Susan M Kendig, RNC, MSN, WHCNP, FAANP   

Pass the Butter

A newly elected Senator, very proud of himself, was invited to a dinner. Certain that everyone would want to talk with him, because he was so important, he arrived early. Unfortunately, he was the first to arrive, so he took his seat, alone in the large banquet hall. A young waitress was doing her job, placing 1 pat of butter on each bread plate. When she came to his seat, the Senator asked for more than 1 pat of butter. She replied, "I'm sorry Sir, it is our policy to only place 1 pat of butter at each place." Chagrinned, he demanded more butter and said, "Do you know who I am?" "Yes," she replied. "I know who you are. But do you know who I am? I give out the butter."^[1]

NPWH keynote speaker Nancy Amidei, MSW, Director of the Civic Engagement Project, Seattle, Washington, used this story to illustrate the power of the vote. Butter is analogous to the coveted property belonging to every US citizen -- the vote. Because each elected official needs votes to attain and keep his office, the voice of every voter is important. With this combined voice, "A little bunch of nobodies can take on the White House and Congress and win!" During the Reagan administration, Amidei's consumer group blew the whistle on ketchup's classification as a vegetable in school meals, paving the way for healthier menus in our public schools.^[1]

What Drives Policy?

Amidei believes there are valuable lessons to be learned in the aftermath of recent hard times, such as the devastation wrought by Hurricane Katrina:

1. The need for a responsible judiciary;
   
   
2. Public-private partnerships -- we can't meet the tremendous needs following a disaster when one of the partners pulls out; and
   
   
3. The need for a crash course in prevention.^[1]

Traditionally, advocates for social improvements have received the message to avoid asking for change and appropriations during "hard times," such as war or in bad budgetary years. Expectations guide actions, so Amidei advises advocates continue clamoring for social improvements even during the "hard times."

Some of our most notable social programs have come about during tough times, including war and depression. The Social Security Act was passed in 1935, between 2 wars and during a great depression; women's access to welfare came about during the Korean War in the 1950s; Medicaid, Medicare, and WIC were all legislated during the Vietnam era; and the Americans with Disabilities Act became law during the first Gulf War. These improvements occurred because advocates set the expectations and didn't give up.^[1]

Fitting Policy Into Busy Lives: A 5-Point Plan

Although nurses are part of a dramatically changing healthcare scene, political activity is not usually a practice priority. Nurses are reluctant or hesitant to become involved in policy-related activity for a number of reasons -- time constraints, feelings of incompetence in the policy arena, or negative feelings about the political process.^[2]

Amidei offers a doable plan for busy clinicians to increase their advocacy efforts and make their voices heard. Building relationships is key to the advocacy process. "When you need a friend it is too late to make one," so Amidei advises getting to know your key legislators before a crisis occurs. A sample introduction that can be used in person, in a letter, or email could be, "Hello, I am Sally Jones, a Women's Health NP from your district. As a healthcare provider, I know first hand that the healthcare system is broken and far too few people have access to healthcare. What are you doing to end poverty and improve the healthcare system, and how can I help?"^[1]

Advocacy simply means speaking up. Lobbying is only one very narrow component of advocacy. Effective advocacy strategies also include gathering information, raising awareness, and helping others to spread the word. Amidei offers the following 5 ideas for fitting advocacy into busy lives.

1. Sign Up for Regular Alerts. Choose an email legislative alert list that tracks policy related to your area of interest. Planned Parenthood and the Kaiser Family Foundation are examples of Web sites with information about women's health issues. Getting on an alert list will keep you informed, provide a sample message, and let you know when your voice is most needed.

2. Communicate With Your Legislators. Mail letters to local offices for federal legislators. Faxing a handwritten note gets increased attention. Or if you choose to communicate via email, mention the bill or issue in the subject line. In any written communication, clearly state your issue and what you would like the legislator to do about the issue. Be sure to include your home address so they know that you live in their legislative district.

Phone messages are another effective means of communication. Many states have a toll free hotline to their state capitol, where you can be connected to your legislator's office. Contact information for each legislator is also listed online at the state capitol Web site.

Regardless of your mode of communication, a few simple rules apply. Always let them know you are a constituent. Focus on the sound-byte -- what is the most important issue and what you want them to do. If you want them to vote a certain way, ask for it. Always try to leave something in writing -- talking points, a summary of your concerns, and your contact information.

3. Help Others to Advocate. Those with busy lives can't do it all, so get others with busy lives involved too. Spread the word about how to advocate. Amidei offered simple, practical suggestions for raising awareness and encouraging advocacy.

Setting up a "Take Five Table" at meetings and events provides an opportunity to help others contact their legislators. Simply provide information about the issue, and provide paper, pens, and envelopes for letters, or provide a laptop with Internet access for emails to legislators, or a cell phone for calls to their offices.

Another idea is to make handouts with the capitol Web site, toll-free number, and legislative session dates on them. These can be handed out at meetings and events to encourage contact with policy makers. Amidei suggests asking advocates to make one toll-free call or write one email per week.

4. Advertise Your Issue. Be sure your legislative official knows why you are there. Amidei suggests wearing or carrying something conspicuous, like a button or logo bag that identifies your issue or agency. Simply writing your message in bold lettering ("ACCESS TO HEALTHCARE NOW") on the colored folder that you carry your papers in lets your message be seen from a distance and can be carried into candidate forums and hearings. The presence of badges, buttons, bags and slogans on folders lets policy makers know that an organized group that cares about the issue is present.

5. Talk at Every Opportunity. Silence can be the death knell for many social issues. So, talk to anyone who will listen -- at the grocery store, waiting for the light to change at the street corner, or after church services. This raises awareness and gets the key issues on voters' radar screens.^[1]

Amidei also suggests preparing a brief, 60-second message that is ready for any occasion when you might have access to a policy maker. Key components of the message include: your name and where you live, your group or agency (there is power in numbers -- remember the butter!), what you want to call their attention to, and what you would like them to do. An alternative approach would be including a brief "word picture" in your message -- something that puts a human face on the issue. Mention something that you are doing that works and talk about how this is helping their community. Remind them that volunteers and the nonprofit sector cannot do the job alone.^[1]

A Word for Public Employees

Generally, public/government employees are prohibited from lobbying or communicating with a legislative official or their staff to urge a specific position on pending legislation. However, public employees can help with information, such as statistics, budget estimates, etc. Amidei suggests public/government employees join groups as an unlisted informational member, serve on nonprofit agency boards, and do activities on their own time as a private citizen, to provide opportunities for advocacy involvement.

The speaker cautioned public employees to communicate carefully -- not to speak for the agency, not to trade on public position when lobbying as a private citizen, and not to use public resources such as a work computer, email, letterhead, copy machines, or work time to participate in lobbying activities.^[1]

What Are the Issues?

Multiple issues affect the nurse practitioner (NP) practice in women's health, as well as women's access to healthcare and NP services. A concurrent session, "Top Ten Policy Issues in Women's Health," presented by NPWH Policy Chair Susan Kendig, RNC, MSN, WHNP, FAANP, Assistant Professor at Barnes-Jewish College of Nursing, St. Louis, Missouri, discussed a few of the current issues affecting practice. Policy issues were addressed in 4 categories:

1. Pharmaceutical regulations, including restrictive formulary therapeutic equivalency ratings;
   
   
2. NP practice issues, including the doctorate of nursing practice degree, rising malpractice costs, and barriers to full prescriptive authority;
   
   
3. Reproductive health issues, including abortion, over-the-counter status for emergency contraception, and flat funding Title X; and
   
   
4. Women's health issues, including access to care and environmental issues.^[3]

Pharmaceutical Issues

Limited formularies, which indicate drugs available for prescription without prior authorization, provide a utilization management tool to control costs. Generally, limited or restrictive formularies employ mechanisms such as preferred medication lists, higher copays for nonformulary drugs, and "fail first" policies (policies that require use of a preferred medication to be shown ineffective before other medications can be prescribed), to control cost. However, there is a paucity of formal studies to document cost savings from these approaches, while there is some evidence of adverse effects.

In a 1996 study, Horn and colleagues studied the effect of preferred drug lists across a variety of common illnesses. They found higher overall costs in terms of increased outpatient visits, hospitalizations, and prescriptions associated with more restrictive formularies.^[4] In a more recent study, focusing on the impact of state Medicaid preferred drug lists on cardiovascular disease patients, the number of outpatient hospital and physician visit increased within the first 6 months after the preferred drug lists were instituted.^[5] "Instead of viewing the debate (regarding restrictive formularies) in such terms as 'cheap' and 'expensive' drugs, the focus needs to be on 'cost-effective drugs.'"^[6]

Drug product substitution is also considered to be a cost containment measure. Therapeutic equivalence evaluations reflect the US Food and Drug Administration (FDA) application of specific criteria to approved multisource prescription drug products. Therapeutic equivalence ratings are assigned in 3 categories. Pharmaceutical equivalents are drugs that have the same active ingredients, doses, and route, and identical strength composition. Pharmaceutical alternatives have the same therapeutic mode but different salts, esters, or complexes and can have different dosage forms, such as extended release. Therapeutic equivalents are pharmaceutical equivalents expected to have the same clinical effect and safety profile, but may differ in release mechanism, inert ingredients, labeling, and storage.^[7] NPs may need to consider different ratings of substituted drugs when issues such as vaginal pH or other responses may occur in relation to a substituted drug.

NP Practice Issues

The Doctorate of Nursing Practice (DNP) is probably one of the most controversial issues currently facing NPs. The practice doctorate is a nonresearch clinical doctorate that would prepare graduates for administrative or policy roles as well as advanced practice clinical roles. Proponents of the DNP cite the availability of high level preparation in nursing practice, increased availability of faculty with advanced clinical skill to teach future NPs, better fit with education and individual career goals, more accurate reflection of academic preparation, and parity with other healthcare professions.^[8,9]

Those skeptical of the recommended practice doctorate cite detracting nursing attention and resources from more important current healthcare issues while the debate continues, a lack of evidence supporting the degree, and marginalization of currently practicing NPs as issues of concern.^[10] The debate regarding the DNP continues to evolve as the American Association of Colleges of Nursing continues to hold stakeholder meetings and refine their recommendations. For an update on the status of recommendations and DNP programs, see the American Association of Colleges of Nursing.

Reproductive Health Issues

NPs in women's health continue to witness threats to women's reproductive rights, including access to emergency contraception and abortion. While many concerns related to abortion access center around teens, 55% of abortions in the United States occur to women aged 20 to 29 years, followed by 22.8% of abortions to women aged 30 to 39 years.^[11] While the tenets of Roe v Wade protecting a woman's right to abortion have held for the past 3 decades, continual challenges to the law have emerged. Recent changes in the makeup of the Supreme Court due to the death of Chief Justice William Rehnquist and retirement of Justice Sandra Day O'Connor may impact the view regarding the constitutional right to privacy that protects Roe.

The emergency contraception over-the-counter controversy continues to limit women's access to emergency contraception. In April 2003, Barr Labs filed an FDA application for over-the-counter status for Plan B. The application was denied and Barr submitted a formal response to the FDA in July 2004. (See FDA information at http://www.fda.gov/cder/drug/infopage/planB/default.htm.) Since that time, the FDA has continued to delay a decision on over-the-counter status for Plan B despite scientific evidence of its safety and the recommendation of their own expert panels.

Following the latest delayed decision in August 2005, Susan Wood, PhD, Assistant Commissioner for Women's Health and Director, FDA Office of Women's Health, resigned in protest over the FDA decisions. According to Wood, "The recent decision announced by the Commissioner about emergency contraception, which continues to limit women's access to a product that would reduce unintended pregnancies and reduce abortion, is contrary to my core commitment to improving and advancing women's health."^[12]

Women's Health Issues

According to the 2005 Kaiser Women's Health Survey, women with private insurance (89%) and Medicare (95%) are most likely to have a regular healthcare provider, as compared with only 50% of uninsured women. Ethnicity also plays a role, with white women (88%) and African American women (81%) having regular access to a women's healthcare provider, while Latina women (64%) are less likely to have such access. According to the survey, nearly 17% of nonelderly women were uninsured. Uninsured women (67%) were also less likely to have a healthcare visit within the last year, when compared with women with private insurance (90%), Medicare (93%), and Medicaid (88%).^[13,14]

Availability of healthcare coverage does not necessarily guarantee access. Approximately 13% of privately insured survey respondents reported being turned away from care due to a provider not accepting new patients. Additionally, 20% of women reported not filling a prescription due to cost during the last year. Of those not filling their prescription due to cost, 17% had private insurance and 19% had Medicaid coverage. Next to the uninsured, those individuals under 65 years of age with an income of $75,000 seem to be the most affected by rising healthcare costs. Of those surveyed, 31% reported paying more than $1000 out of pocket toward healthcare expenses, 33% said they do not have enough money to pay medical costs, and 34% said they have skipped care or prescriptions due to cost.^[13,14]

Conclusion

"I hate all bungling as I do sin, but particularly bungling in politics, which leads to the misery and ruin of many thousands and millions of people." - Goethe

Nurses marry policy to the reality of the daily lives of women, families, and communities. Because NPs are intimately involved in the lives of their patients and the fabric of communities, they are in a unique position to not only see the impact of policy on health, but also to see the need for policies that address health-related issues.^[2] The NPWH 8th Annual Conference provided the "how to" of advocacy in Nancy Amidei's keynote address, and further identified issues of concern in Susan Kendig's subsequent concurrent session.

Participants have gone back to their communities with the tools to build an advocacy program to enhance their advocacy efforts and raise awareness about important issues affecting women's health -- and most importantly with renewed recognition of the power accorded to the "one who gives out the butter."

References

1. Amidei N. Fitting advocacy into busy lives. Program and abstracts of the NPWH 8th Annual Conference; September 28-October 1, 2005; Naples, Florida.
2. Kendig S. From practice to policy: leveraging nursing knowledge in the legislative arena. AWHONN Lifelines. 2002;6:309-312. Abstract
3. Kendig S. Top 10 policy issues in women's health. Program and abstracts of the NPWH 8th Annual Conference; September 28-October 1, 2005; Naples, Florida.
4. Horn SD, Sharkey PD, Tracy DM, et al. Intended and unintended consequences of HMO cost-containment strategies. Results from the managed care outcomes project. Am J Manag Care. 1996;2:253-264.
5. Murawski M, Abdelgawad T. Exploration of the impact of preferred drug lists on hospital and physician visits and the cost of Medicaid. Am J Manag Care. 2005;11:SP35-SP43. Abstract
6. Karki SD. Weighing in on restrictive formularies. Contemp Issues Behav Health Suppl. 2003;S-2.
7. FDA. Food and Drug Administration Center for Dug Evaluation and Research Approved Drug Products With Therapeutic Equivalence Ratings, 25th ed. Available at: http://www.fda.gov/cder/ob/docs/preface/ecpreface.htm. Accessed February 9, 2006.
8. Lenz ER. The practice doctorate in nursing: an idea whose time has come. Online J Issues Nurs. 2005;10. Available at http://www.medscape.com/viewarticle/514543. Accessed February 9, 2006.
9. Rhoads J, Houck J. Squaring off over the practice doctorate. J Nurse Pract. 2005;1:28-29.
10. Meleis AI, Dracup K. The case against the DNP: history, timing, substance and marginalization. Online J Issues Nurs. 2005;10. Available at: http://www.medscape.com/viewarticle/514544. Accessed February 9, 2006.
11. Kaiser Family Foundation. State health facts: reported legal abortions by age group within state of occurrence, 2001. Available at: http://www.statehealthfacts.org. Accessed February 9, 2006.
12. ARHP. Emergency Contraception Resource Center. Available at: http://arhp.org/healthcareproviders/resources/. Accessed February 9, 2006.
13. Kaiser Family Foundation. Women and Health: A National Profile. Available at: http://www.kaiserfamilyfoundation.org/womenshealth/whp070705pkg.cfm. Accessed February 10, 2006.
14. Appleby J. Even the insured can buckle under health care costs. USA Today. August 30, 2005. Available at: http://www.usatoday.com/money/industries/health/ 2005-08-30-health-care-crunch-survey_x.htm. Accessed February 9, 2006.

Susan M Kendig, RNC, MSN, WHCNP, FAANP   

Primary Care and Women

Healthcare for women in the primary care setting requires up-to-date, gender-specific knowledge regarding disease prevention and disease management. In addition, women often look to their healthcare provider for information to help them look and feel healthy throughout their life span. This summary describes the highlights of several of the primary care-focused sessions devoted to wellness, disease states affecting women, and health-enhancing strategies.

Chronic Fatigue Syndrome

Autoimmune disease affects women at a higher rate than men. Chronic fatigue syndrome (CFS) is classified as an autoimmune disease, affecting women at 2 to 3 times the rate of men.^[1] In her presentation, "Hunting Zebra: Understanding and Treating Chronic Fatigue Syndrome," Marianne Nihart, MA, ARNP, CS, BC, who is in private practice in Pacifica, California, and a member of the Clinical Faculty at University of California at Davis, provided a helpful overview of this complex condition.

Fatigue is a common symptom, reported by as many as 20% of individuals seeking medical care. Typically, fatigue is transient, self-limiting, and circumstantial. CFS, on the other hand, is associated with debilitating fatigue and a cluster of symptoms that predominantly feature impaired concentration, impaired short-term memory, sleep disturbances, and musculoskeletal pain. The high prevalence of fatigue in the primary care setting places a barrier to diagnosis of CFS.^[1]

Nihart's presentation dispels 3 myths regarding CFS.

Myth 1: CFS is a relatively rare disorder. In reality, CFS has a prevalence of approximately 200-500 per 100,000, twice the prevalence of multiple sclerosis. Yet only about 16% of those with symptoms have been accurately diagnosed.^[1]

Myth 2: The highest prevalence is among young, affluent, white professional women. CFS does affect women more frequently than men. It is most commonly diagnosed in women aged 20 to 40 years, and affects black and Hispanic individuals, as well as whites.^[1]

Myth 3: CFS is a form of depression. Often, the onset of CFS occurs with influenza. Most women affected by CFS do not have a history of depression, nor does depression seem to occur in CFS clusters or outbreaks. Fatigue is the primary complaint in CFS, although depression may occur later, after the onset of disease.^[1]

CFS is a diagnosis of exclusion. According to the 1994 international case definition from the US Centers for Disease Control and Prevention (CDC), CFS is characterized by the following criteria:

• Persistent or relapsing fatigue lasting 6 months or longer, which is sufficiently severe to reduce the person's ability to perform 1 or more aspects of daily life
  
  
• Must be unexplained by other medical or psychiatric conditions
  
  
• Accompanied by 4 or more of the following symptoms:
  
  
  • Impaired memory
  • Sore throat
  • Tender cervical or axillary lymph nodes
  • Muscle pain
  • Multi-joint pain
  • New headaches
  • Unrefreshing sleep
  • Post-exertional malaise lasting more than 24 hours^[2]

Because CFS is a diagnosis of exclusion, the road to an accurate diagnosis can be long and frustrating. Clinicians who approach the diagnostic process with nonjudgmental empathy, compassion for the struggle, systematic investigative skills, and the ability to instill hope and empower self care are the most likely to successfully work with the CFS patient.^[1]

Generally, the patient will present with fatigue as the chief complaint. During the initial interview, it is helpful to obtain a detailed history, including a review of medications that can cause fatigue. In addition to the symptoms listed in the CDC International Case Definition above, the symptom checklist should include unexplained, generalized muscle weakness, generalized fatigue lasting longer than 24 hours, generalized headaches, migratory painful joints without redness or swelling, areas of lost or depressed vision, visual light intolerance, forgetfulness, excessive irritability, confusion, and an inability to concentrate. Depression may also be present, though not as a primary, defining symptom.

Laboratory screening may include urinalysis, complete blood count and differential, erythrocyte sedimentation rate (ESR) or C-reactive protein, alanine aminotransferase or aspartate transaminase serum level, albumin, globulin, alkaline phosphatase, glucose, calcium, phosphorus, thyroid-stimulating hormone and free T4, and rheumatoid factor if arthritic complaints are present.^[1,2]

Before CFS can be confirmed, the clinician must rule out a myriad of other diagnoses as diverse as eating disorders, Lyme disease, cancer, psychiatric disorders, and other autoimmune diseases.^[1,2] Common differential diagnoses include multiple sclerosis or systemic lupus erythematosus (SLE).

Laboratory or physical findings, as well as disease progression, can help to refine the diagnosis. Other diagnoses to consider include chronic multiple symptom illness (Gulf War illness) and fibromyalgia. Gulf War illness can be differentiated through a history of chemical exposures in the Gulf War. Patients with fibromyalgia tend to present with an emphasis on musculoskeletal pain rather than debilitating fatigue.^[1]

Optimal treatment results are achieved with a multidisciplinary approach that emphasizes education, cognitive behavioral therapy, exercise, stress management, and attention to associated symptoms. Pharmacologic treatment using tricyclic antidepressants for sleep disturbances and nonsteroidal anti-inflammatory drugs (NSAIDs) or mild narcotics for pain management may be helpful. Complementary therapies, such as massage, biofeedback, and meditation, may also help in symptom relief.^[1,3,4]

Longitudinal studies show that although 17% to 64% of patients with CFS improve, less than 10% fully recover, and 10% to 20% worsen during follow-up. Older persons, and those with longer illness duration and comorbid psychiatric conditions, are at risk for poorer prognosis.^[1-3]

Skin Care: Preserving the Fountain of Youth

Women in the primary care setting often express concern regarding the effects of aging on the appearance of their skin. In "Preserving the Fountain of Youth," Julie M. Countess, MD, a dermatologist with Florida Skin Cancer & Dermatology Specialists, PA in Gainesville, Florida, provided an overview of topical anti-aging skin care regimens with known clinical benefit, and an update on minimally invasive procedures, such as botulinum toxin (Botox), fillers, and chemical peels.^[5]

Signs of aging on the face include increased pigmentation, telangiectasia (spider veins), and rougher skin texture, as well as wrinkles and sagging due to fat loss. Popular cosmeceutical ingredients purported to combat the signs of aging consist of vitamin A preparations, including Retin A and retinoids, alpha-hydroxy acids, and the antioxidants -- vitamins C and E, lipoic acid, coenzyme Q-10, green tea, kinetin, and idebenone.^[5]

But what works? According to Dr. Countess, the retinoids, alpha-hydroxy acid, and some antioxidants can have a beneficial effect on skin. Retinoids treat photoaging by reversing cellular atypia, increasing epidermal thickness, and increasing collagen synthesis. This action may result in improved skin texture, reduced pigmentation and fine lines, and smaller pores. Side effects, including peeling and irritation (retinoid dermatitis), redness, and dryness, are more common with the prescription preparations.

In the appropriate vehicle and concentration, according to Dr. Countess, over-the-counter preparations may be as effective as prescription products, with fewer side effects. Dr. Countess recommends applying only a "pea sized" amount of the retinoid preparation about 20 minutes after washing the face, initially at every-other-day intervals. Reading labels is important, as retinyl palmitate is not biologically active in the skin.^[5]

The alpha-hydroxy acids (AHAs) are the most popular anti-aging product. Like the retinoids, AHAs increase skin thickness, improve skin texture, and treat pigmentation problems. In addition to their moisturizing effect, AHAs are also helpful in increasing collagen synthesis and enhancing the quality of elastic fibers. AHAs have a known potential for photosensitivity and irritation, so they should be used with an SPF sunscreen product.^[5,6]

The free-radical theory suggests that the effects of free radicals, lipid peroxidation, DNA damage, and inflammation play a role in aging. The antioxidants work to prevent free-radical damage. Evidence suggests that vitamin C functions as an antioxidant by decreasing free radicals. It has been shown to increase collagen synthesis and decrease pigmentation problems. However, there is less evidence regarding topical vitamin C's effect on improvement of wrinkles, which may be due to irritation and dermal edema. In addition to being very expensive to properly formulate, most vitamin C preparations are unstable when exposed to air or light, and many formulations do not penetrate the top layers of skin.^[5]

Vitamin E is considered to be an excellent moisturizer. Benefits related to prevention of skin cancer and anti-aging have not been established. Contact dermatitis is a common side effect, with a 20% to 33% rate of contact dermatitis occurring when vitamin E is applied to surgical scars.^[5]

Other antioxidant preparations under consideration include lipoic acid and green tea. Topical application of 3% lipoic acid has been shown to reduce redness induced by sun exposure, which suggests that topical lipoic acid could prevent free-radical damage. The polyphenols in green tea have antioxidant properties. Sun-induced redness seems to be decreased in skin treated with green tea components.

Currently, the "cosmeceutical" advantage of these products is unclear.^[5] However, kinetin, another new product, seems to be a safe moisturizer with antioxidant properties that improves fine lines and wrinkles. Although it is not as effective as the retinoids, it may be useful as an adjunct to retinoid therapies.^[5,6]

Regardless of skin care regimen, Dr. Countess says that daily use of sunscreen is essential to skin health. A broad-spectrum sunscreen is best. She recommends SPF 15 for everyday use and SPF 30 for outdoor activity. Patients with sensitive skin may need physical blockers.^[5,6]

In terms of daily skin care, Dr. Countess recommends a simple morning and evening regimen to cleanse, treat, and protect the skin. In the morning, begin by cleansing with a gentle cleanser, or a cleanser with hydroxyl acid. Follow with an antioxidant cream, and protect with sunscreen. At the end of the day, cleanse the face again with the same product, protect with a retinoid, and apply moisturizer, particularly if there are problems with dryness.^[5,6] Women should discuss skin care concerns with their healthcare provider.

Although topical agents may help with skin texture, pigmentation problems, and pores, they will not treat "dynamic lines" -- the furrow between the eyebrows, or fat loss and sagging. Botox, fillers, and radiofrequency treatments may be an option for some conditions. Laser treatments may be considered for treatment of spider veins.^[5]

Rheumatic Diseases

Rheumatic diseases are among the most prevalent chronic conditions in the United States. Although the primary cause is unknown, gender and age appear to play a role. Women account for more than two thirds of those affected by rheumatic disease.^[7] In a general session on rheumatic diseases, Joyce P. Carlone, MN, CFNP, Nurse Practitioner at Emory University, Department of Medicine/Division of Rheumatology, Atlanta, Georgia, provided an overview of the disease process, diagnosis, and treatment of 3 common rheumatoid diseases that affect women.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic disease that is 2.5 times more common in women than in men. In RA, the synovial membrane is inflamed, and there is destruction of the periarticular bone and cartilage. Multiple joints may be affected and joint deformities may be present.^[7,8] A diagnosis of RA is made when 4 or more of the following criteria are present for at least 6 weeks:

• Morning stiffness lasting 1 hour or more
  
  
• Arthritis of 3 joint areas
  
  
• Arthritis of the hand joints
  
  
• Symmetric arthritis
  
  
• Rheumatoid nodules
  
  
• Serum rheumatoid factor
  
  
• Presence of bony erosions on x-ray

Increased ESR correlates with the degree of synovial inflammation. A positive rheumatoid factor in the absence of other symptoms is not diagnostic for RA. Some persons unaffected by RA, the elderly without RA, or persons with other disease states, such as Sjögren's syndrome, may also have positive serum rheumatoid factor.^[7,8]

Pharmacologic treatment of RA includes NSAIDs, such as ibuprofen, naproxen, or celecoxib. Disease-modifying antirheumatic drugs, including hydroxychloroquine, gold, leflunomide, sulfasalazine, methotrexates, and biologics, are also used to treat RA. Leflunomide and methotrexate are category X drugs that have been linked to spontaneous abortion, cleft palate, and hydrocephaly when used prenatally. Men and women both must be off of leflunomide for a minimum of 3 months before trying to conceive. It is also contraindicated during lactation.^[8]

Systemic Lupus Erythematosus

SLE is a relatively uncommon illness, with an estimated prevalence rate of 15 to 52/100,000. Women are disproportionately affected, approximately 8 to 10 times more frequently than men.^[7] The prevalence is even higher in blacks, occurring at a rate of 400/100,000.^[7]

SLE is a chronic inflammatory disease of unknown etiology. It is characterized by the production of autoantibodies. Simply put, the T cells fail to recognize the "self" antigens and the B cells are hyperactive. Patients with SLE may present with constitutional symptoms, such as low-grade fever, weight loss, swollen glands, fatigue, and aching. Raynaud's phenomenon may also be present. Approximately 50% of patients present with symptoms such as musculoskeletal complaints/polyarthritis, skin changes, hair loss, cognitive dysfunction, and serositis. The other 50% of patients exhibit symptoms indicative of internal organ involvement, such as blood value changes and central nervous system, heart, and lung symptoms.

The 1997 American College of Rheumatology revised criteria for SLE can be remembered using the acronym SOAP BRAIN MD:

Serositis

Oral ulcers

Arthritis (deformity can be reduced with SLE)

Photosensitivity

Blood disorder (hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia)

Renal disorder

ANA (antinuclear antibodies)

Immunologic disorder

Neurologic disorder

Malar rash (butterfly rash)

Discoid rash (hyperpigmentation and scarring)^[9]

Laboratory work may be helpful, but is not diagnostic. The ANA is sensitive, but has low specificity for SLE. The autoantibodies to the human-like SM protein (anti LSM) and antibodies to double-stranded DNA (anti-ds DNA) are more specific for SLE.^[8]

SLE can improve, worsen, or stay the same during pregnancy. Pregnancy in SLE is associated with higher rates of miscarriage, stillbirth, premature birth, intrauterine growth restriction, and pre-eclampsia. The best pregnancy outcomes occur when the disease is not active at the time of conception.^[7,8] Some women with SLE are also affected by antiphospholipid syndrome, which is characterized by recurrent arterial/venous thrombosis, fetal losses, thrombocytopenia plus the presence of anticardiolipin antibodies, or lupus anticoagulant.

Antiphospholipid syndrome is suspected when women experience 1 or more miscarriages after the 10th week of gestation with normal fetal morphology, 3 or more miscarriages prior to 10 weeks with hormonal and genetic causes excluded, or 1 or more preterm births at less than 34 weeks' gestation. Treatment of antiphospholipid syndrome in pregnancy includes daily low-dose (81 mg) aspirin, and heparin 5000 - 10,000 U subcutaneously twice daily.^[8]

Scleroderma

Scleroderma, or systemic sclerosis (SS), is a connective tissue disease characterized by degenerative, inflammatory, fibrotic changes of the skin, blood vessels, joints, tendons, skeletal muscle, gastrointestinal tract, lungs, heart, and kidneys.^[10] SS affects approximately 150 patients/million, and many more females than males are affected.^[8]

The 2 major subtypes of SS are diffuse scleroderma and limited scleroderma. Diffuse scleroderma is more severe, with a 5-year survival rate of approximately 75%. Limited scleroderma has a 5-year survival rate of 80% to 85%.^[8] Patients with SS experience tightening and thickening of the skin, usually beginning with the hands, fingers, and face. Raynaud's phenomenon is present in most cases. The internal organs are also affected. Organ damage worsens as the skin damage worsens, with internal organ damage linked to the extent and progression of skin thickening.^[8,10]

Treatment is directed at controlling symptoms. Supportive therapy and monitoring for organ involvement are the foundation of management. Calcium channel blockers, angiotensin-converting enzyme inhibitors, and low-dose aspirin may be prescribed for cardiovascular effects. A number of gastrointestinal effects occur with SS. Esophageal changes may result in dysphagia or gastroesophogeal reflux, which is often treated with proton pump inhibitors. Low-dose prednisone or NSAIDs may help to control arthritis symptoms. Patients receiving prednisone or NSAIDs should be monitored carefully for gastrointestinal bleeding. Nitrate cream helps vasodilatation in the finger vessels and is often recommended for daily skin care.^[8,10]

Pregnancy tends to aggravate gastrointestinal and cardiopulmonary symptoms, and poses an increased threat of renal crisis for the mother. Pregnant women with SS require high-risk obstetric care and monitoring. Because women with SS are at greater risk of vasoconstriction, vascular occlusion, and clotting, estrogen-containing contraceptives are contraindicated. Barrier and progestin-only methods would be appropriate.^[8]

Summary

Rheumatic diseases disproportionately affect women. Diagnosis may be delayed due to the complex nature of the symptoms and diagnostic processes. NPs working with women in OB/GYN practices as well as other primary care practices need to be aware of the diagnostic criteria and initial management parameters for these diseases. In addition to their role in disease management, NPs who provide care to women also provide important health-promotion and disease-prevention information, designed to enhance physical and emotional health and self esteem. This article blends important information about disease state management and health promotion, a combination that reflects women's primary healthcare needs.

References

1. Nihart M. Hunting zebras: understanding and treating fatigue syndrome. Program and abstracts of the NPWH 8th Annual Conference; September 28-October 1, 2005; Naples, Florida.
2. Centers for Disease Control and Prevention. Chronic fatigue syndrome. Available at: http://www.cdc.gov/ncidod/diseases/cfs/index.htm. Accessed February 8, 2006.
3. Hofmann SG. Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain. Evid Based Ment Health. 2003;6:55.
4. Friedberg F, Jason LA. Chronic fatigue syndrome and fibromyalgia: clinical assessment and treatment. J Clin Psychol. 2001;57:433-435. Abstract
5. Countess J. Preserving the fountain of youth. Program and abstracts of the NPWH 8th Annual Conference; September 28-October 1, 2005; Naples, Florida.
6. Kunin A. www.Dermadoctor.com. Available at http://www.dermadoctor.com . Accessed February 8, 2006.
7. Hannan MT. Epidemiology of rheumatic diseases. In: Clinical Care in the Rheumatic Diseases. Atlanta, Ga: Association of Rheumatology Health Professionals; 2001.
8. Carlone J. Rheumatic diseases. Program and abstracts of the NPWH 8th Annual Conference; September 28-October 1, 2005; Naples, Florida.
9. Hochberg M. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40:1725.
10. Ramsey-Goldman R. Connective tissue diseases. In: Clinical Care in the Rheumatic Diseases. Atlanta, Ga: Association of Rheumatology Health Professionals; 2001.