonization . The organism most often responsible for vulvovaginal candidiasis is a fungus called Candida albicans. Other species (e.g., C. glabrata, C. tropicalis) may also cause vulvovaginal candidiasis and are more resistant to treatment . The number of healthy, asymptomatic women who harbor Candida organisms is also increasing. A change in the vaginal environment and pH may cause the candidal organisms to grow, resulting in irritation. Certain health situations may increase the risk of yeast infections [14,16,22,25]:
Taking an antibiotic for an infection in another part of the body may destroy bacteria that are the normal flora of the vagina. Because these bacteria normally keep candidal fungi from flourishing, their removal may allow a yeast infection to develop.
Hormonal changes present during pregnancy or when taking high-dose estrogen oral contraceptives may change the environment of the vagina and make it conducive to the growth of yeast cells. For example, during pregnancy, vaginal secretions become less acidic; the pH changes from about 4 or 5 to about 5.5 or 6.5.
HIV infection or the use of immunosuppressive medications may promote yeast infections. An impaired immune system may allow yeast to grow unchecked.
Diabetes may foster the growth of the fungi because high blood sugar reduces the body's natural ability to resist infection. Diabetes also increases the glucose in the body's tissues, which makes it easier for yeast to grow.
The primary symptom of a yeast infection is a burning and itching sensation on the vulva or in the vagina. Candidiasis typically produces a thick, curdy white discharge resembling cottage cheese with no odor. Symptoms tend to worsen just before menstrual periods, but the cause of this increase is unclear. A male sexual partner may experience a rash or excoriation of the skin of the penis or may be asymptomatic. The CDC does not recommend treatment for men unless candidal inflammation of the penis is present or frequent recurrence of infection occurs .
Many antifungal medications are available over the counter. These medications are convenient and economical for women who are well informed on the etiology and symptoms of fungal infections. Medications available without a prescription include butoconazole, clotrimazole, miconazole, and tioconazole. If the vulva is also infected, a cream is available for topical application in addition to the intravaginal insertions. Yeast infections may be treated with these agents over three to seven days. Candidiasis itself does not pose a serious health risk; however, any infection that does not respond to treatment should be taken very seriously. If over-the-counter treatment does not eradicate the infection, it is very important for the woman to see a healthcare provider to treat the symptoms and rule out other serious problems, such as diabetes and HIV. An infection that does not respond to topical treatment might respond to prescription oral medications, such as fluconazole, a 150-mg pill given in a one-time dose [14,22]. Re-infection from the partner or other serious medical problems must be ruled out when the condition is not resolved .
To confirm that the symptoms are due to candidiasis, a vaginal smear will be examined on a wet mount preparation. On physical exam, the woman's labia and perineum may be red, swollen, and excoriated if the fungus and pruritus has been severe .
The Papanicolaou (Pap) test, or smear, is a safe and inexpensive tool for the early detection of cervical cancer. Developed by Dr. George Papanicolaou in the 1940s, the Pap test became a regular component of the gynecologic examination during the 1950s. It has been the gold standard for the last 50 years; however, reports of false negatives occur in as many as 50% of samples . The Pap test involves scraping the endocervix with a swab, brush, or spatula to obtain a sample of cells [24,27,31]. Most women barely feel the scraping of the cervix during the Pap test. Barriers to gynecological checkups and Pap tests include fear, denial, lack of information, cultural beliefs, social status, embarrassment, absence of symptoms experienced, lack of access to health care, and cost.
Since the introduction of the Pap test, the incidence of invasive cervical cancer and the death rate from cervical cancer have declined significantly in the United States, but the number of women with cervical intraepithelial neoplasia (CIN) has increased at alarming rates . When diagnosed early, the cure rate for CIN is almost 100%. However, approximately 4,100 women die each year from this disease . Approximately 90% of women whose cervical cancer is localized (stage I) at diagnosis are alive five years later, while only 15% to 16% of those with metastatic disease (stage IV) at diagnosis are alive at five years . The percentage of Pap screening is lower among minorities, the elderly, and those without insurance [35,36]. Women who have never been screened for cervical cancer account for approximately 50% of the cases diagnosed in the United States, with an additional 10% of cases diagnosed in women who have not been screened in the previous five years [32,37,38]. Eligible and underserved women should be informed that the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) offers free or low-cost Pap tests and mammograms .
Colposcopy is an office-based procedure using a lighted microscope that permits close and direct examination of the cervix and vagina as well as biopsy and removal of the abnormal tissue. The magnified view of the cervix, vagina, and vulva allows the practitioner to locate and define the size and distribution of CIN . The goal of colposcopy is to detect pre-invasive disease and prevent development of invasive cervical cancer . Lack of skilled technicians, potential for overtreatment, increased risk to patients, and high cost prohibit the widespread use of colposcopy as an adjunct to the Pap test [24,32]. Consequently, new screening technologies have been developed, including liquid-based Pap (LBP) technologies and computer-assisted screening methods. The liquid-based technologies have shown a greater sensitivity to squamous epithelial lesions (SIL) and fewer unsatisfactory samples than the conventional Pap test . The newer methods have been shown to increase life expectancy, but they are associated with a higher cost per screening than the conventional Pap test.
HPV DNA testing is a molecular technique used to identify high risk types of HPV. In 2009, the FDA approved two HPV DNA diagnostic tests: the Cervista HPV HR and the Cervista HPV 16/18 . The Cervista HPV HR is designed to identify 14 high-risk types of HPV. The Cervista HPV 16/18 is designed to specifically detect HPV types 16 and 18, which cause about 70% of all cervical cancers. Both tests are approved for use with LBP samples and should be used in conjunction with the Pap test and patient history to help the practitioner determine needed follow-up, such as colposcopy and/or repeat cytology sampling. The tests are indicated for women 30 years of age and older who are at high risk of disease. They are not recommended for routine screening [24,43,44]. Since 2009, three additional DNA tests have been approved: the Aptima HPV Assay (identifies 14 high-risk types), the Aptima HPV 16 18/45 Genotype Assay (differentiates HPV 16 from HPVs 18/45, but cannot differentiate HPV 18 from HPV 45), and the COBAS HPV Test (specific HPV 16 and 18 genotyping and detects 12 other high-risk types) .
Recommendations vary regarding how frequently women should have Pap tests. National health organizations, such as the American Cancer Society (ACS), the National Cancer Institute (NCI), and the American Medical Association (AMA), have adopted consensus recommendations. Other organizations, such as the ACS, the CDC, and the U.S. Preventive Services Task Force (USPSTF) have developed guidelines for cervical cancer screening. Recommendations from the ACS, the CDC, and the USPSTF are similar and summarized below [14,32,45]:
Pap tests should initiate within approximately 3 years after vaginal intercourse is initiated, or at 21 years of age. A conventional or liquid-based Pap test should be done every 3 years; annual Pap testing is no longer recommended. HPV testing is not recommended alone or in combination with cytology for women younger than 30 years of age.
Beginning at 30 years of age, women who have had 3 or more consecutive normal Pap results should be screened every 5 years with HPV and cytology co-testing. However, more frequent screening may be recommended for women with certain high-risk conditions, such as HIV.
Women of any age with abnormal cytology should be screened according to the American Society for Colposcopy and Cervical Pathology 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors.
Women older than 65 years of age and who have had 2 consecutive normal Pap tests and no abnormal findings for the last 10 years may stop Pap tests.
Most women who have had a total hysterectomy with removal of the cervix do not need Pap tests unless the hysterectomy was done as treatment for cervical cancer or precancerous conditions.
Because cervical precancers grow slowly, having a test every 3 to 5 years will find those that can be treated successfully. Most cases of cervical cancers are caused by HPV, and this condition warrants close follow-up and/or treatment.
There are three FDA-approved vaccines for the prevention of cervical cancer caused by HPV . These vaccines also protect against most types of genital warts and vulvar, vaginal, anal, and oropharyngeal precancerous lesions and cancers caused by HPV . Gardasil, licensed for use in 2006, is a recombinant vaccine effective against HPV types 6, 11, 16, and 18 . It is approved for administration in girls/boys and women/men 9 to 26 years of age . A second vaccine, Cervarix, was approved in 2009 for use in girls and women 10 to 25 years of age and is effective against HPV types 16 and 18 . A third vaccine, Gardasil 9, was licensed in 2014 and protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 in men and women . The CDC's Advisory Committee on Immunization Practices (ACIP) has recommended a three-dose vaccination regimen for all girls (and boys, with the exception of Cervarix) at 11 to 12 years of age with one of the licensed vaccines . Vaccination is also recommended for girls and women 13 to 26 years of age (and boys and men 13 to 21 years of age, again except Cervarix) who have either not been vaccinated or not yet completed the vaccine series [47,48,49]. Vaccines for genital herpes are also in clinical trials.
It is critical to emphasize to the professional and the public that healthcare appointments are needed for women to be assessed for knowledge deficits, sexual risk factors, presence of STIs, contraceptive needs, blood pressure, weight control, clinical breast exams, and any other issues of concern to women.
The cells of the cervix go through a series of normal changes throughout the female lifespan . The term CIN describes and encompasses all epithelial abnormalities of the cervix (i.e., CIN 1 to CIN 3+). The older classification system included only two categories: dysplasia and carcinoma in situ, which influenced different treatment techniques. This system was replaced by The Bethesda System, which was introduced in 1988 and revised in 1991 and again in 2001. Revisions in the "statements of adequacy" were among the major changes in 2001 .
The Bethesda System is the preferred reporting system because, while it retains subgroups, it indicates more of a continuum of pre-invasive cancer of the cervix. For example, definite abnormal cells have been categorized into two levels: low-grade squamous intraepithelial lesions (LSILs), which typically encompass CIN 1, and high-grade squamous intraepithelial lesions (HSILs), which encompass CIN 2 and CIN 3. In The Bethesda System 2001, the category atypical squamous cells (ASC) has replaced the category atypical squamous cells of undetermined significance (ASCUS) and has been divided into two distinct qualifiers: ASC of "undetermined significance" (ASC-US), and atypical squamous cells "cannot exclude HSIL" (ASC-H) [22,24,32,50]. Also in The Bethesda System 2001, atypical findings in the mucus-producing cells of the cervix have been categorized as atypical glandular cells (AGC), and the presence of precancerous cells in the glandular tissue have been categorized as endocervical adenocarcinoma in situ [32,50,51].
The pattern of changes that cervical cells undergo occurs as a continuum over months to years. Women should know that if a Pap test shows any abnormality, the physician or nurse practitioner will perform additional tests to identify the problem. When a vaginal infection is the suspected cause of an abnormal Pap test, the practitioner will treat the infection and then repeat the test, usually in three months. If an infection is not the reason for the abnormal Pap test, the practitioner will often perform a colposcopy and biopsy . Even a minimally abnormal Pap is significant and should not be ignored. The majority of high-grade disease is identified at the time of colposcopy in women with ASC-US and LSIL .
Most risk factors for cervical cancer are related to sexual history. Although the exact cause is unknown, it is thought that cervical cancer is the result of cellular changes in the cervix due to insult from viruses (as discussed) and multiple partners. Women with cervical cancer often report a history of cervical infection and virtually all test positive for HPV . Infections that may lead to cervical carcinoma are caused by HSV-2; HPV types 16, 18, 31, 33, 45, and 58; HIV; and perhaps cytomegalovirus.
HPV 16 is most frequently linked to squamous cancers and HPV 18 to adenocarcinomas [14,22,24,32]. These viruses alter the DNA of nuclei of immature cervical cells. HPV DNA testing may be performed to identify women at high risk for disease. Women whose high-risk HPV infection persists in genital skin cells are at greatest risk for subsequently developing cervical cancer . These women require close follow-up treatment and repeat Pap tests. For example, a patient with ASC-US may often require repeat Pap testing every 3 to 6 months over 6 to 12 months. With an abnormal Pap test, and certainly when 3 consecutive Pap tests over 12 months demonstrate epithelial cell abnormalities, a cervical biopsy under magnified visualization with colposcopy should be done [14,22,24,32]. Fortunately, most women with an abnormal Pap test have an easily treatable precancerous condition of mild dysplasia (CIN 1).
Multiple sexual partners
Early age at first sexual intercourse (i.e., younger than 18 years of age)
History of sexually transmitted infections
Lack of access to or utilization of health care
A nonmonogamous male partner
Diethylstilbestrol (DES) exposure
Lower socioeconomic status
Oral contraceptive use
Intrauterine device use
Multiple full-term pregnancies
The fact that most of the predisposing factors relate to patterns of sexual activity may lead to barriers for early detection and treatment of cervical cancer. Health professionals should be sensitive to women to decrease any embarrassment. Discussions of psychosexual factors and the implications for risk of cervical cancer should be nonjudgmental. Communication should convey that sexual health is regarded as a part of total health, and women should not feel ashamed of what is a normal physiologic function. Societal norms today often differ from the norms of 40 years ago. For example, women often marry later, divorce and remarriage are relatively frequent, and most women have more than one sexual partner in their lifetime (average: 4) . These changes should be considered a social norm, not as a stigma associated with a risk factor for cervical cancer. Health professionals should educate themselves and the women with whom they work regarding sexual health and the risk factors for cervical cancer. Because many women will learn about their positive HPV status at the time that they learn about an abnormal Pap test result, it is important for health professionals to teach women about HPV as early as possible . Health professionals should also encourage sexually active women to participate in regular gynecologic checkups and Pap tests and utilize safe sex practices, such as limiting sexual partners and using latex condoms.
The goal in the treatment of cervical cancer is to eradicate the central cervical disease and any potential spread to the lymph nodes. The upgraded Bethesda System will determine the type of squamous cell abnormality; however, treatment and management decisions may be difficult. For example, if a cure is not likely, the goal may be to remove or destroy as much of the cancer as possible. If the goal is to relieve symptoms, the treatment method is likely to differ. The type of treatment selected will depend on the stage or severity of the disease and the treatment goals, as well as the patient's age, overall health, and preferences [53,54]. The three main types of treatment for cervical cancer are surgery, radiation, and chemotherapy.
There are several types of surgery available for the treatment of cervical cancer. The most common types include :
Cryosurgery kills abnormal cells by freezing them. It is used to treat pre-invasive cervical cancer.
Laser surgery uses a beam to burn off cells or remove a small piece of tissue for analysis. It is used only as a treatment for pre-invasive cancer.
Loop electrosurgical excision procedure (LEEP) removes abnormal tissue or cancer using an electrical current passed through a wire.
Conization involves removing a cone-shaped piece of tissue from the cervix using LEEP or a surgical or laser knife. It is used for early detection and as a lone treatment for women with early cancer who desire children.
Simple hysterectomy removes the uterus but not the tissue next to the uterus. After this surgery, pregnancy is not possible.
Radical hysterectomy removes the uterus, adjacent tissues, the upper part of the vagina, and some pelvic lymph nodes. After this surgery, pregnancy is not possible.
Bilateral salpingo-oophorectomy removes both the ovaries and both fallopian tubes.
Trachelectomy removes the cervix, the upper part of the vagina, and nearby lymph nodes. This method is used for certain young women with early stage cancer who desire children.
Pelvic exenteration removes the cervix, vagina, bladder, rectum, nearby lymph nodes, and possibly part of the colon. It is used in extreme cases for cancer that reoccurs after earlier treatment.
Radiation is a common treatment modality for cervical cancer, because it can be used in all stages of the disease. Radiation destroys the ability of cells to grow and divide. It affects both normal and diseased cells; however, most normal cells are able to recover quickly. Either external or internal radiation therapy may be used. External beam radiation to the pelvis is used to treat the regional nodes and disease, while intracavitary radiation implants treat the central cancer [53,54,55].
The primary goal of radiation therapy is to deliver the highest curative dose while limiting damage to normal tissue. Complications and side effects of radiation therapy vary and may include fatigue, upset stomach, loose bowels, nausea and vomiting, changes to the skin, early menopause, problems urinating, anemia, and low white blood cell counts. In addition, the implant phase of treatment may produce some degree of vaginal stenosis and loss of vaginal lubrication. Learning to use vaginal dilation may help the woman undergoing radiation therapy to minimize the effect of vaginal stenosis [53,55].
Chemotherapy involves the use of drugs (given intravenously or orally) to kill cancer cells. More than one drug may be given during a single treatment. Side effects are common and may include nausea and vomiting, loss of appetite, short-term hair loss, mouth sores, increased risk of infection, bleeding or bruising after minor cuts or injuries, fatigue, early menopause, and infertility. Most side effects cease when treatment ends [53,54].
Following are recommendations for the treatment and management of women with or LSIL and HSIL that encompasses moderate or severe CIN. It is important to note that triage and treatment methods vary and continue to be clinically investigated.
Mild dysplasia might not require any treatment and may resolve on its own; however, it should be checked regularly for any changes. The management options for women with a histological diagnosis of CIN 1 preceded by an ASC-US, ASC-H, or LSIL cytology include accelerated repeat Pap test (every 6 to 12 months) or HPV DNA testing every 12 months [40,56]. Colposcopy is recommended if the repeated Pap test reports ASC-US or greater or if the HPV DNA test is positive. A return to normal screening is recommended if the HPV test is negative or if 2 consecutive Pap tests are negative .
Women with moderate-to-severe dysplasia (and satisfactory colposcopy) may be treated with either ablative modalities (e.g., cryotherapy, laser ablation) or excisional modalities (e.g., loop electrosurgical excision procedure, conization). Exceptions to this recommendation include :
Women with recurrent CIN 2 or CIN 3. A diagnostic excisional procedure is recommended for these women.
Women with a histological diagnosis of CIN 2 or CIN 3 and unsatisfactory colposcopy. A diagnostic excisional procedure is recommended for these women; ablation is unacceptable.
Adolescent and young women. Treatment or observation for up to 24 months, at 6-month intervals, with colposcopy and cytology is recommended (with satisfactory colposcopy).
Pregnant women. Additional colposcopy and cytology are recommended at 12-month intervals, in the absence of invasive disease or advanced pregnancy. If cytology suggests invasive cancer, repeat biopsy is recommended.
Women with cervical adenocarcinoma in situ. If future child-bearing is desired, conservative management is recommended. If not, or if child-bearing is completed, hysterectomy is an option.
Ablative and excisional modalities appear to be similarly effective at eliminating CIN and reducing a woman's risk of future invasive cervical cancer. Patient age and history, interest in future child-bearing, cytology, treatment history, and extent of the disease should be considered when selecting the treatment option . Ablative methods may have an adverse effect on future pregnancies [14,22,24,32,56].
Some women may not feel comfortable initiating a discussion about sexual relations. Health professionals should be sensitive to this and responsible in initiating sexual rehabilitation in women with cervical cancer. Inform women that normal sexual relations may be resumed after cancer treatment. Explore grief over the loss of childbearing ability in premenopausal women. The potential loss of childbearing is a common clinical situation because of the increase in the number of younger women diagnosed with cervical cancer. Reinforce the necessity of follow-up examinations and the need to report any vaginal bleeding.
The following case study illustrates some of the common feelings experienced by women confronted with an abnormal Pap test and the healthcare implications involved in the care of the woman and her partner.
Patient M is a female college student, 21 years of age, who presented to the college health clinic for her annual exam to renew her prescription for birth control pills. Patient M had been involved in a serious relationship with a fellow college student for one year. Following the results of her exam and Pap test, Patient M was diagnosed with HPV and epithelial abnormalities of the cervix. The patient was upset, embarrassed, and angry with herself and her boyfriend. Upon confronting her boyfriend, Patient M learned that he had been sexually involved with another girl on campus, during a brief time when they had broken up, and that this was the likely source of transmission of the virus. Patient M confided in her mother, who was also upset at the notion of the sexually transmitted virus. Patient M's mother had recently been treated for breast cancer, and her daughter's diagnosis renewed many fearful and unpleasant feelings regarding cancer.
Care for Patient M involved exploration of preconceived notions of sexuality and cancer. The patient established good communication with her boyfriend, and both attended a clinic session for pretreatment counseling where factual information was given for the recommended cryosurgery treatment. Concerns regarding future problems with sexual intercourse and fertility were dispelled. Discussion of HPV as a risk factor for cervical epithelial changes was reviewed in a factual manner, and the couple had an opportunity to explore their plans regarding their relationship.
While gynecologic cancers can affect any part of the reproductive tract, the most common type is cancer of the uterus. The three layers comprising the uterus are the inner layer or lining, which is called the endometrium, the middle muscular layer, which is called the myometrium, and the layer of tissue that coats the outside of the uterus, which is known as the serosa . Most uterine cancers begin in the endometrium .
Risk factors for endometrial cancer include advancing age, hormone imbalance, estrogen therapy, use of birth control pills, use of an intrauterine device, breast or ovarian cancer, early menarche (i.e., before 12 years of age), use of the drug tamoxifen, infertility or no pregnancies, obesity, high-fat diet, diabetes, and family history [57,58]. Research has indicated that a relationship of mismatch repair (MMR) gene mutations to endometrial cancer may be present. MMR genetic abnormalities are also considered causal in hereditary nonpolyposis colorectal cancer (HNPCC), which may be a risk factor for endometrial cancer [58,59]. More research is necessary to fully understand the genetics involved in the development of HNPCC-associated uterine cancers.
The one and only early sign of endometrial cancer is abnormal vaginal bleeding or spotting, especially in postmenopausal women. Therefore, women must be instructed to seek treatment when any abnormal bleeding occurs. Endometrial biopsy is the most commonly conducted test, and it may be performed in the office with a pelvic examination. A transvaginal ultrasound may be done before the biopsy to help the physician detect suspicious areas for biopsy. Following a positive biopsy result, the mainstay of treatment is a hysterectomy (simple or total). A bilateral salpingo-oophorectomy may be performed in conjunction with the hysterectomy. Other treatments, depending on the stage of the cancer, include radiation and chemotherapy. Early detection and treatment of endometrial cancer has a very high survival rate because these tumors tend to be well differentiated and localized [55,58].
Ovarian cancer is the fifth leading cause of cancer-related death in women . It is the most fatal of all cancers in women because it is very difficult to detect and diagnose in an early stage. If diagnosed and treated before the cancer has spread beyond the ovaries, the survival rate is about 94%. However, only 20% of all ovarian cancers are found at this early stage [55,60]. By the time it is diagnosed, the cancer may have already spread throughout the pelvis.
Screening for early ovarian cancer remains a scientific challenge, because the symptoms can be somewhat vague. The most common sign of ovarian cancer is enlargement of the abdomen. Women may complain of inability to fasten pants and skirts. Other symptoms may include pelvic pressure or stomach pain, trouble eating or feeling full quickly, and ascites . The exact cause remains unknown; however, evidence suggests a link to endocrine function. The number of times a woman ovulates also may be a factor in the development of the disease, as protection is provided in women who conceive before 25 years of age, experience early menopause, and/or use oral contraceptives for years .
Age is a primary risk factor for ovarian cancer. It occurs most frequently in women 40 to 70 years of age, with more than half occurring in women 63 years of age and older. Survival rate in these women is only about 30% . Other risk factors include family history (with an increase as much as 50% in women who have a mother or sister with ovarian cancer), obesity, no pregnancy before 30 years of age, breast cancer, estrogen or hormone replacement therapy, and environmental factors (e.g., exposure to asbestos) [55,60].
Due to the high mortality rate associated with ovarian cancer, these women and their loved ones require extensive case management with an entire treatment team of surgeons, oncologists, oncology nurse specialists, social workers, and pastoral care. Health professionals should provide these women with the latest information to make informed choices about their treatment options. Radiation therapy is only rarely used in the United States as the main treatment. The recommended treatment of ovarian cancer is surgery followed by chemotherapy. Standard treatment includes three to six courses of chemotherapy with a combination of carboplatin (or cisplatin) and paclitaxel (or docetaxel) .
Methods that may help prevent ovarian cancer include the removal of both ovaries (bilateral oophorectomy) in women who are undergoing hysterectomy for other medical reasons and who have a family history of ovarian cancer. Oophorectomy can be performed by laparoscopy, decreasing the cost, risks, and recovery time for the woman. Tubal ligation and hysterectomy may also lower the risk of getting ovarian cancer; however, these should be performed only for valid medical reasons, not just as preventive measures .
Gynecologic cancer is not always a visible disease. Consequently, the full impact of the cancer is sometimes minimized or further hidden by women, their families, and healthcare professionals. An appreciation and understanding of the magnitude of adjustments for the woman and for the people who care about her is essential. Concerns about treatment, sex, and childbearing are common. Guilt, embarrassment, shame, and body image disturbances are common reactions to the diagnosis of any gynecologic condition. Women may also feel their personal privacy is intruded upon. They may feel defensive and angry about the healthcare team having to treat such a private part of themselves. Some women will associate cancer in the genital area with forms of punishment for real or imagined sexual expression. Shame and guilt associated with the diagnosis can be diminished if healthcare providers communicate with an accepting and nonjudgmental approach. Assessment of how the disease affects a woman's self-image is necessary. Factual information on how the disease or treatment may interfere with normal sexual function should be addressed.
Feelings of guilt, anger, and shame may prevent women from asking questions or initiating a discussion on the subject of sexual activity. The general interactions that should be included in the care of women with gynecological cancer are :
Establish a rapport with the woman. Perform a complete assessment of the woman's preconceived notions about cancer and how the treatment will affect her.
Alleviate fears and misconceptions by communicating accurate facts and answering questions.
Provide as much privacy and comfort as possible. Explore the woman's feelings about privacy and how you can meet her privacy needs within the scope of the treatment.
Encourage verbalization about the causes of the cancer. Reinforce that gynecological cancer has multiple risk factors and that the exact cause is unknown. Encourage the woman not to blame herself for the cancer.
Provide open and sensitive discussions about issues of fertility, sexual expression, body image, and impact of treatment.
Encourage women to follow up with the entire course of the treatment plan and future Pap tests. Inform eligible underserved women that the NBCCEDP offers free or low-cost Pap tests and mammograms.
Encourage safer sexual practices.
Offer the assistance of cancer support groups.
Refer the woman and her family or partner to appropriate resources (e.g., family therapists, psychologists, sex therapists).
Use a nonjudgmental attitude in developing a relationship, and maintain this attitude throughout the entire treatment plan with the woman and her family.
Menarche, the initiation of menses, begins when the brain, ovaries, and adrenal glands have matured. Initial menstrual cycles are usually irregular, as the hormonal communications may be erratic. Pregnancy may occur at any time, even before a girl's first menstrual period, if she has already ovulated. On average, girls in the United States begin menstruating at around 12 to 13 years of age .
Premenstrual syndrome (PMS) is defined as the regular occurrence of premenstrual physical and/or emotional symptoms that may interfere with daily living and functioning in the home and work environment [16,64]. PMS occurs during the luteal phase of the menstrual cycle, when estrogen and progesterone initially rise and then fall if no pregnancy occurs. Common symptoms include anxiety, irritability, mood swings, fatigue, palpitations, crying, forgetfulness, fluid retention, weight gain, and breast tenderness . Dysmenorrhea, or painful menses, is relatively common. Due to differences in reporting methods, incidence estimates range from 20% to 90% of adolescent girls . Dysmenorrhea is characterized by crampy abdominal or pelvic pain on the first day of menstruation and may be accompanied by nausea, diarrhea, fatigue, or lightheadedness.
Despite the prevalence of these conditions, much remains unknown about what causes PMS and dysmenorrhea. Several theories involve the imbalance of hormones or neurotransmitters. Popular theories also include vitamin deficiency, mineral deficiency, and prostaglandin imbalance [22,64,66]. Treatments often seek to balance the levels of hormones or serotonin and address lifestyle issues, such as diet and exercise. Treatment often begins with lifestyle changes for a 2- to 3-month period while the woman logs her symptoms, treatment, and response. Lifestyle changes that may be helpful include decreased sodium and refined sugar intake, decreased consumption of alcohol and caffeine, increased B vitamins and calcium, exercise, relaxation techniques, and increased rest. Calcium supplementation, with two antacid tablets containing calcium twice a day during the luteal phase, has been shown to reduce bloating, pain, mood changes, and food cravings. Aerobic exercise during the luteal phase is thought to be beneficial to decrease anxiety, depression, and anger [64,66].
Medical treatment may include trying to balance hormones with oral contraceptives or balancing serotonin with antidepressants. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, paroxetine, and sertraline, are used for the treatment of PMS and premenstrual dysphoric disorder (PMDD) [64,66]. Most women suffering from dysmenorrhea and PMS may be effectively treated with conservative therapies, such as diet, exercise, cognitive therapies, and calcium supplementation. For the minority who experience severe symptoms or PMDD, pharmacologic interventions are needed. Because severe PMS and PMDD are expected to last until menopause, long-term treatment plans are necessary.
In Western culture, with its strong emphasis on female youth and beauty, menopause may be a difficult adjustment for some women. However, in general, the perimenopausal years should be looked upon as a positive time in a woman's life.
The negative stereotypes associated with menopause probably originated during the period in history when a woman's life expectancy was shorter and she was valued primarily for her reproductive capability. Generations ago, many women did not live past menopause. Women who did live long enough to reach menopause were few and considered to be old if they survived beyond 50 years of age. Consequently, menopause came to be associated with the undesirable attributes of extreme old age.
Although menopause literally means cessation of menses, it is a process rather than a discrete, single occurrence. Menopause is a transition of biological and cultural events over a period of months to years and not purely the single event of absence of menses. Menopause does not occur suddenly unless it is the result of surgery, such as a hysterectomy, medically induced by chemotherapy or radiation, or the result of premature ovarian failure .
Perimenopause refers to the period of a woman's life when she passes through the stages of regression of ovarian function, which typically begins in the late 30s and can be as long as 7 to 10 years [16,22,67]. Menstrual periods stop occurring because the ovaries no longer produce the hormones progesterone and estrogen. The major source of estrogen before menopause is the ovarian follicle, which accounts for more than 90% of the body's total production. This estrogen deficiency may result in symptoms, such as hot flashes, vaginal dryness, emotional changes, and weight gain [22,67]. Some women experience no symptoms at all.
Menopause is a gradual process, not merely the absence of menses.
Menopause takes place over many years, and during this time ovulation may be sporadic. Therefore, contraception should be continued for one year following the last menstrual period.
The average life expectancy of women is 80 years of age, meaning that most women still have one-third of their lives to live after menopause.
Menopause does not mean the end of a woman's sexuality. Rather, it can free women from periods, fear of pregnancy, and contraceptive concerns.
Menopause may be seen as a time of fewer child care responsibilities, with increased opportunities to pursue other goals. This combination of events is often energizing for women who are seeking added dimensions to their careers or relationships.
The transition to menopause often provides more leisure time as well as increasing opportunities for self-expression and community involvement.
In spite of a strong cultural message that youth is valued above age, women who maintain a positive image and value themselves adapt well to menopause.
Menopause is not an illness, but if severe or troubling symptoms persist, a variety of treatments are available.
Along with changes in women's rights and roles in our society, many women and healthcare providers want to replace the negative stereotypes of the menopausal woman with a realistic and positive outlook. This new viewpoint is easier to achieve as women learn more about how to manage the changes that occur during middle age with good health and peace of mind. Women's own understanding and expectations, marital or relationship stability, financial resources, family views, physical health, and sociocultural expectations influence their adjustment to menopause.
Although hormone replacement therapy (HRT) is an option for management of menopausal symptoms, it is not without risk and is not a viable option for every woman. All therapies, including HRT, have risks and benefits.
The NIH established the WHI in 1991 to address cardiovascular disease, cancer, osteoporosis, and quality of life issues in postmenopausal women [69,70]. One component of the Initiative was a randomized clinical trial involving postmenopausal women 50 to 79 years of age. A portion of the trial was conducted to examine the risks, benefits, and long-term effects of hormone therapy. Women with intact uteruses received combined HRT (estrogen plus progestin) or placebo. The study was halted in 2002, three years early, because the WHI safety board found both an increased risk of breast cancer in study participants and a persistence of previously identified risks (i.e., heart attacks, strokes, blood clots in the lungs and legs). The numbers of women who had hip and other fractures or colorectal cancer were lower, and there were no differences in the incidence or mortality rates for women with endometrial cancer. However, when compared to an equal number of women (10,000) taking placebo, there were 8 more breast cancers, 7 more heart attacks, 8 more strokes, and 18 more instances of blood clots to the lungs or legs in the women taking the combined therapy. These results led the safety board to conclude that estrogen plus progestin therapy neither prevents heart disease nor offers benefits sufficient to outweigh the overall risks [69,70].
The WHI also completed a study in which it tested the relative risks and benefits associated with estrogen-only hormone therapy for postmenopausal women without uteruses . It found that although the risks with estrogen-only therapy were significantly less than those identified with estrogen plus progestin, they nonetheless outweighed the benefits. The WHI also found a significant increase in the risk of stroke, a slight increase in the risk for dementia or cognitive decline, a decrease in the risk of hip fracture, and no change in the risk for breast cancer or heart disease. This study was halted in 2004, one year earlier than anticipated [70,71,72].
While the numbers of adverse events are small, it is important to remember that behind each number are a woman, her family, and her community. The following general approach to HRT has been recommended [69,70,73,205]:
HRT may continue to be prescribed to manage menopausal symptoms.
The risks and benefits should be explained to each woman. Alternative therapies or other medications should be discussed as options.
When prescribing HRT, use the lowest dosage for the shortest period of time. When used, optimally prescribe for less than five years. Assess each woman annually.
HRT is not effective for elevated lipids and cardiovascular disease; other therapies and medications should be prescribed. HRT is not a substitute for statins or other lipid-lowering agents.
Other treatments exist for the prevention and treatment of osteoporosis.
Absolute contraindications for HRT include: women with a personal or family history of breast cancer; any other estrogen dependent neoplasia; or a history of estrogen-related thromboembolic disease, such as a woman who experienced a deep vein thrombosis while on oral contraceptives.
The decision to take HRT rests with the individual. Women experiencing difficult menopausal symptoms that are dramatically affecting their quality of life and ability to function may be candidates for HRT in the absence of absolute contraindications. It is best for health professionals to perform a thorough personal and family history, educate women about estrogen, and be willing to help them objectively evaluate the pros and cons of HRT. For women who decide to discontinue HRT, it is best to taper off the drugs to decrease symptoms. However, symptoms may recur. The woman's perception of her experiences, her history of cancer, uncontrolled hypertension, or thrombophlebitis, and her knowledge and concerns about sexuality should all be assessed. Also, women who take HRT should be cautioned about the increased risk of breast cancer and instructed to have regular mammograms as well as clinical breast exams for the duration of the HRT.
At one time or another, many women who menstruate go through the frightening experience of finding a lump in a breast. Less than 20% of these lumps will be malignant or need treatment; however, there are few women's conditions that create as much concern as breast cancer . Understanding breast health, screening protocols, and options for treatment are important dimensions of women's health. While breast cancer remains a concern for many women, early detection and treatment remain the best hopes for improving both the quality of life and survival. Health professionals have important roles, as educators and advocates, in shaping the experiences of women and their families with breast health and breast cancer. Many women with breast cancer live full and productive lives.
An understanding of breast health and breast cancer is important for all women. Aside from nonmelanoma skin cancers, breast cancer is the most frequently diagnosed cancer in women. It is also one of the most treatable, if detected early. One in eight women in the United States will develop breast cancer . Although the cause of breast cancer remains essentially unknown, some risk factors have been identified. The greatest risk factor is being a woman. Other risk factors include current age, age at first menstrual period, age at first live birth, obesity, physical inactivity, race, and personal and family history of breast cancer [6,7]. Many women diagnosed with breast cancer do not have any known risk factors.
Approximately 5% to 10% of women diagnosed each year with breast cancer have a form of the disease resulting from inherited alterations in the genes called BRCA1 and BRCA2 (breast cancer 1 and breast cancer 2). The incidence is highest in women with a family history of breast cancer. The risk of developing breast cancer in women with clinically significant gene mutations is 45% to 65% by 70 years of age, compared with 12.3% of the general population [76,77]. Testing for BRCA1 or BRCA2 is done on a blood sample and can range from several hundred to several thousand dollars . Genetic counseling and risk assessment should accompany the testing. Routine referral is not recommended for women with no family history of breast cancer. However, women with one or more relatives with a BRCA mutation should be offered genetic counseling and testing following evaluation with a validated risk stratification tool .
The ACS, NCI, USPSTF, and others have recommended several methods and timelines for the early detection of and screening for breast cancer in women [78,80,83,84,85]. The health professional should communicate to women and their families that these recommendations are based on the generalized population of women. Individual risk factors and informed choice should still guide each woman.
Early detection of potential malignancies continues to be the single most important factor in the successful treatment of breast cancer. While clinical breast exam occurs only periodically or yearly, breast self-exam (BSE) may be done more frequently. BSE is a method for women to check their own breasts by feeling the breast tissue for changes and lumps and observing the breasts in a mirror for changes in appearance. The ACS and the American College of Obstetricians and Gynecologists (ACOG) recommend BSE as an option for women starting in their 20s; other sources suggest that BSE does not reduce mortality and instead increases the number of biopsies performed and the diagnosis of benign lesions [78,80,84]. Generally speaking, women 20 years of age and older should know how their breasts normally look and feel and report any suspicious breast changes to a health professional at a checkup or when they are found. Signs and symptoms that require follow-up are [22,78,80,206]:
Pain (Breast cancer may or may not be painful.)
Bloody or other spontaneous discharge (not breast milk)
Skin changes (e.g., irritation, dimpling)
Nipple changes (e.g., nipple inversion)
Lymphadenopathy, with or without other symptoms
Any change that the woman finds as unusual for her
Women who ask for information regarding BSE should be cautioned that it may lead to undue anxiety, as benign cysts are relatively common . It is important for women to know that they should not try to diagnose any changes discovered during BSE. There is no substitute for a practitioner's evaluation and further diagnostic tests, and it may be sensible to advise most (low-to-average-risk) patients against performing BSE, aside from noting breast changes (i.e., breast self-awareness) . The USPSTF specifically recommends against teaching BSE to patients .
The clinical breast exam (CBE) has been used by experienced health professionals to find abnormalities in breast tissue in younger women. It has also been used as an opportunity to demonstrate and explain the importance of breast self-awareness . The USPSTF does not endorse CBE for women older than 40 years of age beyond mammography screening, as there is insufficient evidence to support the practice . If mammography is unavailable, CBE is still of value. The ACOG recommends CBE every 1 to 3 years for women 20 to 39 years of age and annually for women older than 40 years of age . The ACS recommends that women 20 to 39 years of age have a CBE at least every 3 years .
Most breast lesions are present for several years before they can be palpated. Lumps that cannot yet be felt through BSE or CBE may be detected by mammography, which is a small-dose, soft tissue x-ray of the breast. Mammography has the potential to detect breast cancer at its earliest stage of development and is therefore recommended as the sole screening modality for women beginning at 40 to 50 years of age [81,83,85]. Although mammograms are not perfect (e.g., they may miss some cancers or indicate things that may not be cancer), their benefits generally outweigh their risks [78,85].
There is little debate that women with special risk factors should begin routine mammograms and breast examinations by a nurse practitioner or physician at about 35 years of age. Mammograms are not as reliable in young women due to the density of the breast tissue; however, the detection of tumors in younger women with denser breast tissue has increased with digital mammography . Ultrasound of the breast is useful to differentiate a solid or fluid structure (cyst) in the breast.
Annually for women 40 years of age and older
If at higher-than-average risk, consider earlier initiation, shorter screening intervals, or the addition of other modalities, such as ultrasound or magnetic resonance imaging (MRI). (The ACS finds no evidence to justify these screening methods, except for instances of BRCA mutation, when annual MRI screening is recommended as an adjunct to mammography.)
Women should be counseled about the possibility of false negatives and false positives.
The ACS further recommends that screening decisions be based on a composite of the woman's health status, life expectancy, and the risks and benefits of mammography [79,83]. Healthcare professionals should periodically perform individualized assessment of risk for breast cancer to help guide women in their decisions about all screening methods.
In 2009 and 2016, the USPSTF revised its recommendations regarding breast cancer screening. Previously, the USPSTF recommendations had mirrored those published by the ACP, the ACS, and the ACOG. However, the USPSTF now recommends that biennial screening mammography be initiated at 50 years of age and continue to 74 years of age . They also recommend against routine mammograms for patients 40 to 49 years of age, taking into account individual patient context. Furthermore, the USPSTF indicates that the evidence is insufficient to assess the benefits and harms of regular BSE, clinical breast exams, and mammography after the age of 74 years . Reactions to these changes from other organizations, including the ACS and the ACOG, have generally been negative .
The cause of breast cancer remains essentially unknown, and it continues to elude research investigators. Although some risk factors have been clearly identified, the significance of many is still controversial. The most evidential risk factors are age, gender, and personal and family history of breast cancer . The identification of a gene in familial breast cancer has been a remarkable step in the direction of identifying risk factors for the prevention of breast cancer.
The impact of breast cancer extends beyond the threat of death and includes an altered self-image, role changes, and changes in support systems and family relationships. The many options for treatment contribute to the complexities that the diagnosis of breast cancer brings to the woman, her family, and her friends. The treatment options depend on the stage of the disease and on other factors, including [87,89,90]:
The type of cancer
Extent of the spread of the cancer
Lymph node involvement
The size of the tumor
Hormonal receptors of the tumor
Desire to participate in a clinical trial
General health status
Women diagnosed with breast cancer should discuss treatment plans with their physicians. Family and support persons should also be included in the discussions. Many women want a second physician to review their diagnosis and treatment plan. Health professionals should reassure women that a short delay while a second opinion is sought should not reduce the success of their treatment. Many patients find it useful to record the sessions during which treatment options are discussed, as it may be difficult to remember the overwhelming amount of information discussed .
Advances in understanding the biology of cancer have occurred over the last few decades. Treatment is based on the theory that breast cancer is a systemic disease. The hope that the cancer has been fully removed has proven to be only part of the biology of breast cancer, and consideration must be given to the fact that micrometastases could be present with or without nodal involvement. Therefore, treatment choices involve not only the surgical procedure, but adjuvant therapy as well. Adjuvant therapies (i.e., methods that enhance survival and complement surgical effectiveness) include chemotherapy, hormone therapy, and radiation therapy. Before decisions can be made about adjuvant therapy, prognostic information must be obtained. Factors that affect prognosis and that should be considered when making treatment decisions are [22,90,91,92]:
Nodal status (positive or negative)
Hormone receptor status (estrogen receptor and progesterone receptor)
Growth factors (ERBB2)
The most important prognostic factor is nodal status. The number of positive axillary nodes has a direct relationship to clinical outcome. For women with negative nodes, tumor size is the most important prognostic factor . The significance of progesterone receptors (PRs) is not as clearly understood as that of estrogen receptors (ERs). About 80% of breast cancers are ER-positive, and about 65% of ER-positive cancers are PR-positive. About 13% of breast cancers are ER-positive and PR-negative. About 2% of breast cancers are ER-negative and PR-positive . Patients with ER-positive breast cancer generally respond favorably to the anti-estrogen agent tamoxifen .
ERBB2, a growth factor, is emerging as an important prognostic marker. The ERBB2 protein is expressed at low levels in normal breast tissue, but in about 25% to 30% of women with breast cancer, this protein is overexpressed. This overexpression is correlated with poor disease-free survival . The FDA has approved trastuzumab, a monoclonal antibody, for use in conjunction with paclitaxel to target cells that overexpress ERBB2 [96,97]. Clinical trials have indicated that women with breast cancer who are overexpressing ERBB2 and who receive chemotherapy in addition to trastuzumab have a higher survival rate .
Triple-negative breast cancer (TNBC) is defined as the absence of staining for ERs, PRs, and ERBB2. TNBC is insensitive to some of the most effective therapies available for breast cancer treatment, including HER2-directed therapy (e.g., trastuzumab) and endocrine therapies (e.g., tamoxifen, aromatase inhibitors). Combined chemotherapy is the standard therapy for early-stage TNBC . A 2014 review and meta-analysis of the adjuvant use of platinum agent to treat TNBC showed a three-fold increase in complete response compared to neoadjuvant therapies containing no platinum agent .
Until recently, a radical mastectomy was the standard treatment for breast cancer. While surgery remains a primary component of treatment, it often conserves more breast tissue and is combined with other therapies . If the woman has carcinoma in situ, for example, the treatment option might be a modified mastectomy or lumpectomy and radiation therapy, with or without hormonal therapy . Women who have stage I or stage II cancer are often candidates for breast-conserving surgery (i.e., lumpectomy, breast radiation, surgical staging of the axilla) . While not all women are candidates for this approach, it has demonstrated the same survival rate as other surgical techniques while preserving breast tissue .
The epidemiology of breast cancer indicates that, in many women, it is a hormonally influenced malignancy. Cancer cells are tested after surgical removal, and hormonal therapy may be used when the cancer is sensitive to estrogen (i.e., ER-positive) . Tamoxifen is a synthetic anti-estrogen that has been found to effectively treat women with ER-positive or ER-unknown breast tumors. The optimal duration of tamoxifen appears to be five years. The NCI has recommended that adjuvant therapy with tamoxifen be discontinued in all patients after five years. The benefit of taking tamoxifen for more than 5 years is unknown . Serious side effects of tamoxifen include blood clots, strokes, uterine cancer, and cataracts; other common side effects include hot flashes, night sweats, and vaginal dryness . Tamoxifen is not recommended in women with a prior history of deep vein thrombosis, pulmonary embolus, stroke, or transient ischemic attack .
In summary, the treatment choices for breast cancer include:
The following case studies of women with breast cancer illustrate the range of treatment choices available. They also illustrate the necessity for healthcare providers to have a broad knowledge base from which to communicate information and provide support during this decision-making period. The case studies also provide mental health providers with the opportunity to be supportive from an informed position.
The patient described her experiences as follows: "My mother had breast cancer when she was 60, so I was more aware of screening. When I was 52, I went to my gynecologist for a routine checkup and discussed everything. I actually said to my physician, 'By the way, don't you think I should have a mammogram?' So I did, and they discovered it. I cannot sing the praises of a mammogram any higher. The cancer could not be felt, and it was discovered as a result of the mammogram. The cancer had not spread to the lymph nodes, so I had a lumpectomy. After the surgery, the surgeon just said, 'Go home, everything's great, and you'll be fine.' However, I think that fear, once you hear you have any cancer, is awful. Once I found out that it hadn't gone into the lymph nodes, I did feel a whole lot better."
This woman's experiences highlight several key points for health professionals. First, women should act as advocates for themselves if physicians or practitioners do not initiate the topic of breast screenings. Second, this is a good example of breast cancer discovered by a mammogram in its earliest stages, long before the mass was large enough to be palpated. Lastly, the woman's descriptions of her emotions when diagnosed with cancer should be included when developing her treatment plan. Just because a woman is fortunate enough to be diagnosed early and is a good candidate for breast-conserving treatment, such as lumpectomy, does not mean she does not have emotional adjustments to make as a woman living with breast cancer.
Another patient described her experiences with treatment decisions as follows: "You know, I started backwards because the lump was under my arm first. It took the surgeon about 15 minutes to find the spot in my breast. We discussed my options, and I chose to have a lumpectomy. I opted for this because, being 42, I was pretty young, and I could probably get by with just a lumpectomy. Unfortunately, that didn't work, because when the report came back, they said the tissue around the lump was not healthy. So, they left the option to me regarding further surgery, and I had 10 weeks to think about it. During that 10 weeks, I had my chemotherapy. That was a very hard 10 weeks. My husband said it didn't matter to him whether I lost a breast, and he would rather prefer that I was overtreated, but it was a hard decision. I kept thinking: How am I going to look? How am I going to feel? Am I still going to be a woman? It took me a long time, and I finally decided it didn't matter, that I was going to live. It didn't matter what I had to do in order to do it. So, I said okay, and I elected to have the mastectomy done."
This woman's experience also highlights key points for health professionals to understand when working with women with breast cancer. The patient was persistent in seeking care for a lump under her arm. This is a reminder that breast cancer may not always be obvious in the breast. Also, unexpected or borderline test results place the woman and her family in a position where the treatment decisions are not black or white. Health professionals should provide support, information, and a caring attitude as women make decisions that are difficult and emotive.
Breast reconstruction is a plastic surgery that rebuilds and recreates natural-looking breasts for women who have lost theirs to cancer. Reconstruction can be achieved by inserting saline-filled or silicone gel-filled implants beneath the skin and chest muscles. The silicone implants are used less frequently than in the past due to concerns about immune system diseases. However, studies have allayed some of the concern about this risk, and the FDA approved silicone implants again in 2006. Newer types of silicone implants use a thicker "cohesive" gel that reduces the risk of leakage should the implant rupture . Breast reconstruction can also be achieved with tissue flap reconstruction, which uses tissue from another part of the body, such as the buttocks, abdomen, or back [103,104]. The two most common types of tissue flap reconstruction are the transverse rectus abdominis muscle (TRAM) flap surgery, which involves constructing a breast from the lower abdominal skin and fatty tissue, and the latissimus dorsi flap, which uses tissue from the upper back. Other flap procedures include the deep inferior epigastric artery perforator (DIEP) procedure and the gluteal free flap. The DIEP procedure is similar to the TRAM, except that it does not use muscle to form the breast mound. The gluteal free procedure (also similar to the TRAM) uses tissue from the gluteal muscle of the buttocks . Nipple reconstruction involves using tissue obtained from the opposite nipple areola complex or tissue from the upper portion of the inner thigh. The reconstructed breast and nipple may not have the same level of sensation during sexual arousal [103,105,106]. The transverse upper gracilis flap (TUG flap) is a newer option for women who are either not eligible for or are not interested in the TRAM or DIEP flaps. The TUG flap uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. The TUG flap is a good option for women who need a smaller or medium-sized breast . Some physicians have begun using FDA-regulated products made of donated human skin (e.g., AlloDerm, DermaMatrix) or an animal-skin acellular matrix (e.g., Strattice). These products are another new option in breast reconstruction; outcome studies are still in progress .
In the wake of the controversy about silicone gel and saline-filled implants, more women are choosing reconstruction using their own tissue. The TRAM flap approach offers the advantage of creating a softer, more natural-appearing breast mound of autogenous tissue, without the risks associated with manufactured implants . It also produces an abdominal lipectomy, or "tummy tuck," in the donor area, which some women find beneficial.
It is important for healthcare professionals to educate women and their families about the surgical procedures when discussing treatment options. Preoperatively, any woman considering reconstruction should meet with a plastic surgeon to discuss her candidacy for the TRAM procedure. Women with obese abdomens are at much higher risk for flap loss and are poor candidates . Likewise, heavy smokers and diabetics are at risk for consequences of poor flap vasculature due to prolonged healing times and infection. Any previous surgery that transected the abdominis muscle may preclude that particular muscle for the flap .
Most experts agree that good results can be obtained with reconstruction when the cancer surgeon and the plastic surgeon plan the surgeries together [103,105]. In some instances, the reconstruction may be done simultaneously with the mastectomy, with the two surgeons working in concert. However, immediate reconstruction is not possible for some women. Women with advanced cancer, who will need further procedures, may be advised to postpone reconstruction because of its potential to interfere with treatment. Those undergoing radiation may not be good candidates for reconstruction if they have any damage to the skin [103,105].
Some women who are eligible for immediate reconstruction may delay the procedure to give themselves time to recover from the mastectomy and ensure that the cancer is gone. Some of these women may not want to go through another surgery and do not elect to have the reconstruction. Delaying the procedure gives women time to think about the decision, decreases time under anesthesia, and decreases stress on the body during the mastectomy. A mastectomy alone takes about 1.5 to 3 hours. Reconstruction with saline implants adds another 1.5 hours. A TRAM procedure takes 4 to 8 hours, depending on the type .
Reconstruction is a serious procedure, and some women find it difficult to make decisions about it when already dealing with the life-and-death questions regarding their cancer treatment. Women should decide if they want reconstruction in the immediate future, at a later date, or not at all. If they elect to have reconstruction, they should decide which procedure is best for them . A thorough psychosocial assessment of the woman's feelings about reconstruction should also be completed. It is important that the woman feel confident and comfortable with herself, with or without reconstruction. The breast can have a strong impact on body image, sexual attractiveness, and intimacy.
For any woman with breast cancer, with or without reconstruction, rigorous follow-up is needed. The importance of educating the patient and family on the significance of follow-up diagnostic tests and visits cannot be overstated. The woman should perform monthly breast exams, and clinical breast exams with the oncologist or surgeon should be done. Yearly mammograms, or more frequently as deemed necessary, should be completed. These women should be screened carefully for recurrence .
The goal of adjuvant therapy is to find the most effective therapeutic regimens while minimizing toxicities. Studies have shown that adjuvant therapy may increase the chance of long-term survival by preventing a recurrence . Available treatment options have expanded to include new medications and combinations of medications for the adjuvant management of breast cancer . For example, multiple trials of polychemotherapy have demonstrated that treatment with combination therapy and/or tamoxifen produces a reduction in the risk of relapse and death [90,109]. Because breast cancer is so common, even a modest improvement in therapy will save many lives.
Adjuvant systemic therapy is an important and essential component of the management of primary breast cancer. Aromatase inhibitors (AIs), such as anastrozole, letrozole, and exemestane, are commonly used in postmenopausal women in both early and advanced breast cancer, either after tamoxifen therapy or instead of tamoxifen therapy [90,109]. These inhibitors work by blocking production of androgenic precursors, thereby depriving breast cancer cells of estrogen. Anastrozole is generally well tolerated, and clinical trials have indicated that AIs are as effective as tamoxifen, without some of the side effects, such as hot flashes, thromboembolic disease, and increased risk of endometrial cancer. Anastrozole has also demonstrated improved efficacy for 5 years over tamoxifen alone [109,110,111]. Ovarian ablation or suppression to reduce the amount of estrogen produced by the body (either permanently or temporarily) may be recommended for some premenopausal women. For example, premenopausal women who have BRCA1 or BRCA2 gene mutations are at very high risk of breast cancer recurrence and of ovarian cancer . The burden on oncologists is to balance the benefits to each individual patient against the potential toxicities that may develop, based on the prognostic risk factors of the particular breast cancer diagnosis.
It is beyond the scope of this course to discuss all the new cytotoxic drugs and their combinations. One exciting area of research is the identification of specific molecular abnormalities of cancer cells. As previously mentioned, trastuzumab, a humanized monoclonal antibody against the ERBB2 oncoprotein, has produced objective responses with ERBB2-overexpressing breast carcinoma and has improved the efficacy of various combinations of cytotoxic drugs . All breast cancer patients should have their ERBB2 status analyzed, including women with either node-positive or node-negative breast cancer. This analysis may help patients and their healthcare providers with the decisions about adjuvant chemotherapy.
Healthcare professionals should stay informed about the latest trends, results of clinical trials, and new standards of adjuvant breast cancer treatment to most effectively inform women and their families about treatment options. After the decisions have been made, it is the responsibility of the health professional to provide the woman with physical and emotional comfort interventions throughout the course of treatment.
Regardless of the type, staging, or treatment for breast cancer, the woman and her support persons will have unique needs. Clinical experience and research findings have indicated that the important health issues for women with breast cancer include :
Ability to nurture physical and emotional well-being
Need for effective communication and expression of loss and fears
Sexuality and relationship concerns
The following techniques are measures to address the experiences and needs of women as they learn to live with the diagnosis and treatment of breast cancer :
Experience: Confronting the diagnosis of cancer.
Need: Time and space to adjust to the diagnosis
Interaction: Give only the information needed or asked for.
Need: Expression of thoughts, fears, and uncertainties
Interaction: Encourage sharing of thoughts and feelings. Explore and clarify misconceptions or unrealistic fears. Encourage networking with other patients with a similar diagnosis or situation.
Experience: Developing strengths in living with diagnosis
Need: Coping mechanisms
Interaction: Explore which skills and strengths work for this patient and her family. Suggest journaling, music, and imagery.
Need: To fight to keep a positive outlook
Interaction: Encourage the patient to do what is important to her. Promote self-nurturing activities and positive self-talk.
Interaction: Encourage release of energy through playful activities. Encourage distancing from dwelling on cancer through humor and fun activities.
Experience: Maintaining connections with family and friends and spirituality
Need: To interrelate with family, friends, and self and to address spirituality needs
Interaction: Encourage the woman to ask for help and allow herself to experience others' expressions of support and caring. Offer the resource of a cancer support group. Offer communication and validation of experiences with other patients with cancer. Encourage her to seek support from spouse/partner as well as others. Spouses or partners may not be able to fulfill all the woman's connection needs. The spouse/partner is also dealing with the loss from his or her own perspective. Suggest outlets to connect with herself, such as journaling, poetry, and meditation.
Cardiovascular diseases are the leading cause of mortality in women . The incidence of cardiovascular disease in women continues to rise markedly in perimenopause and menopause. Research has shown that both natural and surgically induced menopause are associated with changes in serum lipid profiles, with a decline in high-density lipids (HDL) and an increase in low-density lipids (LDL) . These cholesterol changes may be factors in the development of a woman's increased risk of postmenopausal heart disease.
The primary pathological risk for heart disease is driven by the deposition of cholesterol in plaque-laden arterial walls. Angina pectoris occurs when the patient experiences a deficit of oxygen being infused through the myocardium. The pain sensation is thought to occur due to a state of anaerobic physiology. Myocardial infarction (MI) occurs with a necrosis of the myocardial cells due to an anaerobic insult. These anaerobic conditions may be caused by a clot or spasm or by atherosclerotic plaque in the coronary arteries. The most common cause is atherosclerosis. Contrary to common belief, many women who die suddenly of coronary heart disease (CHD) have no prior symptoms . This highlights the need for preventive screening with blood pressure monitoring, lipid profiles, weight management, smoking cessation, and prevention and management of diabetes mellitus.
CHD, especially MI, has historically not been thought of as a woman's disease either by practitioners or by women. This may be in part because cardiovascular disease patterns show interesting gender differences. Nurses and other health professionals can play a key role in educating their peers and patients about the facts of heart disease in women.
There are several key gender differences in cardiovascular disease that require consideration for healthcare practice [55,113,115,116,117,118,119,120]. Between 25 and 35 years of age, men have three times the incidence of CHD as women. Women tend to show signs of cardiovascular disease at a more advanced age than men. Although menopause decreases women's estrogenic protection from heart disease, this biological advantage persists until 65 to 70 years of age. At older ages, women who have heart attacks are twice as likely as men to die from them within a few weeks. Women represent slightly more than half of all deaths from cardiovascular disease annually in the United States. Overall, the lifetime risk of a woman dying as a result of heart disease is one in three.
The signs and symptoms of CHD in women often differ significantly from those in men. Women may have unspecified pain and vague symptoms, which may often lead both the physician and the patient to look for other causes. Healthcare professionals should suspect MI in women just as they would in men. Women should be asked about how their symptoms change in response to exercise, extremes in temperature, and heavy meals. Common indications of CHD and acute MI in women include chest, arm, back, and neck pain, although women are less likely to report chest pain during a heart attack than men . Women with MI have been found to be more than twice as likely as men to present with back pain. Other symptoms include fatigue, chest pain at rest, shortness of breath, and weakness.
The differences in symptomatology in women compared to men may be in part attributed to anatomical and physiological differences in their cardiovascular systems. Women's hearts are generally smaller, with smaller arteries and a higher resting heart rate. Research has also suggested that women may deposit plaque more diffusely than men. This diffuse distribution of plaque is not as easily visualized using traditional angiograms as the large, obstructive blockages that are more common in men.
Diabetes is more prevalent in women than in men and is a major risk factor for cardiovascular disease. Health professionals should emphasize that heart disease is not an inevitable consequence of aging; it is a disease process that can be greatly influenced by lifestyle behaviors, such as diet, exercise, not smoking, maintaining proper weight, and monitoring blood pressure and cholesterol. It can also be influenced by pharmacotherapy, when appropriate. Healthcare providers, women, and the general community should recognize that the years surrounding menopause are accompanied by a higher risk for coronary disease. The major risk factors for heart disease in women are :
Hypertension (blood pressure >130/80 mm Hg or on antihypertensive medication)
High LDL (>100 mg/dL)
Low HDL (<40 mg/dL)
Family history of CHD
Age (>55 years)
Obesity or body mass index (BMI) >25
Large waist-to-hip ratio (abdominal obesity) or a waist circumference >35 inches
The American Heart Association (AHA) reports that women represent only 38% of NIH-funded cardiovascular studies . Almost 75% of cardiovascular clinical trials do not report sex-specific results, and women are under-represented in studies of FDA-approved medical devices. Gender differences in response to cardiac medications have also been identified. The AHA has encouraged Congress to pass legislation that would help eliminate the cardiovascular health disparities that women face .
Patients have combinations of multiple social, psychological, cultural, physical, and addictive behaviors that contribute to negative lifestyle behaviors. The major modifiable risk factors for CHD are cigarette smoking, hyperlipidemia, hypertension, diabetes, physical inactivity, excessive alcohol consumption, substance abuse, stress, birth control pills, and excessive weight.
There are many steps that women can take to reduce their risk of cardiovascular disease. The first step is to increase awareness of the need to take responsibility at a younger age and develop health behaviors that will decrease her cardiovascular risk as she ages and becomes more prone to heart disease. Childhood is the best time to develop positive health behaviors, but it is never too late.
While MIs are uncommon in premenopausal women, the factors that affect the change after menopause are not exactly clear. Because women present with heart disease at different ages and with different signs and symptoms, they may not be taken as seriously as men. Women are usually diagnosed with heart disease when they are in an older age cohort, more likely to be on other medications, and have other conditions, such as diabetes, hypertension, and osteoporosis.
Approximately 75% of U.S. adults are either overweight, obese, or extremely obese . Health professionals should respond to this public health epidemic by educating women and by supporting their efforts to change behaviors involving their diet and exercise routines. Regular exercise has many benefits, such as preventing unhealthy weight gain, helping with weight loss, and lowering a woman's risk of heart disease, stroke, and high blood pressure . Exercise has also been shown to affect muscle growth and metabolism [124,125]. When working with women who continually struggle to maintain weight control, it is important to develop a teaching plan that emphasizes the relationship between diet and exercise.
Metabolic rate is a measure of energy utilization, or how fast one's body burns calories . Many factors affect metabolic rate, including gender, age, heredity, food intake, body composition, activity level, and frequent cycles of weight loss [126,127]. Frequent weight loss through severe caloric restriction followed by increased caloric intake and weight gain seems to slow metabolic rate in many people. This is commonly called "starvation metabolism," "yo-yo dieting," or "weight cycling." It is as though the body fears starvation and becomes more efficient at conserving and storing energy. This weight loss cycling is harmful to a woman's health, as well as discouraging, and some studies suggest a link to hypertension, gallbladder disease, heart disease, diabetes, and depression [124,128]. Maintaining a healthy weight is best achieved by combining healthy eating and physical activity .
When counseling women who either need or desire to lose weight, it is important to emphasize that regular physical activity provides major health benefits that are generally independent of body weight. Exercise guidelines should take a lifespan approach that emphasizes lifetime physical activity . Nurses and health professionals may suggest the following measures to encourage the habit of lifelong exercise [123,129,130]:
Avoid inactivity. Some physical activity is better than none.
Choose physical activities that are fun, and vary them to prevent boredom.
Create activity opportunities (e.g., take the stairs instead of the elevator; take quick walking breaks when at work).
Exercise with someone else. Women who have exercise partners may feel safer. Also, research has shown that partners help to reinforce consistent exercise patterns.
A minimum of 150 minutes of moderate-intensity aerobic exercise spread throughout the week provides substantial health benefits. Examples of moderate-intensity activities include brisk walking (3 miles/hour or faster), bicycling slower than 10 miles/hour, water aerobics, and general gardening. Include a five-minute warm-up and cool-down at the beginning and end of each exercise session to prevent injury.
Include muscle-strengthening activities at least two days per week to realize benefits (i.e., increased bone strength, muscular fitness) not achieved through aerobic exercise alone. Examples of muscle-strengthening activities are resistance (weight) training, push-ups, pull-ups, and working with resistance bands.
The U.S. Department of Agriculture has developed MyPlate, which offers personalized information designed to help individuals plan, assess, and meet general nutritional needs and make food choices based on sound dietary guidelines . In general, women should select vegetables, fruits, whole grain foods, legumes, fish, poultry, and lean meats low in saturated and trans fats and cholesterol and use methods of cooking such as broiling. While vitamins and minerals are provided in adequate amounts in a balanced diet, special consideration should be given to each woman's history and developmental life events. For example, the menopausal woman should balance cholesterol and calcium needs by consuming low fat dairy products for a daily calcium intake of 1000–1200 mg . Losses of iron due to menstruation and increased needs during pregnancy place women at greater risk for iron deficiency anemia. Health professionals should be alert to the following situations [55,133]:
Women who have very heavy menstruation
Women who are dieting (particularly diets less than 1500 calories per day)
Vegetarians and women who do not eat red meat
Iron absorption is a complex process that varies with the foods consumed. Eating foods high in vitamin C facilitates the body's absorption of iron. Therefore, vitamin C intake from fruits, fruit juices, or vegetables should be encouraged at meals in combination with the selected iron food source. While moderate amounts of lean meat contribute to iron status, the consumption of meat is not essential for adequate iron. Vegetarians should consume legumes and nuts for iron as well as protein. Choosing breads, cereals, and pasta enriched with iron also supplies a fair amount of iron for women . Groups of women who are at greater risk for low iron levels include adolescent girls of childbearing age, pregnant women, and female athletes who engage in regular, intense exercise. These women should be screened for iron deficiency and prescribed supplements if needed . Experts no longer simply recommend a diet low in total fat. Instead, there is greater emphasis on awareness of the type of fat and on reducing the intake of saturated fats, cholesterol, and trans fats. All fats are composed of fatty acids, which are the building blocks of fat. The amounts and mixtures of fatty acids determine the attributes of fats. Fatty acids may be saturated, monosaturated, or polyunsaturated, differing in the amount of hydrogen they contain . Saturated fatty acids are mainly found in foods derived from animals, such as meat, poultry, butter, and milk. Polyunsaturated fatty acids are found in plant foods, such as corn and sesame oils, as well as fish and seafood. Monosaturated fatty acids are found in plant foods, such as canola, peanut, and olive oils, as well as nuts and avocados. Trans fats are present in a wide range of foods, including most foods made with partially hydrogenated oils, such as baked goods, fried foods, and some margarine. Through hydrogenation, unsaturated fatty acids can be made more saturated, resulting in the formation of a more stable semisolid form (trans fat) . Health professionals should educate women that fats are essential for health but that moderation in the amount and type of fat consumed is important. Women should be advised to consume a majority of the fat in their diet as polyunsaturated and monosaturated fat, while reducing the amount of saturated and trans fat. The American Heart Association recommends eating at least two servings of fish rich in omega 3 oil, such as salmon, trout, and herring, every week . Portion control is a major component of weight management as is a decrease in consumption of fat and overall calories.
When counseling women about exercise and nutrition, health professionals should begin by obtaining the woman's health history. Inquire about whether she exercises, and document the specifics of her exercise routine, including the type, amount, frequency, and her level of satisfaction with the routine. Encourage her to maintain a diary of eating and exercise patterns. Discuss nutrition concerns such as weight control, lowering cholesterol, and food likes and dislikes. If she is allergic to milk products, discuss other sources of dietary calcium and calcium supplementation. Discuss ways to balance cholesterol and calcium by consuming low-fat yogurt, skim milk, pudding made with skim milk, and low-fat cheese. Ask her to log her fat, iron, and calcium intake for two weeks to increase awareness about her dietary choices. Help her to plan an exercise routine that slowly increases in intensity, and conduct follow-up discussions to evaluate her progress and recommend alternatives, when necessary. Consult with a dietician and physician as needed.
The health provider who does a thorough health and diet history to identify nutritional risks for the various developmental stages of women will be able to adapt the dietary guidelines to meet the additional special dietary needs for that woman. Table 1 provides an example of a nutrition teaching plan for women.
EXAMPLE TEACHING PLAN: NUTRITION
Ensure that your diet contains a variety of foods, with the majority being fruits, vegetables, and grain products. The majority of your calories should come from grains, fruits, and vegetables. Limit fat intake to 30% of your daily calories. Monitor the type of fat you consume. Choose foods low in saturated fat, trans fat, and cholesterol. Visit the ChooseMyPlate site, athttp://www.choosemyplate.gov, to determine the recommended daily servings of each of the food groups based on age, sex, and average daily physical activity.
Tips regarding saturated fat, trans fat, and cholesterol intake include:
Use sugar and salt in moderation. Drink at least 8 glasses of water per day. Consume 1000–1500 mg of calcium and 400–600 IU of vitamin D per day. Good sources of calcium include:
Consume 400 micrograms (0.4 milligrams) of folate per day. Sources of folate include:
Obtain 15 mg of iron per day. Sources of iron include:
Consume 20–35 grams of fiber per day. Sources of fiber include:
With three-quarters of Americans overweight or obese, the rising incidence of the constellation of obesity, dyslipidemia, heart disease, and diabetes in women is a critical public health issue . Diabetes is a major source of morbidity, mortality, and economic burden in the United States, yet it can frequently be prevented by lifestyle changes . Public health education marketed toward women that includes information about weight management, exercise, controlling blood glucose levels, and preventive diabetic health may reduce the incidence of diabetes.
There are two types of diabetes: type 1 and type 2. Type 1 diabetes is caused by autoimmune destruction of the pancreatic islets. Type 2 diabetes, which is more prevalent, is a defect of insulin secretion, actions, and insulin resistance. Risk factors for type 2 diabetes include [121,139]:
Hypertension (>130/80 mm Hg in adults on at least two separate occasions and measured in both arms)
Family history of diabetes (parents or siblings with diabetes)
Overweight (BMI >25)
Race/ethnicity (i.e., African Americans, Hispanic Americans, Native Americans, Pacific Islanders)
Habitual physical inactivity
HDL cholesterol <40 mg/dL and/or a triglyceride level >250 mg/dL
History of gestational diabetes or delivery of a baby weighing more than 9 pounds (Women who have had gestational diabetes have a 35% to 60% chance of developing diabetes in the next 10 to 20 years.)
Polycystic ovary syndrome
Persons presenting with any of the listed risk factors should be screened for diabetes on a yearly basis. Any person presenting with polyuria (frequent urination), polydipsia (extreme thirst), unexplained weight loss, and/or repeated infections should also be screened . Screening consists of a comprehensive history and physical along with blood glucose levels, both fasting and two hours post-prandial. A fasting blood glucose of 100 mg/dL or less is well within the normal range. An elevated blood glucose of more than 126 mg/dL on more than one occasion supports the medical diagnosis of diabetes .
Although genetic susceptibility and environmental factors have a role in the development of type 2 diabetes, the current epidemic can be primarily associated with particular lifestyle behaviors. These behaviors include the lack of regular exercise, consumption of high saturated fat diets, dyslipidemia, obesity, and smoking. Moderate sustained weight loss and regular moderate to vigorous exercise can decrease the risk of developing type 2 diabetes.
Education and prevention are of great importance in decreasing the incidence of diabetes in women and promoting self-management practices to reduce complications when it is diagnosed. Self-management decisions and actions are taken by patients in response to their environment and situation in order to improve their health status. Women need the skills, information, and community and financial resources for effective self-management. Healthcare providers should help prevent the onset of the disease, promote early detection, and encourage preventative services to reduce the number of short- and long-term complications. These interventions can improve patient outcomes and ultimately reduce healthcare costs. To accomplish these objectives, a multifaceted management approach should be adopted that consists of patient and family education, promotion of self-management, a well-established communication plan between the healthcare providers and the patient, and regular up-to-date feedback on the patient's outcomes. Early, preventative interventions may reduce the morbidity, mortality, and economic burden of diabetes. Table 2 provides a quick reference of specific interventions for the prevention of selected long-term complications of diabetes.
AMERICAN DIABETES ASSOCIATION RECOMMENDATIONS
|Foot ulcers, with high potential for amputations||
Osteoporosis is a condition resulting from decreased density, or thinning, of the bone due to aging. It is the most common of all skeletal disorders, and osteoporosis and low bone mass affects 54 million men and women in the United States at an estimated cost of $19 billion . Women experience the most bone loss during the first 5 to 7 years following menopause; they lose 2% to 5% of bone tissue per year immediately before, and for about 8 years after, menopause [141,142,143]. Because osteoporotic bone is more porous and weaker than normal bone, fractures may occur more easily . Osteoporosis is responsible for more than 2 million fractures annually, including 297,000 hip fractures, 547,000 vertebral fractures, 397,000 wrist fractures, and more than 675,000 other site fractures . It is estimated that half of all women in the United States 50 years of age and older will have such a fracture [140,143].
Women are at a higher risk for osteoporosis than men primarily because of differences in bone mass and density. It is important to emphasize the factors that contribute to the development of osteoporosis when educating women about preventive screening practices and positive lifestyle behaviors. The risk factors for osteoporosis are [141,143,144]:
Family history of osteoporosis. This is primarily known through health history information, particularly if any female relatives have had a broken wrist or hip or had a dowager's hump.
Hysterectomy and/or surgical removal of ovaries before 50 years of age. Secondary osteoporosis is used to define the reduction of bone mass developing from reasons other than the aging process. Young women who have had their ovaries surgically removed run the same risk of developing osteoporosis as postmenopausal women.
Smoking. Women who smoke increase their odds of developing osteoporosis.
Alcohol. Women who consume excessive amounts of alcohol experience a greater calcium loss, which may result in osteoporosis. Women who drink wine, beer, or other alcoholic beverages daily increase their risk of osteoporosis.
Small, thin body frame. Slender women of European and Asian descent have a higher incidence of osteoporosis than African American women, largely as a result of differences in peak bone mass and density.
Soft drinks and coffee. Women who drink soft drinks or more than a few cups of coffee daily increase their chance of developing osteoporosis due to a loss of calcium.
Inactivity. Women who do not exercise at least one hour a week with weight-bearing activities, such as walking, jogging, or low impact aerobics, are at increased risk for developing osteoporosis.
Strenuous exercise causing amenorrhea. Exercising so strenuously that the woman has irregular periods or no periods at all is as harmful to bone health as inactivity. A balanced diet and a sound exercise program are key health promotion habits for the prevention of osteoporosis.
Low dietary calcium intake. Many background factors contribute to a woman's dietary intake of calcium. Women should be interviewed during the health history to determine any milk allergies or lactose intolerance, eating disorders, such as bulimia or anorexia nervosa, or continued dieting for weight management that often excludes dairy products. Most women do not consume adequate calcium levels in their young adult years to achieve peak bone mass.
Increasing calcium intake
Taking vitamin D supplements
Avoiding excessive caffeine, soft drinks, and alcohol
Increasing physical activity, including weight-bearing exercises
Completing bone density screening, if at risk for osteoporosis
Calcium needs vary with age. The NIH recommendations for the daily needs of girls and women are :
9 to 18 years of age: 1300 mg/day
19 to 50 years of age: 1000 mg/day
51 years of age and older: 1200 mg/day
14 to 18 years of age, pregnant or lactating: 1300 mg/day
19 to 50 years of age, pregnant or lactating: 1000 mg/day
Dairy products account for the majority of the calcium in the average American diet. However, it is thought that the average daily calcium intake for women from dietary sources is only about half of the recommended amount. Dietary calcium sources include milk products, calcium fortified foods (e.g., orange and grapefruit juice, cereals, breads, soy beverages), fish (e.g., salmon, sardines), and shellfish. Nonfat and low-fat versions of dairy foods can help balance calories and cholesterol. Three 10-ounce glasses of milk supplies 1000 mg of calcium. Women requiring dietary calcium may also choose to take supplements.
Daily calcium intake should not exceed 2000 mg, including dietary sources and supplements. Most commercial preparations of calcium supplements come in 200–500 mg pills. A woman taking three 500 mg pills of a calcium supplement may take the pills in divided doses during the day or in a single bedtime dose. Gastrointestinal upset is the most common side effect. Constipation, flatulence, gastric distension, and nausea may be experienced.
Because vitamin D is needed for proper calcium absorption, one preventive measure is to ensure a daily intake of at least 600 IU up to 70 years of age and 800 IU after 70 years of age [143,145]. The Institute of Medicine (IOM) has identified the tolerable upper intake level of vitamin D as 4000 IU. At least one study suggests that 600–800 IU per day (and even 4000 IU per day) may be much too low, particularly for overweight and obese patients, who require 1.5 times and 2 to 3 times the recommended dose, respectively . Unlike the IOM, the Endocrine Society supports these levels of additional supplementation for overweight/obese individuals . Certain researchers also maintain that the optimal human serum 25-hydroxyvitamin D level is 115 nmol/L, which would require a dietary daily vitamin D intake of 10,000 IU in the absence of adequate sunlight exposure . Hypercalcemia, a possible risk factor of excessive vitamin D intake, was not seen in study participants taking 20,000 IU supplementation.
A 2011 Cochrane review concluded that supplementation with cholecalciferol (vitamin D3) reduces mortality in elderly women, but that supplementation with ergocalciferol (vitamin D2) or active forms of vitamin D (i.e., alfacalcidol and calcitriol) does not . The review looked at data from 50 randomized trials with nearly 100,000 participants. Whereas alfacalcidol and calcitriol caused hypercalcemia, cholecalciferol did not. There was an increased risk of kidney stones with cholecalciferol supplementation at higher doses, though it is possible that coadministration of vitamin C could negate this effect . A 2014 Cochrane review of 159 studies reaffirmed the conclusions of the 2011 review . Based on these data, providers should recommend or prescribe vitamin D3 over other forms, but perhaps not in patients at risk for nephrolithiasis [207,208].
Exposure to sunlight is also a source of vitamin D but has drawbacks, including skin damage and increased cancer risk. Levels of UV available from the sun fluctuate throughout the year depending on latitude and vary based on time of day; additionally, skin color (measured by the Fitzpatrick scale) affects rates of vitamin D synthesis . It is estimated that individuals with Fitzpatrick type III skin (creamy white, sometimes burns, though tans evenly) with 25% of skin exposed can synthesize about 400 IU of vitamin D at higher latitudes (e.g., Boston) format noon between April to October in approximately 3 to 8 minutes. In southern latitudes (e.g., Miami), these individuals can synthesize the same amount of vitamin D anytime of the year in about 3 to 6 minutes . These times are extended in individuals with darker skin pigmentation, at times of the day/year with less UV intensity, and if sunscreen in used on all exposed skin.
Vitamins and minerals are essential for life, and they will be provided when a woman consumes a balanced, nutritious diet. However, because women do not always have the time, education, or finances to consume a balanced diet, it is essential to understand the common mineral deficiencies in women.
Pharmacologic management of osteoporosis offers an opportunity to increase bone density and decrease the incidence of fracture and the accompanying debilitating symptoms. Women and their families should be informed that [141,143]:
Taking medication to prevent or treat osteopenia and osteoporosis does not mean that intake of calcium and vitamin D is no longer needed.
Moderate weight-bearing exercise is still encouraged.
When placed on a new medication, follow-up should occur within two weeks to one month.
An annual bone density test to evaluate treatment effectiveness is suggested.
Alendronate is a bisphosphonate with proven results in building bone mineral density. It may be taken in either a 10 mg dosage daily or a 70 mg dose once weekly . The once-weekly dosing is convenient, making the drug more appealing. Due to the potential for esophageal burning and erosion, patients should take the medication upon arising with 6 to 8 ounces of water and remain upright with no other oral intake for 30 minutes . All food and beverages interfere with absorption, and it is essential that no other intake, including coffee, is ingested for at least 30 minutes after administration. Reported side effects include bone, joint, or muscle pain, and hypocalcemia .
Risedronate is also a bisphosphonate, and it may also be prescribed for the treatment of osteoporosis. Dosage is generally 5 mg once daily, 35 mg taken once a week, or 150 mg once a month. The benefits and side effects are similar to those seen with alendronate, and the same precautions when taking the medication apply, including remaining upright and avoiding food and drink intake for 30 minutes .
Ibandronate is another bisphosphonate that may be prescribed for the prevention and treatment of osteoporosis. Ibandronate has been shown to reduce the incidence of spine fractures by about 50% over 3 years . Ibandronate is taken orally in a dose of 150 mg once a month . It may also be administered as an intravenous infusion of 3 mg every 3 months. If the monthly dose is chosen, it should be taken on the same day every month . As with the other bisphosphonates, care should be taken to avoid food and drink, other than water, after taking the medication. After 3 to 5 years of treatment, discontinuing ibandronate should be considered in patients at low risk for fracture .
Zoledronic acid is approved for the prevention and treatment of osteoporosis in postmenopausal women. For treatment of osteoporosis, it is administered once a year in a 5-mg IV infusion over 15 minutes . It may also be administered every 2 years as a preventive measure. An acute reaction (e.g., arthralgia, fever, flu-like symptoms, myalgia) may occur within the first 3 days following infusion in up to 44% of patients . Symptoms usually resolve within 3 to 4 days of onset but occasionally persist as long as 14 days. After 3 to 5 years of treatment, discontinuing zoledronic acid should be considered in patients at low risk for fracture .
Note: In 2008, the FDA reviewed the bisphosphonates marketed in the United States in response to study results that had associated their use with an increased incidence of atrial fibrillation. The FDA has found no clear association between atrial fibrillation and the use of bisphosphonates . The FDA is additionally conducting an ongoing review to determine whether use of oral bisphosphonates is associated with an increased risk of esophageal cancer . Another concern with bisphosphonate therapy is osteonecrosis of the jaw, which is typically associated with existing oral infection. Patients should be evaluated by a dentist, and any necessary dental work should be completed prior to initiation of bisphosphonate therapy . The benefits of bisphosphonate therapy are believed to outweigh the potential risks.
Calcitonin prescribed for osteoporosis is a synthetic salmon calcitonin administered intranasally daily (i.e., 1 spray of 200 units in one nostril); a 100 unit per day intramuscular or subcutaneous injection preparation is also available . Patients should alternate nostrils to avoid irritation. Side effects include rhinorrhea, headache, back pain, and nosebleed. Calcitonin is contraindicated in women with hypersensitivity to salmon protein .
Raloxifene is a selective estrogen receptor modulator (SERM), which means that it affects some (but not all) of the same receptors as estrogen, and in some instances, it blocks or antagonizes estrogen. Raloxifene acts like estrogen in building bone and preventing bone loss, and it appears to block some estrogen effects in the breast and uterus . The decrease in estrogen-related adverse effects on the breast should increase compliance and decrease fractures. Raloxifene may be taken orally in doses of 60 mg daily, at any time of the day, and without regard to meals . Raloxifene does not reduce hot flashes. Side effects, though uncommon, include hot flashes, leg cramps, and deep vein thrombosis . Raloxifene should be used with caution in women with coronary heart disease or in women at risk for coronary events.
Teriparatide is a parathyroid hormone analog that increases gastrointestinal calcium absorption and results in increased bone mineral density, bone mass, and strength. It has been shown to decrease osteoporosis-related fractures in postmenopausal women. Teriparatide is administered subcutaneously in a 20-mcg dose once daily. The patient should be either sitting or lying down during initial administration. Transient hypercalcemia is a common side effect . This medication contains a boxed warning regarding an increase of osteosarcoma in animal studies. A patient registry has been established to collect data regarding human risk and is available at http://forteoregistry.rti.org.
Denosumab is a RANK ligand (RANKL) inhibitor/human monoclonal antibody. It binds to RANKL, thereby leading to decreased bone resorption and increased bone mass in osteoporosis. Denosumab is approved for treatment of osteoporosis in postmenopausal women. It is administered subcutaneously in a single 60-mg dose once every 6 months . A blood test should be performed before each dose to confirm that the patient's blood calcium level is normal. Common side effects include fatigue, headache, dermatitis, hypocalcemia, and nausea .
An inadequate supply of calcium over a lifetime contributes to the development of osteoporosis, with the body's greatest need for calcium occurring during childhood and adolescence . Dietary instruction about the importance of adequate calcium intake is of special importance when developing a teaching plan for girls and women, because peak bone mass may be enhanced by optimum calcium intake and exercise, especially during the growth years. Osteoporosis is often called the "silent disease" because there are no symptoms during the early stages . An early prediction of who may be at risk is helpful.
Psychological health includes the factors in every woman's life related to a balance of work and home, stress, relationships, family issues, and a sense of meaning and healing. Some experts debate that psychological health, as a concept, focuses on the "well" population. Others feel that mental health promotion includes the plight of the mentally ill and the specific issues related to their environment and conditions. The World Health Organization defines mental health as "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" .
Psychological health promotion is a process that facilitates healing by restoring harmony and balance between the mind and the body. Mind-body therapies and complementary therapies may alleviate stress-related health problems. Nursing interventions to promote psychological health include touching, listening, caring, music, humor, and storytelling.
To maintain psychological health, women should find time each day to focus on what their body/mind is telling them. They should also take at least 15 minutes a day to do something they find special and relaxing. Other actions that promote psychological health include:
Regular exercise. Exercise increases endorphins in the body and improves emotional and physical health. The risk of coronary artery disease almost doubles in sedentary individuals.
Nutritious diet. Establishing healthy eating habits early and consuming fruits and vegetables have shown to help reduce the risk of cancer. Women who are overweight have a higher death rate than lean women.
Regular screening. This is an opportunity to be screened for common conditions such as hypertension, breast and cervical cancer, and depression. It is also a time to address health concerns, get answers to any questions, and discuss how to make desired or necessary lifestyle changes.
Adequate rest. Avoid eating, exercising, or stimulating activity right before bedtime. Establish a nightly ritual to develop a relaxed sleeping pattern. Sleep allows individuals to be more equipped to deal with everyday life. It will also help alleviate stress.
Smoking cessation (if already smoking). Smoking does not just affect the lungs but may also affect every organ in the body. Smoking affects and harms the smoker and also those who are exposed to the secondhand smoke.
Injury risk reduction, which includes:
Practicing safer sex
Avoiding involvement in violence or contact with violent persons
Being aware of safety principles at home and when traveling
Wearing vehicle seatbelts
Never driving under the influence of alcohol or drugs
Women fulfilling multiple roles often need the support of health providers to take care of their own psychological needs. Health history questions to assess and support a woman's mental health needs include [16,112]:
Do you pay attention to your inner feelings?
How many hours of sleep do you get per night? Do you feel rested?
Do you engage in activities that help you relax?
Do you have hobbies?
Do you take at least 15 minutes for yourself each day?
Do you have at least one person in whom you can confide?
Do you have a spiritual outlet?
What lifts your spirits?
Depressive disorders are more common in women than in men, and early detection and treatment of depression may be enhanced with screening as a component of the annual exam. Depression may result in physical and psychological symptoms that cause a significant amount of distress and impairment to the woman and her family, and it may occur in the absence of mania. The risk factors for depression are [16,147,149]:
Family or personal history of depression or postpartum depression
Poor self-concept or self-esteem
Other chronic health conditions
Loss or death
Stressful life occurrences
Depression may occur as a single occurrence, or it may periodically reoccur, but it remains independent of life events. The woman will either demonstrate a depressed mood, or she will express a lack of interest in all or most of her routine activities. Women with depression experience a constellation of symptoms. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), major depressive disorder is diagnosed when five or more of the following symptoms are present for at least two consecutive weeks and represent a change in recent functioning; one of the symptoms must be either loss of interest or pleasure or depressed mood :
Self-reported or objective depressed mood, most of the time (e.g., sadness, emptiness, hopelessness)
Significant loss of interest or pleasure in usual activities
Significant weight loss or gain or alteration in appetite
Sleep disturbances manifested by insomnia or hypersomnia
Psychomotor agitation or retardation (objective)
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to concentrate
Recurrent thoughts of death
Additionally, the patient must have both :
Significant distress related to their symptoms or impairment of functioning (e.g., social, work, other).
No other known medical condition or to which the episode may be attributable, including the psychological effects of a substance.
Note: The episode should not be considered a depressive disorder if the symptoms are related to a significant loss (e.g., bereavement), as these may be a normal part of the grieving process, for example. The DSM-5 criteria also require that the patient's depression should not be better explained by a psychotic disorder (e.g., schizophrenia, schizoaffective disorder, delusional disorder) and the patient has never had a manic episode or a hypomanic episode .
The USPSTF has recommended that adults be screened for depression in clinical practices that have the appropriate systems in place to assure accurate screening, diagnosis, and follow-up . The following screening tools are some of the most widely used with established validity. All positive screening tests should be followed with an extensive interview and health history for a full diagnostic work-up [147,150]:
Beck Depression Inventory: The most widely used instrument; recognized as the "gold standard" among self-report measures of depression. All 21 items apply to the past two weeks, including the current day. Emphasis is on the cognitive symptoms of depression.
Zung Self-Rating Scale: 20 items, rated by how much time each depressive symptom is present. Zung describes the scale as a "depression thermometer."
Geriatric Depression Scale: 15 yes/no questions. Takes 5 to 7 minutes to complete; is one page long and easy to understand.
Center for Epidemiological Studies Depression Scale (CES-D): 20 items; emphasis is on depressed mood during the past week, psychomotor retardation and somatic complaints, lack of well-being, and interpersonal difficulties.
Suicide is a major, preventable public health problem and one of the leading causes of death among women (particularly adolescent and young women) in the United States . A previous suicide attempt is one of the strongest predictors of subsequent suicide. Cognitive therapy has been shown to reduce by half the rate of repeated suicide attempt, because it helps those who attempt suicide to focus on alternative actions when thoughts of self-harm arise . The risk factors for suicide may vary with age, gender, or ethnic group. They may occur in combination or change over time and may include [16,152]:
Previous attempts at suicide
Family history of mental disorder, substance abuse, or suicide
Firearms in the home
Abuse (emotional, physical, or sexual)
Alcoholism and other substance abuse
Women who die by suicide are frequently found to have seen a primary care provider in the year prior to death. This emphasizes the importance of providers being able to recognize and treat the risk factors to help prevent suicide .
Anxiety disorders affect about 40 million adults in the United States each year, and women are 60% more likely than men to have an anxiety disorder in their lifetime . They are characterized by symptoms of physiological arousal (e.g., palpitations, sweating) with moods of excessive worry that interfere with normal functioning, persist over time, and worsen if not treated [153,154]. Anxiety disorders are further classified as panic disorder, agoraphobia, phobias, generalized anxiety disorder, separation anxiety disorder, selective mutism, social anxiety disorder, acute stress disorder, anxiety due to medical conditions, and other/unspecified disorders . Women may exhibit several disorders simultaneously. For example, anxiety is common in depression disorders, and depressive symptoms are common in anxiety disorders. The most common risk factors for anxiety include :
Physical and mental illness
Stressful life situations or crises
Family history of anxiety disorders
Abuse or domestic violence
Alcohol or substance abuse
Anxiety disorders are generally treated with medication, psychotherapy, or both. The treatment choice will depend on the type of disorder and on the individual's preference .
Intimate partner violence is control by one partner over another . Abusers physically, sexually, verbally, and/or emotionally abuse their partners and/or destroy their partner's property . Economic control, stalking, and control of social contacts are all forms of violence against women. Experiencing fear in a relationship is characteristic of an abusive situation, regardless of whether there is physical violence. The fear of physical harm is enough to consider the relationship abusive .
The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence using a validated screening tool and provide or refer identified victims to intervention services . Tools that have been studied and found to have high sensitivity and specificity include the HITS (Hurt, Insult, Threaten, and Scream), the Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/OVAT), STaT (Slapped, Threatened, and Throw); HARK (Humiliation, Afraid, Rape, Kick), the Modified Childhood Trauma Questionnaire–Short Form (CTQ-SF), and the Woman Abuse Screening Tool (WAST). Additionally, many major medical organizations and state licensing boards mandate screening for partner violence . Direct questioning has been found to be effective for identifying women experiencing partner violence . To assess women for the risks or presence of domestic violence, healthcare providers should ask, and encourage women to ask themselves, the following questions :
What stresses do you have in your relationship with your partner?
How do you handle disagreements?
Do you feel safe in your relationship with (name spouse/partner)?
Should I be concerned for your safety?
Are there situations in which you feel afraid?
Have you ever been threatened or abused?
Has your partner forced you to have sexual intercourse that you did not want?
If positive responses to items above: Ask, "Are your friends/family aware that this is happening?"
If negative responses to items above: Ask, "Do you think you could tell them if it did happen? Would they help you?"
Do you have a safe place to go in an emergency situation?
If you are in danger now, would you like me to help you find a shelter?
Would you like to talk with a social worker/counselor to help you develop a plan?
Any questions answered affirmatively should be followed with additional questions in order to determine the following :
How and when mistreatment occurs
Who perpetrates it
How the woman copes with it
What she plans to do to protect herself (and her children, if applicable)
The prevalence of violence in American society exceeds all other Western nations. Health professionals should increase awareness about safety, and the specific rules of gun safety, in the home. The American Academy of Pediatrics has recommended that gun safety education be included in each visit to the pediatrician. The CDC reported that in 2009, 2,465 children 19 years of age and younger died from a firearm-related incident . In the United States, unintentional firearm-related injuries result in almost nine times as many pediatric fatalities as the next twenty-five industrialized countries combined . The key points for gun safety education are provided in Table 3 and Table 4.
TEACHING PLAN: GUN SAFETY
TEACHING PLAN: GUN SAFETY FOR PATIENTS AND CAREGIVERS
If there is a gun in your home: Teach the child about gun safety when the child starts to ask questions or acts out gun play. Keep your lessons simple, but credible. Repeat, repeat, and repeat.
Teach facts, not fear: The first rule for small children is DO NOT TOUCH. When the child is older, taking them to a gun range may take away the "forbidden fruit" attraction. Consider having them take a gun safety course.
Distinguish between fantasy and reality: Many parents establish their home as a "no gun zone," meaning no real or pretend guns allowed. If children are allowed to play with pretend guns, teach them the difference between real and pretend. Tell them to always first assume that a gun is real. Toy guns may present an opportunity to teach safe and proper gun handling.
Options for safe storage: Vaults, safes, and locked metal storage boxes. Store ammunition and the firearm in separate safes. Think about gun storage from your child's point of view. Children will climb up onto areas that you think they cannot reach. Consider using trigger or action-blocking locks for additional safety.
Practice what you preach: Follow the rules you have set for your children. Remember, you are their role model. Do not leave firearms lying around. If your child discovers a gun outside the home or in the home of a friend, they should know the four steps of the Eddie Eagle gun safety program:
DO NOT TOUCH.
LEAVE THE AREA.
TELL AN ADULT.
Discuss gun safety with other parents or family members if your child spends time in their homes. It is not enough to assume that if they do have guns in the house, then they have them stored properly.
Alcohol, drug, and tobacco abuse are prominent public health issues for women and their families. It is estimated that more than 1 in 10 children in the United States live with a substance-abusing parent . Consequences of the addictive use of alcohol, drugs, and tobacco are related to liver disease, heart disease, stroke, breast and lung cancer, HIV/AIDS, hepatitis, violence, sexual victimization, and auto accidents. One in four deaths is attributable to alcohol, tobacco, or illicit drug use .
Factors that may increase a woman's risk for substance abuse or dependence include genetic influences, early initiation of smoking and substance use, and victimization. At least part of the increased risk for substance abuse in women as compared to men may be attributed to gender-related differences in metabolism, brain chemistry, or genetic risk factors. Early assessment and treatment are key in increasing awareness and preventing serious consequences for women, their families, and the community.
Women commonly seek help for alcoholism from primary care clinicians; however, few are queried about alcohol or drug use when they visit a primary care physician . Health professionals should assess adolescents and women for alcohol and substance use during the health history . The screening tools available have wide applicability for screening high-risk patients. The CAGE questionnaire (Table 5) is a brief tool that uses "have you ever" questions to detect alcoholism in adults and in adolescents older than 16 years of age . The CRAFFT screening test (Table 6) is a two-part test used to screen adolescents for substance-abuse problems and disorders. Part one, which contains six questions, is administered to the youth. Part two contains a list of items to discuss/investigate with the parent [166,167]. Other screening tools (Table 7) may be used based on patient population and time available. Women and girls whose scores indicate a problem should have extensive interviews and medical follow-up. Community resources and referrals should be provided to the women and their families.
Two or more "yes" answers indicate probable alcoholism. Any one "yes" answer deserves further evaluation.
CRAFFT SUBSTANCE ABUSE SCREENING TOOL: TESTED FOR ADOLESCENT CLINIC PATIENTS
Two or more "yes" answers indicate a significant problem.
PRIMARY CARE ASSESSMENT FOR ALCOHOL PROBLEMS
Drug abuse prevention programs for adolescents should be adapted to emphasize the points that are meaningful to them (e.g., bad breath or ill-smelling clothes for those who smoke). Prevention programs also should increase academic and social competence with skills such as study habits and academic support, communication, self-efficacy, and assertiveness. The programs should also enhance protective factors (e.g., strong family bonds, parental monitoring, clear rules, training in drug education/information) and reduce or reverse risk factors (e.g., chaotic home environment, ineffective parenting, poor school performance). Research has indicated that many of the same protective/risk factors that apply to substance abuse also apply to youth violence, delinquency, risky sexual behaviors, and teen pregnancies. Early intervention is key .
Socioeconomic factors and cultural beliefs and practices affect the health behaviors of women, thereby influencing their access to and use of health services; confidence in practitioners and recommended prevention guidelines; and health beliefs in general. Health professionals should assess cultural beliefs and demonstrate respect for diverse belief systems. The following information summarizes risk factors and recommended screening procedures for African American and Hispanic women to decrease the gap in health status for women in these groups.
There are many important health promotion issues of special concern to African American and Hispanic women. For example, they are at higher risk than white women for many conditions, including diabetes, hypertension, obesity, heart disease, stroke, kidney disease, vision loss, tuberculosis, arthritis, HIV/AIDS, lupus, and advanced cervical and breast cancers [171,172]. Emphasis on health education, assessment and early screening, and self-management with health-promoting behaviors can minimize or prevent these conditions. Table 8 and Table 9 contain treatment guidelines for African American and Hispanic women.
TREATMENT GUIDELINES FOR AFRICAN AMERICAN WOMEN TO DECREASE HEALTH DISPARITIES
|Health Concerns||Screening Test||Risk Factors||Health Promotion|
|Diabetes||Blood sugar test with annual exam if abnormal follow-up with primary care physician (PCP) or nurse practitioner (NP)||
|High blood pressure||Blood pressure checked with annual exam. If normal, get blood pressure checked every 1 to 2 years; if abnormal, follow up with PCP/NP.||
|Obesity||Blood pressure check, blood sugar test, weight check||
|HIV/AIDS||Oral exam, vision test, Pap smear and pelvic exam, tuberculosis test, thyroid test, and STI tests||
|Breast health/breast exam||
|There are no preventive measures, but lifestyle modifications can minimize risk factors (i.e., eating a healthy diet, weight control, smoking cessation).|
|Heart health: minimizing heart disease and stroke||Discuss the following tests with PCP if family history present: Blood pressure and cholesterol check; exercise stress test; test for diabetes||
|Autoimmune disease (e.g., lupus, arthritis)||Thyroid test Autoimmune screening test Tuberculosis test||
|General health||Discuss with PCP/NP.||Discuss with PCP/NP.||Discuss with PCP/NP.|
TREATMENT GUIDELINES FOR HISPANIC WOMEN
|Health Illnesses||Health Strategies|
|Diabetes: Affects 1 in 10 Latino women; within this group, Hispanics are 17 times more likely to die from diabetes-related complications than non-Hispanic white women of the same age.||
|Breast cancer: The most commonly diagnosed cancer in Latinas. The occurrence of breast cancer for Hispanic women is rising and the risk is nearly double for women who are obese.||Explain the importance of performing breast self-examinations every month, and demonstrate multiple techniques. Encourage yearly breast examinations by healthcare provider or nurse practitioner. Begin yearly mammogram screening at 40 years of age; sooner if there is a positive family history of breast cancer or if your healthcare provider or nurse practitioner believe it necessary.|
|AIDS and sexually transmitted infections: Hispanic women are at higher risk for rape and domestic abuse and have a higher HIV infection rate than white women in the United States.||Initial discussion should begin between 10 and 12 years of age and may be easier if parent is not in room. Recognize and acknowledge that this is a sensitive and personal topic but one that must be discussed. Explore level of knowledge regarding topic. Clarify any misconceptions or myths. Discuss transmission of AIDS/STIs. Discuss safe sex, abstinence, condom use, "buddy system" for parties, and general safety measures. Encourage patient to voice concerns or ask questions at any time during discussion. Re-affirm information with patients periodically.|
|Glaucoma/vision disorders: Open-angle glaucoma is the leading cause of blindness among U.S. Hispanics. Hispanic women are also more likely to suffer vision impairment from cataracts, glaucoma, and diabetic retinopathy than men.||Report any visual changes immediately to a healthcare provider or nurse practitioner. Encourage use of safety gear including sunglasses and protective eye wear during activities. Begin yearly ophthalmology examinations at 50 years of age; sooner if any visual changes occur or positive family history of diabetes or glaucoma exists.|
African American and Hispanic women have a higher prevalence of diabetes and diabetes-related complications and death than national averages. About 1 in 4 African American women 55 years of age and older has diabetes, which is nearly twice the rate of white women . Improving the lipid profile, weight management, and exercise patterns of women with diabetes may decrease their risk of diabetes-related cardiovascular disease and other complications. Maintaining a blood pressure less than 130/80 mm Hg will also help minimize heart disease and stroke, which are more common in African Americans .
African American women have the highest death rates from heart disease. Their symptoms are generally atypical when suffering from angina or MI, making diagnosis more difficult. They often present with shortness of breath as their chief complaint, rather than angina, and they also often have normal electrocardiograms [116,171]. African American women are less likely than others to be referred for cardiac catheterization, which is necessary to diagnose coronary artery disease .
HIV/AIDS, which at one time was thought to be a disease of homosexual men, is the fifth leading cause of death in African American women 25 to 59 years of age and the eleventh leading cause of death among Hispanic women 25 to 59 years of age [173,175]. HIV/AIDS-related illness is the number one cause of death in African American women 25 to 34 years of age, and 66% of new HIV infections among women occur in African American women, primarily through heterosexual contact .
Social, cultural, economic, and educational factors, as well as access to care, play major roles in the health behaviors of African American women regarding CBE, mammography, and other preventive care practices. Although age-adjusted breast cancer incidence rates are higher in white women, African American women have a higher mortality rate due to more advanced stage of the cancer at the time of diagnosis . Health professionals should improve culturally sensitive health education and screening programs to increase health awareness and promote positive health practices among women of color.
Complementary therapies are defined as nontraditional therapies that can interface with traditional medicine and surgical therapies. They may also be used as complements to other therapeutic and pharmacologic treatments. Because they are used in addition to, rather than instead of, traditional medicine and surgical therapies, the term complementary therapy is preferable to alternative therapy. Health care has traditionally focused on technology and on the treatment of symptoms that were indicative of pathology. In the holistic model, the emphasis is on achieving maximum body/mind health, and treatment focuses on minimal interventions with appropriate technology and a wide range of noninvasive therapies. Complementary therapies are not a single modality of healing but an array of practices, including diet and clinical nutrition, herbal medicine, hydrotherapy, aromatherapy, guided imagery, therapeutic or healing touch, yoga, and spirituality .
Holism and complementary therapies draw from the healing wisdom of many cultures, including Indian, Chinese, Native American, and Greek. Holism is based on a few overarching philosophies: the healing power of nature; treat the cause rather than the effect; first, do no harm; treat the whole person; the health provider is a healer and a teacher; and prevention is the best cure .
Women buy the majority of complementary medicinal treatments and have an array of products at their disposal, from vitamins to Chinese herbs. However, no regulatory agency enforces labeling requirements or quality control for these products. Scientific evidence supporting the quality or effectiveness of these products is scant; therefore, it is prudent for both the public and healthcare professionals to continue to support research on complementary therapies. The National Center for Complementary and Integrative Health at the NIH was established by Congress in 1998 to evaluate the effectiveness of these therapies .
Menopausal women for whom HRT is contraindicated or who prefer not to use HRT may wish to try herbal remedies. Phytoestrogens are herbal sources that contain estrogen-like substances. Soy protein powder is the phytoestrogen most commonly used for menopausal symptoms. Women usually mix it into fruit juice or milk twice a day. Other examples of phytoestrogens or estrogen-like substances include ginseng, garlic, black cohosh, and red sage . Some women report significant relief from hot flashes and menopausal symptoms with these remedies. Women should be advised, however, that these products are not regulated by the FDA, and that safety and efficacy studies are not available.
Dong quai, a Chinese herb, is an estrogen precursor that may be given either as a tea or placed under the tongue. This herb is said to enhance the body's own production of estrogen . Primrose oil is another product that has been reported by menopausal women to produce a relaxation effect and relieve hot flashes. However, studies have not shown primrose oil to be helpful in treating or managing the potential complications of menopause .
Practitioners often recommend that a woman seek complementary therapies from a professional who is experienced and credentialed. For example, a naturopath or traditional Chinese doctor can match the therapy to the woman's needs. The American Holistic Nurses Association (AHNA) has established a core curriculum and offers a course for certification in holistic nursing . Taking time to learn about complementary therapies is becoming essential to providing optimal care for patients. The permitted practice of complementary therapies varies according to each state's regulations and laws. At the very least, it is important for healthcare professionals to act as advocates and teachers for patients interested in learning more about complementary therapies.
Aromatherapy utilizes the healing properties of essential oils extracted from plants and herbs to induce a certain reaction or feeling . According to some practitioners, the chemical makeup of essential oils gives them a host of useful pharmacologic properties. Aromatherapy may act as an antibacterial, antiviral, or antispasmodic agent, as well as a diuretic, vasoconstrictor, or relaxation agent . Treatments may be administered through inhalation, from candles or steam, or external applications to the skin via baths, massage, or compress. Lavender candles have been noted to be effective as relaxation agents, and a drop of lavender on the pillow at night has been used clinically to induce sleep in patients with insomnia . Again, because aromatherapy products have not been researched by a regulatory agency, it is best to seek expert advice before using them.
Guided imagery is defined as access to the imagination through a mental guide . When a patient uses general healing imagery, she forms an image of an event, such as a healing light, forgiveness, or a specific treatment healing the body. Guided imagery is best known for its direct effect on physiology. Through imagery, an individual attempts to stimulate changes in body functions usually considered inaccessible to conscious influence. Imagery serves as a bridge for connecting body, mind, and spirit. Imagery is noninvasive and cost-effective, and it can be practiced by the patient either alone or with guidance. By definition, imagery involves information from all the senses—hearing, seeing, touching, tasting, and feeling. Visualization involves primarily the visual sense. Visualization may be utilized as part of the body-mind imagery information process. For example, pregnant women are often taught guided imagery and visualization techniques to use during labor contractions. Guiding the mother through a series of images during contractions is intended to soothe, distract, reduce sympathetic nervous stimulation, and enhance relaxation. The image and visualization is selected by the mother during her pregnancy. The process is intended to allow her to incorporate her personal image to create a dominant parasympathetic response. For example, some women choose climbing a mountain or the rise and fall of the ocean tide to visualize during labor contractions.
Interventions, such as relaxation techniques, imagery, and visualization, work for two main reasons. First, they provide novel stimuli, and the body-mind responds to this information. Second, they facilitate mind modulation of the autonomic, endocrine, immune, and nervous systems. Preliminary studies have demonstrated that imagery may be an effective part of treatment in a wide variety of conditions, from childbirth to cancer [185,186,187]. Stress-related conditions, such as headaches, back pain, spastic colon, and fatigue, often respond well to imagery techniques. In addition, the emotional aspects of illness can be eased through imagery, which may encourage both physical and emotional healing.
Meditation is a safe, simple, and cost-effective way to balance a person's physical, emotional, mental, and spiritual energy states. It is easy for patients to learn and has been used as a complementary therapy in treating everything from occupational stress to cancer and menopause. It has also been employed as part of an overall therapeutic treatment for hypertension and heart disease .
Although there are many approaches to meditation, most techniques can be grouped into two basic approaches: concentration and mindful meditation . The simplest form of concentration meditation is to sit quietly and focus the attention on breathing. The patient is often encouraged to complement this with exercises to relax each muscle group of the body and to free the mind of any unpleasant distractions. In mindful meditation, the patient sits quietly and witnesses whatever goes through the mind, not reacting or becoming involved with thoughts or worries. Meditation requires practice but is easy for the patient to master. Patients are encouraged to set time aside each day for the process of concentrating and focusing one's attention while maintaining a passive and unworried attitude. Relaxation makes it possible to retreat mentally from one's surroundings, stresses, and health concerns. Benefits of meditation and relaxation techniques include decreasing anxiety, easing muscle tension, and providing a period of rest as beneficial as a nap. Forms of mediation include deep breathing exercises, imagery, and yoga .
The meaning of the word "yoga" is union, or the integration of the physical, mental, and spiritual energies . Yoga is among the oldest known systems of health practiced in the world today. Research into yoga has had a strong impact on the fields of stress reduction, mind/body medicine, and cardiovascular disease. The physical posture, breathing exercises, and meditation practices of yoga have been proven to reduce stress, lower blood pressure, and regulate heart beat . Yoga is often best practiced when it is learned from an expert, as it is not as easily taught at the bedside as are other simple meditation techniques. Women who have access and the financial resources for yoga classes may benefit from the concentration, relaxation, and sense of well-being provided by this ancient physical movement form. While yoga is an overall philosophy as well as an exercise, patients do not need to embrace the philosophy to benefit from the activity. When practiced for relaxation, such as during menopause or cancer therapy, it involves breathing and stretching exercises. Because yoga practices and postures vary from the basic to advanced, starting with the gentle stretches and breathing techniques makes it ideally suited for patients undergoing the demands of chemotherapy or for women who have been sedentary and are attempting to begin an active relaxation and exercise program.
The interactions of movement, exercise, and relaxation are important in complementary therapies. Physical expressions of energy benefit patients by reducing depression, elevating mood, increasing energy levels, assisting in addiction programs for alcohol and smoking, and strengthening the immune system. Movement and exercise also have many physiological benefits for women, particularly in relation to decreasing the percentage of body fat, increasing bone density, and increasing both glucose sensitivity and glucose tolerance . Health professionals should encourage women to try new expressions of movement, such as yoga, dancing, and Tai Chi.
Healing or therapeutic touch is described as an energy field interaction between two or more people with the intent to rebalance or repattern the energy field in order to facilitate relaxation and self-healing . Healing touch is a collection of noninvasive, energy-based techniques intended to make energy available to the patient . It involves localized and systemic techniques to enhance relaxation and balance energy. Touch or healing therapy includes a broad range of hand techniques that a practitioner may use either on or near the body to support balance and function. The hand may be used to apply pressure and motion on the skin and on the underlying muscle of the patient for purposes of relaxation, improvement of circulation, relief of pain, and other therapeutic effects. Touch as a therapeutic intervention in the United States remained underdeveloped until research demonstrated its benefits in the 1950s . Following this, therapeutic massage became widely used during childbirth in the form of backrubs, abdominal massage over the uterus, and perineal massage at the time of delivery. Research studies have demonstrated that touch helps women cope with labor . Older people are likely to receive the least amount of touch, and less mobile elderly people particularly respond positively to touch.
The process of healing touch involves much more than skin contact. It involves many aspects of being present with the patient and nonverbal interaction and response. Nurses refer to the "hands on" practice of nursing as touch therapy, therapeutic touch, healing touch, and a variety of other terms. Despite the different labels, the intent is to demonstrate care to another through touch. The objectives of these techniques are also the same: to provide relaxation, relieve physical and emotional discomfort, and aid in healing. However, just as not all nurses choose to work with the technology in intensive care, not all will choose to learn therapeutic touch techniques. Courses that teach healing or therapeutic touch are available for healthcare professionals. Generally, nurses know after a few encounters with therapeutic touch technique if this approach works for them as health professionals.
Touch is an ancient practice, and most cultures have developed forms of touch therapy that utilize rubbing, massaging, and holding as manifestations of the desire to heal and care for one another . However, attitudes vary among cultures. One group may view touch as natural, while others view it as taboo. The healthcare provider must be aware of personal and cultural beliefs regarding touch.
There has been a growing interest in health and whole-person theology within the healthcare profession. It is crucial to emphasize that spirituality and religion are not synonymous. Spirituality may be defined as the unifying force of a person and a source of inner strength . It is expressed and experienced uniquely by each individual through and within connections to a Higher Power, Life Force, the environment, nature, other people, or the self. Religion refers to a belief system and practices of worship. Religion is defined as an individual's beliefs in relation to the supernatural and usually includes a structured community of believers . Religion per se is chosen. Spirituality is not subject to choice but is simply a manifestation of the person's wholeness.
Any approach to discussions of spirituality will depend upon the patient's background and beliefs. Spiritual care may be provided in many ways by healthcare professionals. Many healthcare providers may be uncomfortable with the concept, because they feel that spiritual care is intrusive and do not consider the wide variety of ways to provide spiritual comfort. Spiritual care also includes serving as a therapeutic presence and listening and talking to patients. Other traditional interventions include praying with patients, referring them to chaplains or clergy, and providing them with reading materials. While much is discussed in theory about the spiritual dimension, spiritual care, or spirituality, the practice of such care is infrequently carried out. Suggestions have been made that healthcare leaders and educators work toward increasing the comfort of providers in offering spiritual care by providing resources and education. The healthcare provider should learn to convey openness to the patient's expression of spirituality. Emphasis on spiritual care has declined within the healthcare professions in the pursuit of professionalism, and the trend has been to leave these aspects unattended altogether or strictly left to the clergy.
General guidelines for responding to the spiritual concerns of the patient can initiate from the basic premise that persons are spiritual beings. Healthcare practitioners should encourage patients to share concerns. Patients may need assistance in sharing very difficult aspects of their illness with others. Encouraging the patient to tell stories, show pictures, and connect with important milestones in their life is essential to spiritual expression. A health professional should have a willingness to be present with uncertainty, pain, or suffering, seeking not to "fix" but to be in the mystery with another. It is important for the healthcare provider to make statements to acknowledge the patient's spiritual states. It is also important to clarify with the patient if any specific resources or referrals are needed to help her deal with her concerns.
Women with breast cancer often focus beyond the immediate context of daily life and use spiritual transcendence to abstract meaning and peace of mind from stressful experiences. Spirituality is a source of strength and meaning for many of them. One premenopausal woman with breast cancer described her experiences: "I believe faith and prayer is what allowed me to accept what was happening…During my chemotherapy treatment I would feel ill. I would lie down for a short while because I felt like I was burning up inside. Then, I would go to church and cry and pray. I never asked God why or to heal my illness. I prayed to God to give me courage to accept what was happening to me."
Another woman with breast cancer described the feeling of calm presence that spirituality gave her. She reported: "When you go through a time like this, you're so much closer to the Lord than you are at any other time. I don't know if it is because of my condition or what, but I could just sit back and see God working in my family's lives and my life, too."
A young woman with cancer shared a personal story of the difference between religious beliefs and spirituality for her. She stated: "I am not a religious person. I mean, I don't go to church and I don't pray. During all of my chemotherapy sessions, I felt like I wasn't alone. I felt like there was somebody there…I know that while I was doing it, I wasn't by myself. I know that somebody or something was there whether I was praying and asking for help or not."
These examples illustrate the processes that these women used to consciously pause and pay attention to the spiritual dimension. Healthcare providers can help women by encouraging them to make intentional decisions to pause and take time out for reflection. Unfortunately, with the pace and multiple responsibilities of daily life, women are not always able to take time out for reflection. The provider can assist the patient to be quiet and mindful of what is going on in her health situation. The process of relaxation and imagery facilitates awareness and expression of the spiritual self. It is also important for the healthcare provider to explore situations that facilitate the experience of rest, leisure, and peace of mind. This approach will depend upon the belief system of the individual patient. Although it may be a useful adjunct for healing for many women, it will not apply to all.
Based on the philosophy that menopause is not an "illness" but a normal life event, there are many complementary therapies that women may find effective during this life transition. Scientific findings remain uncertain about the long-term consequences of untested complementary therapies. It also remains unclear how women weigh the risks and benefits of all the variables, including osteoporosis, coronary disease, breast and endometrial cancer, herbal remedies untested and unapproved by the FDA, cost of therapies or prescriptions, and monitoring adverse events. It is thought that healthcare providers are most interested in disease prevention and that women are most interested in relief of menopausal symptoms. Women's decision patterns regarding complementary therapies often fall into these major categories [69,70,73]:
Their decision to take therapies and change health practices is based on the severity of menopausal symptoms, such as hot flashes and insomnia.
They consider symptoms when making decisions about HRT, but they also consider new research findings that demonstrate increased risk of heart disease and breast cancer.
They are concerned about the regimen of HRT, because they do not want to be bothered with spotting or menses.
They consider health risks, particularly the risks of heart disease and breast cancer, to be paramount in their decisions regarding HRT and other complementary therapies.
Healthcare professionals should make an effort to help women maintain a positive attitude toward menopause, seek as much current information as possible regarding both traditional and complementary therapies, and maintain a program of follow-up care to monitor the progress or adverse outcomes of the therapies selected.
Patient T is a teacher, 52 years of age, who had Stage 1 breast cancer detected by a screening mammogram seven years ago. At that time, she underwent a lumpectomy and radiation therapy. She chose not to take tamoxifen because it was not recommended as being necessary by her surgeon and she is not a good pill-taker. She adheres to her suggested routine of follow-up care, including BSE, yearly mammogram, and CBE with the surgeon who performed her lumpectomy. She has been in good health since her breast cancer treatment and has had no further incidence of cancer.
Patient T presented to the women's health clinic because she was experiencing hot flashes during the night, which was contributing to sleep deprivation. She was so fatigued that she felt it was interfering with her ability to perform her demanding job. In discussing treatment options, Patient T was well informed of her contraindication for HRT due to her history of breast cancer. Furthermore, she reported that even if she had not had breast cancer, she probably would not adhere to HRT because she did not really believe in taking pills and she was very cautious regarding the risk of cancer. The nurse discussed various complementary therapies, including black cohosh tea, relaxation therapies during the nighttime hot flashes, and the options for her to redirect some work responsibilities. Patient T did find that the tea and relaxation exercises were helpful, and she was able to temporarily reassign some teaching assignments to a student teacher. At her one-month follow-up appointment, Patient T reported that her episodes of hot flashes were becoming less frequent and her sleep patterns had improved. Due to the contraindication for HRT, the issue of osteoporosis was discussed and Patient T had a baseline bone densitometry test. She was given a consultation with a dietician to emphasize dietary and supplemental calcium, vitamin D therapy, and a heart-healthy diet pattern. Patient T also made the choice to maintain a more consistent aerobic exercise program by walking during her lunch hour in the school gym with the purpose of decreasing risk factors for both osteoporosis and heart disease.
Health behaviors involve complex variables and decisions. These decisions are best made within a partnership of equity and support from health professionals. The following is a model plan for the woman making health-related decisions or lifestyle changes, regardless of the specific health issue of concern to her and her family. The health professional should focus on a multidisciplinary model to ensure that the woman and her family have referrals to dieticians, counselors, specialists, and community health resources, as needed.
A diagnosis related to health risk/health-promoting behavior often occurs in women with risk factors and/or symptoms of heart disease, weight gain, osteoporosis, or cancer. Specific health needs for these women include :
Strengths of the woman and her family
Need for culturally sensitive education and expression of questions
Sexuality and relationship concerns
Spirituality and psychological needs
Community resources and collaborative care
Time and space to adjust to the lifestyle change
Healthcare professionals may intervene in the following ways to ensure that women's health needs are addressed :
Encourage networking with other women with a similar situation.
Encourage women to ask for help and to allow themselves to experience others' expressions of support and caring.
Focus on current strengths in making decisions and lifestyle changes.
Explore which skills and strengths work for the woman and her family.
Give the information needed or requested. Offer brochures and Internet resources.
Encourage sharing of thoughts and feelings on barriers to the lifestyle change.
Explore and clarify misconceptions or unrealistic fears.
Educate the patient on any medication regime prescribed for her treatment, including medication, dosage, side effects, and desired benefit. Review any over-the-counter medications or herbal therapies being used.
Educate the patient regarding risk factors, screening guidelines, and recommended diagnostic or laboratory tests and follow-up plans.
Encourage the patient to seek support from her spouse/partner as well as others.
A spouse or partner may not be able to fulfill all of the woman's connection needs. Suggest outlets to connect with herself, such as journaling, poetry, and meditation.
Discuss the need to fight to keep a positive outlook. Explain that relapse is expected.
Encourage the woman to do what is important to her. Promote self-nurturing activities and positive self-talk.
Suggest journaling, music, imagery, and/or yoga for relaxation and to enhance maintenance of health-promoting behaviors.
Encourage release of energy through humor and playful activities.
If a woman has a religious background, encourage personal expressions and prayer.
Discuss behavior changes and treatment options in relation to expense, financial circumstances, and insurance reimbursement.
Discuss alternative behaviors or treatments when the woman has financial burdens.
Offer the resource of a support group, counselor, or specialist, as needed.
Offer community resources and validation of experiences with others in the community.
As health professionals practicing in collaboration with other healthcare and community professionals, it is vital to be knowledgeable regarding proper health screening for women. In educating women and conducting health screenings, health professionals play a key role in the prevention of illness and the optimization of good health. Health professionals and patient advocates have an obligation to help patients truly understand and integrate the need for routine screening as a preventive strategy. Within these general guidelines, and practicing in collaboration with other professionals, it is important to take into account each woman's history and risk factors. Table 10 summarizes health screening guidelines, laboratory and diagnostic tests, and immunization recommendations to be used for patient education, referral, and clinical practice.
HEALTH SCREENING FOR WOMEN ACROSS THE LIFESPAN
|Screening Tests||Age 18 to 39 Years||Age 40 to 49 Years||Age 50 to 64 Years||Age 65 Years and Older|
|General health: Full check-up, including height, weight, and BMI||Dependent on risk factors||Yearly||Yearly||Yearly|
|Blood pressure measurement||At least every 2 years, if normal; yearly if elevated; discuss treatment if 140/90 or higher||At least every 2 years, if normal; yearly if elevated; discuss treatment if 140/90 or higher||At least every 2 years, if normal; yearly if elevated; discuss treatment if 140/90 or higher||At least every 2 years, if normal; yearly if elevated; discuss treatment if 140/90 or higher|
|Cholesterol screening||Begin testing at 20 years of age if at high risk for heart disease; discuss need with physician and/or nurse.||Dependent on risk factors; discuss need with physician and/or nurse.||Dependent on risk factors; discuss need with physician and/or nurse.||Dependent on risk factors; discuss need with physician and/or nurse.|
|Bone mineral density test||—||—||Dependent on risk factors||At least once at 65 years of age or older|
|Diabetes (blood glucose test)||If blood pressure is higher than 135/80 or if taking antihypertensives||If blood pressure is higher than 135/80 or if taking antihypertensives||If blood pressure is higher than 135/80 or if taking antihypertensives||If blood pressure is higher than 135/80 or if taking antihypertensives|
|Mammogram||Discuss with healthcare provider||Discuss with healthcare provider||Every 2 years||Every 2 years through age 74|
|Pap and pelvic exam||Every 3 years beginning at 21 years of age||Every 3 years with normal cytology||Every 3 years with normal cytology||Discuss with healthcare provider|
|Chlamydia test||If sexually active or pregnant, yearly until 24 years of age. Continue to perform exam if at high risk.||If at high risk of contracting an STI, this test may be needed.||If at high risk of contracting an STI, this test may be needed.||If at high risk of contracting an STI, this test may be needed.|
|Sexually transmitted infections (STIs) tests||Both partners should be tested for STIs, including HIV, before initiating sexual intercourse.||Both partners should be tested for STIs, including HIV, before initiating sexual intercourse.||Both partners should be tested for STIs, including HIV, before initiating sexual intercourse.||Both partners should be tested for STIs, including HIV, before initiating sexual intercourse.|
|Colorectal cancer screening (using fecal occult blood testing, sigmoidoscopy, colonoscopy)||Only if symptomatic||Only if symptomatic||Annually||Annually through 75 years of age|
|Double contrast barium enema (DCBE)||Only if significant risk factors or rectal bleeding||Only if significant risk factors or rectal bleeding||Every 5 to 10 years, only if not having colonoscopy or sigmoidoscopy||Every 5 to 10 years, only if not having colonoscopy or sigmoidoscopy|
|Rectal exam||Only if significant risk factors or rectal bleeding||Only if significant risk factors or rectal bleeding||Every 5 to 10 years||Every 5 to 10 years|
|Vision exam||Every 2 years||Every 2 years||Every 2 years||Every 2 years|
|Hearing test||Every 10 years||Every 10 years||Every 3 years||Every 3 years|
|Dental exam||1 to 2 times a year, based on risk factors||1 to 2 times a year, based on risk factors||1 to 2 times a year, based on risk factors||1 to 2 times a year, based on risk factors|
|Mental health screening||Abuse and depression screen with office visits, based on risk factors and symptoms.||Abuse and depression screen with office visits, based on risk factors and symptoms.||Abuse and depression screen with office visits, based on risk factors and symptoms.||Abuse and depression screen with office visits, based on risk factors and symptoms.|
Immunizations are not only recommended for children. Each year, vaccine-preventable diseases have a costly impact, resulting in doctor's visits, hospitalizations, and premature deaths . It is the health professional's responsibility to ensure the well-being of patients by adhering to immunization recommendations. Table 11 lists the 2015 CDC recommendations for adult immunizations .
SUMMARY OF ADOLESCENT/ADULT IMMUNIZATION RECOMMENDATIONS
|Hepatitis B vaccine||
|Anaphylactic allergy to yeast|
|Varicella vaccine||Persons of any age without reliable history of varicella vaccine or disease||
|Hepatitis A vaccine||
|Two doses: Second dose at either 6 to 12 months or 6 to 18 months after first||A history of sensitivity to alum or the preservative 2-phenoxyethanol|
|Tetanus, diphtheria, and acellular pertussis vaccine (Td/Tdap)||Persons of any age without a certain history of Td/Tdap vaccination||
|Influenza vaccine||All persons 6 months of age and older||
|Pneumococcal polysaccharide vaccine (PPSV)||
|Safety during first trimester of pregnancy has not been evaluated.|
|Measles, mumps, and rubella vaccine (MMR)||
|One or two doses. If a second dose is necessary, administer at least 1 month after first.||
|Human papillomavirus vaccine||All women 13 to 26 years of age who have not completed the vaccine series at 9 to 12 years of age||
|Herpes zoster vaccine||All adults 60 years or age and older, regardless of whether they have experienced a prior episode of herpes zoster||One dose||
Healthcare professionals should provide comprehensive, holistic care that includes every dimension of a woman's life—emotional, esthetic, physical, spiritual, and experiential—as well as her family and community. Adhering to this philosophy of care allows healthcare professionals to provide women with the means to grow and change. Whether confronting breast cancer, menopause, or everyday decisions about diet and exercise, women should receive support, economical treatment options, and information about community resources from their healthcare providers.
Health professionals should take leadership roles in promoting primary care, primary prevention, and healthy lifestyles for women across the lifespan. Women today lead diverse lives, and the challenges for the women's health professional are many. Increased funding for women's health research and new studies on women's health issues will assist in providing direction to health professionals. Disparity in health outcomes between various racial groups is cause for healthcare education and practice to work toward a community-based response to the health of the public. It is critical that health professionals collaborate with other disciplines and community agencies to improve health outcomes for women and their families. Although there are no "quick-fix" solutions, healthcare providers can make a difference by continuing to progress toward improving women's health.
Health promotion is an interdisciplinary activity involving the nurse, physician, psychologist, nutritionist, therapist, and social worker, with a focus on the woman's own perspective. Health professionals should act in partnership with women to promote well-being and healing. Health includes health education, marketing the health message, lifestyle modification, engaging in social and environmental change, and encompassing the patient's cultural values. In partnership with women, health professionals can support physical and mental health promotion strategies to improve health outcomes for the women, their families, and the community. The major U.S. public health epidemics, including heart disease, obesity, diabetes, substance abuse, and domestic violence, are all amendable to change via health promotion strategies. Nurses and other health professionals are in a position to engage with the patient in motivating and regulating their health-promoting behaviors.
It is an exciting time for women's health. Women are living longer, and research results and practice strategies hold promise for the prevention and early treatment of health issues. More importantly, women are becoming increasingly informed about health issues.
The key points for health issues distinctive to women across the lifespan are:
Health is defined in a relational nature between the woman and her environment.
Health professionals should obtain specific health history data and perform assessment parameters to care for the woman based on her unique health needs, medical history, and risk factors.
Health issues and risk factors are embedded in cultural beliefs. Health barriers for minority women in the United States have resulted in disparities in quality of care and outcomes.
Health professionals should conduct physical examinations to identify normal and alterations in normal for women in relation to their stage of the life cycle.
Interventions for treatment involve collaboration with multidisciplinary professionals to implement recommended traditional and complementary therapies.
Evidence-based health screening guidelines and immunization recommendations should be implemented in the care of women throughout their lifespan.
Women's health has evolved into a specialty that focuses on gender-specific care, shared responsibility, and informed treatment options. The situations highlighted in this course review a few of the major health issues of the contemporary woman. Health professionals are encouraged to utilize further continuing education and other resources to continue their investigation of women's health issues.
1. World Health Organization. Milestones in Health Promotion: Statements from Global Conferences. Available at http://www.who.int/healthpromotion/Milestones_Health_Promotion_05022010.pdf. Last accessed June 3, 2015.
2. Young LE. Transforming health promotion practice: moving toward holistic care. In: Young LE, Hayes V (eds). Transforming Health Promotion Practice: Concepts, Issues and Applications. Philadelphia, PA: F.A. Davis Company; 2002.
3. West LA, Cole S, Goodkind D, He W. 65+ in the United States: 2010. Available at https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23-212.pdf. Last accessed June 3, 2015.
4. U.S. Census Bureau. Older Americans Month: May 2015. Available at http://www.census.gov/newsroom/facts-for-features/2015/cb15-ff09.html. Last accessed June 3, 2015.
5. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. Available at https://www.census.gov/prod/2014pubs/p25-1140.pdf. Last accessed June 3, 2015.
6. National Cancer Institute. Fact Sheet: Breast Cancer Risk in American Women. Available at http://www.cancer.gov/types/breast/risk-fact-sheet. Last accessed June 3, 2015.
7. American Cancer Society. Breast Cancer Facts and Figures 2013–2014. Available at http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042725.pdf. Last accessed June 5, 2015.
8. National Institutes of Health Office of Research on Women's Health. Moving into the Future with New Dimensions and Strategies for Women's Health Research: A Vision for 2020 for Women's Health Research. Available at http://orwh.od.nih.gov/research/strategicplan/ORWH_StrategicPlan2020_Vol1.pdf. Last accessed June 5, 2015.
9. U.S. Department of Health and Human Services. Healthy People 2020. Available at http://www.healthypeople.gov/2020/topicsobjectives2020/default. Last accessed June 5, 2015.
10. MacDonald MA. Health promotion: historical, philosophical, and theoretical perspectives. In: Young LE, Hayes VE (eds). Transforming Health Promotion Practice: Concepts Issues and Applications. Philadelphia, PA: F.A. Davis Company; 2002: 22-45.
11. U.S. Department of Health and Human Services. Pap Test Fact Sheet. Available at http://www.womenshealth.gov/publications/our-publications/fact-sheet/pap-test.html. Last accessed June 23, 2015.
12. Centers for Disease Control and Prevention. Making Sense of Your Pap and HPV Test Results. Available at http://www.cdc.gov/std/hpv/pap. Last accessed June 23, 2015.
13. Centers for Disease Control and Prevention. Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States. Available at http://www.cdc.gov/std/stats/sti-estimates-fact-sheet-feb-2013.pdf. Last accessed June 23, 2015.
14. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR03):1-137.
15. Centers for Disease Control and Prevention. Sexually Transmitted Diseases (STDs). Available at http://www.cdc.gov/std. Last accessed June 24, 2015.
16. Youngkin EQ, Davis MS, Schadewald D, Juve C. Women's Health: A Primary Care Clinical Guide. 4th ed. Upper Saddle River, NJ: Prentice Hall; 2012.
18. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Sexually Transmitted Disease Surveillance, 2013. Available at http://www.cdc.gov/std/stats13/surv2013-print.pdf. Last accessed July 1, 2015.
19. LexiComp Online. Available at http://online.lexi.com. Last accessed July 15, 2015.
20. Centers for Disease Control and Prevention. Fact Sheet: Syphilis. Available at http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm. Last accessed July 1, 2015.
21. Centers for Disease Control and Prevention. Fact Sheet: Genital Herpes. Available at http://www.cdc.gov/std/Herpes/STDFact-Herpes.htm. Last accessed July 1, 2015.
22. Chan PD. Gynecology and Obstetrics, 2011 Edition. Laguna Hills, CA: Current Clinical Strategies; 2011.
23. Corey L, Wald A, Patel R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med. 2004;350(1):11-20.
24. Berman NR. Human papillomavirus and cervical cancer screening: recent advances improve the clinical picture. Adv Nurse Pract. 2002;10(10):26-35.
26. Cottrell BH. An updated review of the evidence to discourage douching. MCN Am J Matern Child Nurs. 2010;35(2):102-107.
27. Taber's Online. Available at http://www.tabers.com/tabersonline/ub. Last accessed July 1, 2015.
28. Centers for Disease Control and Prevention. Fact Sheet: Bacterial Vaginosis. Available at http://www.cdc.gov/std/BV/STDFact-Bacterial-Vaginosis.htm. Last accessed July 1, 2015.
30. Mashburn J. Etiology, diagnosis, and management of vaginitis. J Midwifery Womens Health. 2006;51(6):423-430.
31. MedlinePlus. Pap Smear. Available at http://www.nlm.nih.gov/medlineplus/ency/article/003911.htm. Last accessed July 1, 2015.
32. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol. 2012;137(4):516-542.
33. American Cancer Society. How Many Women get Cancer of the Cervix? Available at http://www.cancer.org/Cancer/CervicalCancer/OverviewGuide/cervical-cancer-overview-key-statistics. Last accessed July 2, 2015.
34. American Cancer Society. How is Cervical Cancer Staged? Available at http://www.cancer.org/Cancer/CervicalCancer/DetailedGuide/cervical-cancer-staged. Last accessed July 2, 2015.
35. National Cancer Institute. A Snapshot of Cervical Cancer. Available at http://www.cancer.gov/research/progress/snapshots/cervical. Last accessed July 31, 2015.
36. Wong QC, Collins R, Kalkstein K, Roth A, Gintautas J. Cervical cancer screening among elderly urban women in a primary care setting. Proc West Pharmacol Soc. 2005;48:154-156.
37. Spence AR, Goggin P, Franco EL. Process of care failures in invasive cervical cancer: systematic review and meta-analysis. Prev Med. 2007;45(2-3):93-106.
38. Freeman H, Wingrove B. Excess Cervical Cancer Mortality: A Marker for Low Access to Health Care in Poor Communities. Rockville, MD: National Cancer Institute; 2005.
39. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Available at http://www.cdc.gov/cancer/nbccedp. Last accessed July 2, 2015.
40. Mayo Clinic. Cervical Cancer. Available at http://www.mayoclinic.org/diseases-conditions/cervical-cancer/basics/definition/con-20030522. Last accessed July 6, 2015.
42. U.S. Food and Drug Administration. Medical Devices: Cervista HPV 16/18 P080015. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm134061.htm. Last accessed July 6, 2015.
43. American Society for Colposcopy and Cervical Pathology. Consensus Guidelines: HPV Genotyping Clinical Update. Available at http://www.asccp.org/ConsensusGuidelines/HPVGenotypingClinicalUpdate/tabid/5963/Default.aspx. Last accessed July 8, 2015.
44. U.S. Food and Drug Administration. FDA Approved First DNA Test for Two Types of Human Papillomavirus. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm149544.htm. Last accessed July 7, 2015.
45. U.S. Preventive Services Task Force. Final Recommendation Statement, Cervical Cancer: Screening. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm. Last accessed July 7, 2015.
46. U.S. Food and Drug Administration. Vaccines, Blood and Biologics: Gardasil. Available at http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM094042. Last accessed July 8, 2015.
47. Centers for Disease Control and Prevention. HPV Vaccine Gardasil: What You Need to Know. Available at http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv-gardasil.pdf. Last accessed July 8, 2015.
48. Centers for Disease Control and Prevention. Human Papillomavirus (HPV) Vaccine Safety (Detailed Information). Available at http://www.cdc.gov/vaccinesafety/Vaccines/HPV/hpv_detailed.html. Last accessed July 8, 2015.
49. U.S. Food and Drug Administration. Vaccines, Blood and Biologics: Cervarix. Available at http://www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm186957.htm. Last accessed July 8, 2015.
50. Apgar BS, Zoschnick L, Wright TC Jr. The 2001 Bethesda System terminology. Am Fam Physician. 2003;68(10):1992-1999.
51. Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287(16):2114-2119.
52. American Cancer Society. What Are the Risk Factors for Cervical Cancer? Available at http://www.cancer.org/Cancer/CervicalCancer/DetailedGuide/cervical-cancer-risk-factors. Last accessed July 8, 2015.
53. American Cancer Society. How is Cancer of the Cervix Treated? Available at http://www.cancer.org/Cancer/CervicalCancer/OverviewGuide/cervical-cancer-overview-treating-general-info. Last accessed July 8, 2015.
54. National Cancer Institute. Cervical Cancer Treatment (PDQ). Available at http://www.cancer.gov/types/cervical/patient/cervical-treatment-pdq#section/all. Last accessed July 8, 2015.
55. Carlson KJ, Eisenstat SA, Frigoletto FJ Jr, Schiff I (eds). Primary Care of Women. 2nd ed. St. Louis, MO: Mosby; 2002.
56. Wright TC Jr, Massad LS, Dunton CJ, et al. 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol. 2007;197(4):340-345.
57. Allen KM, Phillips JM. Women's Health Across the Lifespan: A Comprehensive Perspective. Philadelphia, PA: Lippincott Williams & Wilkins; 1997.
58. American Cancer Society. Endometrial (Uterine) Cancer. Available at http://www.cancer.org/acs/groups/cid/documents/webcontent/003097-pdf.pdf. Last accessed July 8, 2015.
59. Banno K, Susumu N, Yanokura M, et al. Association of HNPCC and endometrial cancers. Int J Clin Oncol. 2004;9(4):262-269.
60. American Cancer Society. Ovarian Cancer. Available at http://www.cancer.org/docroot/CRI/CRI_2x.asp?sitearea=&dt=33. Last accessed July 8, 2015.
61. American Cancer Society. Chemotherapy for Ovarian Cancer. Available at http://www.cancer.org/Cancer/OvarianCancer/DetailedGuide/ovarian-cancer-treating-chemotherapy. Last accessed July 8, 2015.
62. Ekwall E, Ternestedt BM, Sorbe B. Important aspects of health care for women with gynecological cancer. Oncol Nurs Forum. 2003;30(2):313-319.
63. Anderson SE, Must A. Interpreting the continued decline in the average age at menarche: results from two nationally representative surveys of U.S. girls studied 10 years apart. J Pediatr. 2005;147(6):753-760.
64. Pritham UA. Managing PMS and PMDD. Exploring new treatment options. Nurs Womens Health. 2002;6(5):430-437.
65. Davis AR, Westhoff CL. Primary dysmenorrhea in adolescent girls and treatment with oral contraceptives. J Pediatr Adolesc Gynecol. 2001;14(1):3-8.
66. Mayo Clinic. Premenstrual Syndrome (PMS). Available at http://www.mayoclinic.com/health/premenstrual-syndrome/DS00134. Last accessed July 8, 2015.
67. Mayo Clinic. Menopause. Available at http://www.mayoclinic.com/health/menopause/DS00119. Last accessed July 8, 2015.
68. George SA. The menopause experience: a woman's perspective. J Obstet Gynecol Neonatal Nurs. 2006;31(1):77-85.
69. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33.
70. Women's Health Initiative. Available at http://www.nhlbi.nih.gov/whi. Last accessed July 6, 2015.
71. National Institutes of Health. NIH Asks Participants in Women's Health Initiative Estrogen-Alone Study to Stop Study Pills, Begin Follow-Up Phase. Available at http://www.nhlbi.nih.gov/news/press-releases/2004/nih-asks-participants-in-womens-health-initiative-estrogen-alone-study-to-stop-study-pills-begin-follow-up-phase. Last accessed July 8, 2015.
72. Shumaker SA, Legault C, Kuller L, et al. Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative memory study. JAMA. 2004;291(24):2947-2958.
73. Bruckner MC, Youngkin EQ. What's a woman to do? Exploring HRT questions raised by the women's health initiative. Nurs Womens Health. 2002;6(5):408-417.
74. National Breast Cancer Foundation. Breast Self-Exam (BSE). Available at http://www.nationalbreastcancer.org/About-Breast-Cancer/Breast-Self-Exam.aspx. Last accessed July 8, 2015.
75. American Speech-Language-Hearing Association. Who Should be Screened for Hearing Loss? Available at http://www.asha.org/public/hearing/Who-Should-be-Screened/. Last accessed July 15, 2015.
76. Moyer VA, U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(4):271-281.
77. National Cancer Institute. Breast Cancer Prevention (PDQ): Overview. Available at http://www.cancer.gov/cancertopics/pdq/prevention/breast/HealthProfessional/page1. Last accessed July 9, 2015.
78. American Cancer Society. How is Breast Cancer Found? Available at http://www.cancer.org/Cancer/BreastCancer/OverviewGuide/breast-cancer-overview-diagnosed. Last accessed July 9, 2015.
79. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89.
80. National Cancer Institute. Breast Cancer Screening (PDQ). Available at http://www.cancer.gov/types/breast/hp/breast-screening-pdq#section/all. Last accessed July 9, 2015.
81. Qaseem A, Snow V, Sherif K, Aronson M, Weiss KB, Owens DK. Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians. Ann Int Med. 2007;146(7):511-515.
82. Ekwaru JP, Zwicker JD, Holick MF, Giovannucci E, Veugelers PJ. The importance of body weight for the dose response relationship of oral vitamin D supplementation and serum 25-hydroxyvitamin D in healthy volunteers. PLoS One. 2014;9(11):e111265.
83. Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: update 2003.CA Cancer J Clin. 2003;53(3):141-169.
84. American College of Obstetricians and Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol. 2011;118(2 Pt 1):372-382.
85. U.S. Preventive Services Task Force. Breast Cancer: Screening. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=breast%20cancer. Last accessed January 21, 2016.
86. American Cancer Society. Press Release: American Cancer Society Responds to Changes to USPSTF Mammography Guidelines. Available at http://pressroom.cancer.org/index.php?s=43&item=201. Last accessed July 9, 2015.
87. Breastcancer.org. Treatment and Side Effects. Available at http://www.breastcancer.org/treatment. Last accessed July 9, 2015.
88. Terushkin V, Bender A, Psaty EL, Engelsen O, Wang SQ, Halpern AC. Estimated equivalency of vitamin D production from natural sun exposure versus oral vitamin D supplementation across seasons at two US latitudes. J Am Acad Dermatol. 2010;62(6):929.e1-e9.
89. American Cancer Society. How is Breast Cancer Treated? Available at http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-overview-treating-general-infor. Last accessed July 9, 2015.
90. National Cancer Institute. Breast Cancer Treatment (PDQ). Available at http://www.cancer.gov/types/breast/hp/breast-treatment-pdq#section/all. Last accessed July 9, 2015.
91. Gonzalez-Angulo AM, Buzdar AU, Hortobagyi GN. Primary systemic therapy for operable breast cancer: present role and perspectives. In: Bonodonna G, Hortobagyi GN, Valagussa P (eds). Textbook of Breast Cancer: A Clinical Guide to Therapy. 3rd ed. London: Taylor and Francis Group; 2006.
92. Perez EA. Conventional adjuvant chemotherapy: where are we 30 years later? In: Bonodonna G, Hortobagyi GN, Valagussa P (eds). Textbook of Breast Cancer: A Clinical Guide to Therapy. 3rd ed. London: Taylor and Francis Group; 2006.
93. Breastcancer.org. What is Hormonal Therapy? Available at http://www.breastcancer.org/treatment/hormonal/what_is. Last accessed July 9, 2015.
94. Visvanathan K, Chlebowski RT, Hurley P, et al. American Society of Clinical Oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction.J Clin Oncol. 2009;27(19):3235-3258.
95. Singer CF, Kostler WJ, Hudelist G. Predicting the efficacy of trastuzumab-based therapy in breast cancer: current standards and future strategies. Biochim Biophys Acta. 2008;1786(2):105-113.
96. National Collaborating Centre for Cancer. Early and Locally Advanced Breast Cancer: Diagnosis and Treatment. London: National Institute for Health and Clinical Excellence; 2009.
97. National Cancer Institute. Trastuzumab. Available at http://www.cancer.gov/about-cancer/treatment/drugs/trastuzumab. Last accessed July 9, 2015.
98. Gonzalez-Angulo AM, Hortobagyi GN, Esteva FJ. Adjuvant therapy with trastuzumab for HER-2/neu-positive breast cancer. Oncologist. 2006;11(8):857-867.
99. Breastcancer.org. Triple-Negative Breast Cancer. Available at http://www.breastcancer.org/symptoms/diagnosis/trip_neg. Last accessed July 9, 2015.
100. Petrelli F, Coinu A, Borgonovo K, et al. The value of platinum agents as neoadjuvant chemotherapy in triple-negative breast cancers: a systematic review and meta-analysis. Breast Cancer Res Treat. 2014;144(2):223-232.
101. American Diabetes Association. Diabetes Complications. Available at http://www.diabetes.org/living-with-diabetes/complications. Last accessed July 13, 2015.
102. National Cancer Institute. Hormone Therapy for Breast Cancer. Available at http://www.cancer.gov/types/breast/breast-hormone-therapy-fact-sheet. Last accessed July 9, 2015.
103. American Cancer Society. Breast Reconstruction after Mastectomy. Available at http://www.cancer.org/cancer/breastcancer/moreinformation/breastreconstructionaftermastectomy/index. Last accessed July 10, 2015.
104. National Cancer Institute. Surgery to Reduce the Risk of Breast Cancer. Available at http://www.cancer.gov/types/breast/risk-reducing-surgery-fact-sheet. Last accessed July 10, 2015.
105. Wagner LH, Ruth-Sahd LA. Pregnancy after a TRAM flap procedure: principles of nursing care. J Obstet Gynecol Neonatal Nurs. 2000;29(4):363-368.
106. Mayo Clinic. Breast Reconstruction with Flap Surgery: Results. Available at http://www.mayoclinic.org/tests-procedures/breast-reconstruction/basics/results/prc-20020499. Last accessed July 10, 2015.
107. Breastcancer.org. TRAM Flap Reconstruction: What to Expect. Available at http://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/tram/what-to-expect. Last accessed June 10, 2015.
108. Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;365(9472):1687-1717.
109. National Cancer Institute. Adjuvant and Neoadjuvant Therapy for Breast Cancer. Available at http://www.cancer.gov/cancertopics/factsheet/Therapy/adjuvant-breast#r1. Last accessed July 10, 2015.
110. Forbes JF, Cuzick J, Buzdar A, Howell A, Tobias JS, Baum M. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100-month analysis of the ATAC trial. Lancet Oncol. 2008;9(1):45-53.
111. Joy AA. San Antonio Breast Cancer Symposium 2007—adjuvant endocrine therapy update: ATAC 100 highlights. Curr Oncol. 2008;15(1):68-69.
112. Roux G, Dingley CE, Bush HB. Inner strength in women: metasynthesis of qualitative findings in theory development. J Theory Construction Testing. 2002;6(1):86-93.
113. Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61(4):1-117.
114. Maxson J. Remedying dyslipidemia NCEP-ATP III strategies to slow CVD. Clin Rev. 2002;12(10):53-60.
115. Womenshealth.gov. Heart Disease Fact Sheet. Available at http://womenshealth.gov/publications/our-publications/fact-sheet/heart-disease.cfm. Last accessed July 10, 2015.
116. American Heart Association. Facts: Cardiovascular Disease: Women's No. 1 Health Threat. Available at http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_302256.pdf. Last accessed July 10, 2015.
117. Penque S, Halm M, Smith M, et al. Women and coronary disease: relationship between descriptors of signs and symptoms and diagnostic and treatment course. Am J Crit Care. 1998;7(3):175-182.
118. Clouse AL, Sherif K. Women's Health in Clinical Practice: A Handbook for Primary Care. Totowa, NJ: Humana Press; 2008.
119. Bairey Merz CN, Shaw LJ, Reis SE, et al. Insights From the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) Study. Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol. 2006;47(3 suppl):S21-S29.
120. Pepine CJ, Kerensky RA, Lambert CR, et al. Some thoughts on the vasculopathy of women with ischemic heart disease. J Am Coll Cardiol. 2006;47(3 suppl):S30-S35.
121. The Cleveland Clinic. Diabetes Basics. Available at http://my.clevelandclinic.org/health/diseases_conditions/hic_Diabetes_Basics. Last accessed July 13, 2015
122. Fryar CD, Carroll MD, Ogden CL. Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, Trends 1960–1962 through 2011–2012. Available at http://www.cdc.gov/nchs/data/hestat/obesity_adult_11_12/obesity_adult_11_12.pdf. Last accessed July 10, 2015.
123. Womenshealth.gov. Physical Activity (Exercise) Fact Sheet. Available at http://www.womenshealth.gov/publications/our-publications/fact-sheet/physical-activity.cfm. Last accessed July 10, 2015.
125. Tipton KD, Wolfe RR. Exercise, protein metabolism, and muscle growth. Int J Sport Nutr Exerc Metab. 2001;11(1):109-132.
126. Souhami RL, Moxham J. Textbook of Medicine. 4th ed. Philadelphia, PA: Elsevier Health Sciences; 2002.
127. Oliver JE. Fat Politics: The Real Story Behind America's Obesity Epidemic. New York, NY: Oxford University Press; 2006.
128. Mehta T, Smith DL Jr, Muhammad J, Casazza K. Impact of weight cycling on risk of morbidity and mortality. Obes Rev. 2014;15(11):870-881.
129. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Available at http://www.health.gov/paguidelines/pdf/paguide.pdf. Last accessed July 10, 2015.
130. Thompson PD, Buchner D, Piña IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109-3116.
131. U.S. Department of Agriculture. ChooseMyPlate. Available at http://www.choosemyplate.gov. Last accessed July 10, 2015.
132. National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Calcium. Available at https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional. Last accessed July 10, 2015.
133. Dudek SG. Nutrition Handbook for Nursing Practice. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
134. Womenshealth.gov. Anemia Fact Sheet. Available at http://www.womenshealth.gov/publications/our-publications/fact-sheet/anemia.html?from=AtoZ. Last accessed July 10, 2015.
135. International Food Information Council Foundation. The Truth about Fats and Oils and Health. Available at http://www.foodinsight.org/The_Truth_about_Fats_and_Oils_and_Health. Last accessed July 10, 2015.
136. American Heart Association. Diet and Lifestyle Recommendations. Available at http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp#.T3sZxRGrmSo. Last accessed July 10, 2015.
137. Erickson JD. Folic acid and prevention of spinal bifida and anencephaly: 10 years after the U.S. Public Health Service recommendation. MMWR. 2002;51(RR13):1-3.
138. U.S. Department of Health and Human Services, U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. Available at http://www.health.gov/dietaryguidelines/dga2005/document/pdf/DGA2005.pdf. Last accessed July 10, 2015.
139. Centers for Disease Control and Prevention. Diabetes Data and Statistics. Available at http://www.cdc.gov/diabetes/data. Last accessed July 10, 2015.
140. Office of the Surgeon General. Report of the Surgeon General's Workshop on Osteoporosis and Bone Health: December 12–13, 2002. Washington, DC. Rockville, MD: Office of the Surgeon General; 2003.
141. Womenshealth.gov. Osteoporosis Fact Sheet. Available at http://womenshealth.gov/publications/our-publications/fact-sheet/osteoporosis.html?from=AtoZ. Last accessed July 13, 2015.
142. MedlinePlus. Menopause. Available at http://www.nlm.nih.gov/medlineplus/menopause.html. Last accessed July 13, 2015.
143. National Osteoporosis Foundation. Learn About Osteoporosis. Available at http://nof.org/learn. Last accessed July 13, 2015.
144. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteoporosis. Available at http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/default.asp. Last accessed July 13, 2015.
145. National Institutes of Health. Calcium and Vitamin D: Important at Every Age. Available at http://www.niams.nih.gov/Health_Info/Bone/Bone_Health/Nutrition/default.asp. Last accessed July 13, 2015.
146. World Health Organization. Mental Health: A State of Well Being. Available at http://www.who.int/features/factfiles/mental_health/en. Last accessed July 14, 2015.
147. U.S. Preventive Services Task Force. Screening for Depression in Adults. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening. Last accessed July 14, 2015.
148. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
149. National Institute of Mental Health. Depression. Available at https://www.nimh.nih.gov/health/topics/depression/index.shtml. Last accessed July 14, 2015.
150. Zung WW. The role of rating scales in the identification and management of the depressed patient in the primary care setting.J Clin Psychiatry. 1990;(51 suppl):72-76.
151. National Center for Injury Prevention and Control. WISQARS Leading Causes of Death Reports, National and Regional, 1999–2013. Available at http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html. Last accessed July 14, 2015.
152. National Institute of Mental Health. Suicide in the U.S.: Statistics and Prevention. Available at http://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml. Last accessed July 14, 2015.
153. National Institute of Mental Health. Anxiety Disorders. Available at http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml. Last accessed July 14, 2015.
154. Uphold CR, Graham MV. Clinical Guidelines in Family Practice. 4th ed. Gainesville, FL: Barmarrae Books; 2003.
155. American Psychiatric Association. Intimate Partner Abuse and Relationship Violence. Available at http://www.apa.org/about/division/activities/partner-abuse.pdf. Last accessed July 14, 2015.
156. U.S. Preventive Services Task Force. Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Screening. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening. Last accessed July 14, 2015.
157. Sprague S, Madden K, Dosanjh S, Petrisor B, Schemitsch EH, Bhandari M. Screening for intimate partner violence in orthopedic patients: a comparison of three screening tools. J Interpers Violence. 2012;27(5):881-898.
158. National Center for Injury Prevention and Control. WISQARS Fatal Injury Reports, National and Regional, 1999–2013. Available at http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Last accessed July 14, 2015.
159. Centers for Disease Control and Prevention. Patterns of Unintentional Injuries among 0-19 Year Olds in the United States, 2000–2006. Available at http://www.cdc.gov/safechild/images/CDC-ChildhoodInjury.pdf. Last accessed July 14, 2015.
160. National Rifle Association. Safety Programs: Eddie Eagle. Available at https://eddieeagle.nra.org. Last accessed July 14, 2015.
161. Substance Abuse and Mental Health Services Administration. Study: More Than 1 in 10 Children Live with a Substance Abusing Parent. Available at http://www.samhsa.gov/newsroom/press-announcements/200904290100. Last accessed July 14, 2015.
162. National Institute on Drug Abuse. Medical Consequences of Drug Abuse. Available at http://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse. Last accessed July 15, 2015.
163. D'Amico EJ, Paddock SM, Burnam A, Kung FY. Identification of and guidance for problem drinking by general medical providers: results from a national survey. Med Care. 2005;43(3):229-236.
164. Becker KL, Walton-Moss B. Detecting and addressing alcohol abuse in women. Nurse Pract. 2001;26(10):13-16, 19-23.
166. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607-614.
167. Dhalla S, Zumbo BD, Poole G. A review of the psychometric properties of the CRAFFT instrument: 1999–2010. Curr Drug Abuse Rev. 2011;4(1):57-64.
168. Running A, Berndt A. Management Guidelines for Nurse Practitioners Working in Family Practice. Philadelphia, PA: F.A. Davis Company; 2003.
169. Martin AC, Schaeffer SD, Campbell R. Managing alcohol-related problems in the primary care setting. Nurse Pract. 1999;24(8): 14-39.
170. National Institute on Drug Abuse. NIDA InfoFacts: Lessons from Prevention Research. Available at http://www.drugabuse.gov/publications/drugfacts/lessons-prevention-research. Last accessed July 15, 2015.
171. Womenshealth.gov. Minority Women's Health: African Americans. Available at http://womenshealth.gov/minority-health/african-americans/index.html. Last accessed July 15, 2015.
172. Womenshealth.gov. Minority Women's Health: Latinas. Available at http://womenshealth.gov/minority-health/latinas/index.html. Last accessed July 15, 2015.
173. Centers for Disease Control and Prevention. Deaths, Percent of Total Deaths, and Death Rates for the 15 Leading Causes of Death in 5-Year Age Groups, by Race and Sex: United States, 1999–2013. Available at http://www.cdc.gov/nchs/data/dvs/LCWK1_2013.pdf. Last accessed July 15, 2015.
174. Black Women's Health Imperative. Black Women and HIV/AIDS. Available at http://www.bwhi.org/issues-and-resources/black-women-and-hiv-aids. Last accessed July 15, 2015.
175. Centers for Disease Control and Prevention. Deaths, Percent of Total Deaths, and Death Rates for the 15 Leading Causes of Death in 5-Year Age Groups, by Hispanic Origin, Race for Non-Hispanic Population and Sex: United States, 1999–2013. Available at http://www.cdc.gov/nchs/data/dvs/LCWK4_2013.pdf. Last accessed July 15, 2015.
176. Dossey BM, Keegan L. Holistic Nursing: A Handbook for Practice. 5th ed. Sudbury, MA: Jones and Bartlett Publishers; 2009.
177. Holisticonline. Alternative Medicine: Definitions. Available at http://holisticonline.com/Alt_Medicine/altmed_definitions.htm. Last accessed July 15, 2015.
178. National Center for Complementary and Alternative Medicine. Available at http://nccam.nih.gov. Last accessed July 15, 2015.
179. MedlinePlus. Dong Quai. Available at http://www.nlm.nih.gov/medlineplus/druginfo/natural/936.html. Last accessed July 15, 2015.
180. MedlinePlus. Evening Primrose Oil. Available at http://www.nlm.nih.gov/medlineplus/druginfo/natural/1006.html. Last accessed July 15, 2015.
181. American Holistic Nurses Association. Available at http://www.ahna.org. Last accessed July 15, 2015.
182. Buckle J. Clinical aromatherapy: therapeutic uses for essential oils. Adv Nurse Pract. 2002;10(5):67-68, 88.
183. MedlinePlus. Lavender. Available at http://www.nlm.nih.gov/medlineplus/druginfo/natural/838.html. Last accessed July 15, 2015.
184. Goldberg B, Goldberg MA. Alternative Medicine: The Definitive Guide. 2nd ed. Berkeley, CA: Ten Speed Press; 2002.
185. Holisticonline. Guided Imagery or Visualization. Available at http://www.holisticonline.com/guided-imagery.htm. Last accessed July 15, 2015.
186. Simonton OC, Creighton J, Matthews S. Getting Well Again. Reissue. New York, NY: Bantam Books; 1992.
187. Harsora P, Kessman J. Nonpharmacologic management of chronic insomnia. Am Fam Physician. 2009;79(2):125-130.
188. Merck Manual. Mind-Body Techniques. Available at http://www.merckmanuals.com/home/special-subjects/complementary-and-alternative-medicine-cam/mind-body-techniques. Last accessed July 15, 2015.
189. Holisticonline. Health Conditions that are Benefited by Meditation. Available at http://1stholistic.com/Meditation/hol_meditation_benefits_health_conditions.htm. Last accessed July 15, 2015.
190. Holisticonline. Yoga. Available at http://holisticonline.com/Yoga/hol_yoga_home.htm. Last accessed July 15, 2015.
191. Begley SS. The energetic language of therapeutic touch: a holistic tool for nurse practitioners. Adv Nurse Pract. 2002;10(5):69-71.
192. Mish FC, Copeland RD, Despres JM, Lowe JG, Pease RW Jr. Rader JL (eds). The Merriam-Webster Dictionary. 11th ed. Springfield, MA: Merriam Webster Mass Market; 2004.
193. Womenshealth.gov. Screening Tests and Vaccines. Available at http://www.womenshealth.gov/screening-tests-and-vaccines/screening-tests-for-women. Last accessed July 15, 2015.
194. U.S. Preventive Services Task Force. Thyroid Dysfunction: Screening. Available at http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/thyroid-dysfunction-screening?ds=1&s=thyroid%20dysfunction. Last accessed July 15, 2015.
195. U.S. Preventive Services Task Force. Screening for Colorectal Cancer. Available at http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/colorectal-cancer-screening. Last accessed July 15, 2015.
196. Centers for Disease Control and Prevention. ACIP Recommendations. Available at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Last accessed July 15, 2015.
197. Centers for Disease Control and Prevention. 2015 Adult Immunization Schedule. Available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Last accessed July 15, 2015.
198. Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule—United States, 2015. Available at http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Last accessed July 15, 2015.
199. Centers for Disease Control and Prevention. Vaccine Information Statements (VIS). Available at http://www.cdc.gov/vaccines/hcp/vis/index.html. Last accessed July 15, 2015.
200. U.S. Food and Drug Administration. FDA Approves Gardasil 9 for Prevention of Certain Cancers Caused by Five Additional Types of HPV. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm426485.htm. Last accessed June 30, 2015.
201. Tjaden P, Thoennes N. Extent, Nature, and Consequences of Rape Victimization: Findings from the National Violence Against Women Survey. Available at https://www.ncjrs.gov/pdffiles1/nij/210346.pdf. Last accessed June 30, 2015.
202. Bernard HU, Burk RD, Chen Z, van Doorslaer K, zur Hausen H, de Villiers EM. Classification of papillomaviruses (PVs) based on 189 PV types and proposal of taxonomic amendments. Virology. 2010;401(1):70-79.
203. U.S. Food and Drug Administration. Nucleic Acid Based Tests. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm330711.htm. Last accessed July 6, 2015.
204. Kinsey Institute. Frequently Asked Questions to the Kinsey Institute. Available at http://www.kinseyinstitute.org/resources/FAQ.html. Last accessed July 8, 2015.
205. Agency for Healthcare Research and Quality. Menopausal Symptoms: Comparative Effectiveness of Therapies. Available at http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2052. Last accessed July 8, 2015.
206. National Cancer Institute. Understanding Breast Changes: A Heath Guide for Women. Available at http://www.cancer.gov/types/breast/understanding-breast-changes. Last accessed July 9, 2015.
207. Bjelakovic G, Gluud LL, Nikolova D, et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev. 2011;(7):CD007470.
208. Bjelakovic G, Gluud LL, Nikolova D, et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev. 2014;1:CD007470.
209. Adami S, Idolazzi L, Rossini M. Evidence of sustained vertebral and nonvertebral antifracture efficacy with ibandronate therapy: a systematic review. Ther Adv Musculoskelet Dis. 2011;3(2):67-79.
210. American Dental Association. American Dental Association Statement on Regular Dental Visits. Available at http://www.ada.org/en/press-room/news-releases/2013-archive/june/american-dental-association-statement-on-regular-dental-visits. Last accessed July 15, 2015.
211. American Optometric Association. Recommended Eye Examination Frequency for Pediatric Patients and Adults. Available at http://www.aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/recommended-examination-frequency-for-pediatric-patients-and-adults?sso=y. Last accessed July 15, 2015.
1. National Center for Immunization and Respiratory Diseases. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Surveill Summ. 2011;60(2):1-64. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=25633. Last accessed July 22, 2015.
2. Centers for Disease Control and Prevention. Chlamydial infections. In: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR12):44-49. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=25583. Last accessed July 22, 2015.
3. Faculty of Sexual and Reproductive Healthcare. Contraception for Women Aged 40 Years. London: Faculty of Sexual and Reproductive Healthcare; 2010. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=24716. Last accessed July 22, 2015.
4. The North American Menopause Society. The 2012 hormone therapy position statement of the North American Menopause Society. Menopause. 2012;19(3):257-271. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=36195. Last accessed July 22, 2015.
5. U.S. Preventive Services Task Force. BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing. Last accessed July 22, 2015.
6. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123(11):1243-1262. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=33603. Last accessed July 22, 2015.
7. Florence R, Allen S, Benedict L, et al. Diagnosis and Treatment of Osteoporosis. Bloomington, MN: Institute for Clinical Systems Improvement; 2013. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=47543. Last accessed July 22, 2015.
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