The resources on this page are all created by the CTC-SRH to assist clinical services providers in managing common sexual and reproductive health concerns and related preventive health care issues. Some resources are helpful before, during, and after clinical encounters as quick reference guides, while others are focused at implementing or improving new services or protocols.
To find trainings with CE, browse our Training Tool Library
Are you a clinician who is new (3 years or less) to Title X? We want to hear from you!
The CTC-SRH is seeking input from clinicians who are new to Title X on their clinical training needs relevant to Title X Statute and Regulations and Billing and Coding for Reproductive Health Services.
This quick 2-minute survey will help the CTC-SRH create trainings and products to support clinicians new to Title X settings.
By sharing your insights, you'll be contributing to the development of tailored trainings and resources to assist you and fellow clinicians embarking on their Title X adventure.
Thank you for your time and responses!
Take SurveyThe Clinical Training Center for Sexual + Reproductive Health is ringing in the new year with leadership changes. Please help us by congratulating Jacki Witt on her nearly 20 years of service as the Project Director and welcoming Dr. Kristin Metcalf-Wilson as the new Project Director. Read below for Jacki's farewell message to the field and Kristin's vision for the CTC-SRH and Title X.
Welcome to the Clinical Training Center for Sexual and Reproductive Health - training the Nation's Title X Workforce.
In recognition of Endometriosis Awareness Month, Clinical Connections interviewed Mary Lou Ballweg, President/Executive Director (and Founder) of the Endometriosis Association to learn more about the Association and how they support professionals and people with the disease. Endometriosis is a chronic estrogen-dependent immune disease characterized by the development and presence of endometrial-like tissue in anatomical locations and organs outside of the uterus.
CTC-SRH: Ms. Ballweg, tell us a little bit about the history and mission of the Endometriosis Association and reasons why you support their work.
MS. BALLWEG: In 1980, I was a filmmaker and consultant. Suddenly, I was really sick. Bedridden. Ended up on food stamps which was extremely humiliating. I didn’t even know what I had…and was going through what many women still go through…I was told it was normal. It will go away when you have a baby, which is nonsense, or even implications that it is in your head.
I had been involved in women’s health…I had helped start a women’s clinic. So I did my own research and thought I had this thing called endometriosis…so I went to my OB/Gyn and told her what I thought. She said, well we could do surgery, a laparoscopy, and confirm the diagnosis, but even if we do, there isn’t really anything we can do about it. Which was pretty discouraging, but I had to have a definite diagnosis. For insurance, for my family, and my own mental health, etc.
So, once I was diagnosed, I linked up with a friend at the Bread and Roses Women’s Health Center --- it doesn’t exist any more….I told her I needed a support group and so we started one. Women from all over the US, Canada, and eventually all over the world started contacting us about a support group. How do we start one?
I had done a review of the medical literature and there wasn’t very much. I went to NIH and asked them what they were doing….and they said nothing. So, I went back to our group and the group said we will do the research! So, we started the research with a comprehensive ten-page survey. Incredibly naïve and incredibly ambitious and wonderful. For one dollar, we sent a brochure and the survey to people. By a year and a half out, we had more data than anyone had ever collected on endometriosis. We got so much data, we started working with the Medical College of Wisconsin to help us computerize and analyze the data…and this was in the 80’s…so we were working with the huge mainframe computers on their campus. So, analysis of this data set commenced and we started publishing the findings. And eventually, we worked and published with researchers at the NIH. The patterns were pretty incredible….we found first of all that this was not just a pelvic disease; this is an immune system disease…these women and their families have a lot of immune system associated diseases.
CTC-SRH: Can you tell us about the epidemiology and demographics of people who are diagnosed with endometriosis?
MS. BALLWEG: Who has the disease, a much larger group, is a different group than who is diagnosed. This is a difficult question. We really don’t know. We know how many people are diagnosed, but not how many people have the disease. It is still taking up to 10 years on average to get a diagnosis. And those are the people that actually get a diagnosis. If you are poor, do not have insurance, are Black or Hispanic, you might never get a diagnosis. And if you are a teen or pre-teen, forget it! It is really tough. So, more white women tend to get diagnosed. In fact early on, it was categorized as a ‘white career woman’s disease’ – ‘thin, nervous, perfectionist’….it was just nonsense.
The reality is that any female and a few males can get endometriosis. We just don’t know the actual numbers because so many are undiagnosed. Now this is going to change…..hopefully, in the near future because there are several non-invasive tests in development. People have figured out that there is a huge market. So we see endometriosis in girls as young as nine and in post menopausal women and in all ages between. I have talked with women in their seventies who are still dealing with symptoms…..the pain and the up and down cycles…and many have had hysterectomies.
One risk factor is early menarche…it pains me to think of little girls that young not only having their periods, but having excruciating pain with them. Some people will have mild symptoms, some will have severe. It can progress and can remit and relapse…it is like autoimmune diseases…the way it acts, but nobody is willing to label it that yet. Women with endometriosis are at increased risk for seven autoimmune diseases, including Hashimoto’s thyroiditis, rheumatoid arthritis, multiple sclerosis, lupus, hypothyroidism, and fibromyalgia. That is work that I published with the NIH. So, early menarche, inflammatory disorders, even before menarche, such as allergies and asthma and inflammatory gastrointestinal conditions. In the family, you often see that a patient’s mother and grandmother or other family members had endometriosis also…so it was thought that it was genetic. Now we look at epigenetics…environmental exposures which can affect the first generation and as many as five successive generations as shown in work with our team at Vanderbilt. And a number of toxins, which act epigenetically, have been linked to endometriosis.
CTC-SRH: The diagnosis is often delayed….what are the reasons for this and how can providers be more attentive to signs and symptoms of this disease?
MS. BALLWEG: So currently - and this goes nicely with Condom Awareness Month - the only available MPTs are condoms. We know condoms have great benefits, but condoms have not fully addressed the problem. I think there are a lot of challenges with common use and questions about how far condoms have come. There are several MPTs in development right now, and at multiple stages in development.
Complete medical history taking is the key. Be sensitive to the fact that people may not tell you everything. They may not tell you about how painful their periods are, or that they have pain with sex, or bowel and intestinal symptoms, especially related to their menstrual cycles. And the reason, unfortunately, is that they have likely been told previously by other health care providers that this is normal. They have been told that it is part of being female, which is a terrible thing to say, especially to young girls. So the patients downplay it. Clinicians have to probe more. Ask the leading questions. Many health care providers just don’t ask the right questions. Are you unable to work, unable to go to school, do you miss social events because of your period? History is critical. And also the full medical history…asthma, allergies, and any other inflammatory diseases, and bowel issues since we know those are associated with endometriosis.
CTC-SRH: Where can our readers get more evidence-based information about endometriosis, including current treatments, and client education and s https://endometriosis.ca/upport tools?
MS. BALLWEG: Although the title to this article would lead one to believe that it is only about animal research, in fact, it is an overview of endometriosis and covers pain management, infertility, and surgical management. [insert citation] If people are looking for a website, the Johns Hopkins one is pretty good. https://www.hopkinsmedicine.org/health/conditions-and-diseases/endometriosis. It’s really tough, because like other diseases, the science and the research is at least 10 years ahead of clinical availability. Prevention starts way before puberty….we are just beginning to uncover how important it is to pay attention to allergies and asthma. We have a lot of work to do.
CTC-SRH: Thank you for talking with me today… this has been so informative.
MS. BALLWEG: Thank you for taking these messages to your communities.
This interview is intended for informational purposes and does not constitute legal or medical advice or endorsement of a specific product. Opinions expressed herein are the views of the contributors and do not necessarily reflect the official positions of the Department of Health and Human Services (DHHS), Office of the Assistant Secretary of Health (OASH), or the Office of Population Affairs (OPA or the Center for Sexual + Reproductive Health (CTC-SRH). No official support or endorsement by DHHS, OPA, or CTC-SRH is intended or should be inferred.
NCTCFP: Dr. Haddad, tell us a bit about what led you to the work you do with multipurpose prevention technologies, or MPTs.
DR. HADDAD: I am an OB/Gyn and I trained in Boston, then moved down to Atlanta where I completed a complex family planning fellowship at Emory. During my fellowship, I started doing some global health work in Malawi with the integration of family planning within HIV settings. A lot of the work that I started building upon was at the intersections between reproductive infectious diseases and contraception. So, recognizing overlapping burdens, unmet need, and, on the clinical side, many challenges with providing comprehensive care for these intersecting conditions, I focused primarily on family planning while also doing quite a bit of work in HIV care settings.
A lot of my research grew from that clinical work and also grew in the areas of translational research related to reproductive infectious diseases and contraception. About two and a half years ago, I moved over to Population Council, where I became their medical director, and I started working more on the product development side. This was, and is, exciting because as a researcher, I can recognize the gaps that exist, but I wanted to go beyond just identification into working to find solutions to address them.
NCTCFP: The HIV/sexually transmitted infection (STI) syndemics and the unmet need for effective and accessible contraceptive methods continue to pose significant health risks for people worldwide. Can you give us a brief overview of the public health rationale for the interest in and the evolution of the development of MPTs over the last decade or so?
DR. HADDAD: There are several things, I think, that multi-purpose prevention technologies have an opportunity to address. First is motivation for use and self-perception of risk. STI and HIV prevention and perceived risk may not always align with actual risk, so people may feel stigmatized or feel low self-perception of risk, and not use prevention methods. This actually puts them at risk. Coupling [STI and HIV prevention] with something that they may feel concerned about, like pregnancy, may enhance the use of these prevention technologies. That's the public health benefit of reducing the risks of sexually transmitted infections that have overlapping burdens.
The issues of stigma alone….in some relationships, couples may struggle with communication around the prevention of STIs and HIV. There are issues of trust where concerns about pregnancy may not be as stigmatized, and so, being able to integrate prevention that some people may actually be very concerned about but may not be comfortable integrating into their relationship would then be facilitated.
My hope is by integration, it also opens opportunities for expanding outlets for distribution as well. So, for instance, where contraception is very medicalized, there's a way to enhance wider distribution by making it about broader prevention. Prevention now gets normalized as part of routine counseling, and it's just an added benefit. I like to use the example of when I buy toothpaste - I may be looking for something to prevent cavities, but I will pick up the toothpaste that whitens my teeth, freshens breath, and prevents gingivitis, even if those are not my perceived issues. If I’m just going to do the same thing every day, I may as well get the additional benefits.
That’s where I see the largest public health benefit occurring. We all do it - go for the extras - I buy the milk with additional omega 3 and vitamin D, I mean, even if you're not concerned about it, you want to get that extra benefit. So that's where I see an opportunity to normalize broader prevention. It’s a problem….we make sexual and reproductive health something that you have to whisper about. I hope MPTs offer an opportunity to recognize that these issues affect all persons, so opening that avenue for greater use, acceptability, and access is key.
NCTCFP: What MPT products are already available and what can we expect in the near future? What is the estimated uptake for the products globally and in the US?
DR. HADDAD: So currently - and this goes nicely with Condom Awareness Month - the only available MPTs are condoms. We know condoms have great benefits, but condoms have not fully addressed the problem. I think there are a lot of challenges with common use and questions about how far condoms have come. There are several MPTs in development right now, and at multiple stages in development.
The one that is probably closest to market is the dual prevention pill. The reason this is closest to market is that combines two approved products - oral HIV pre-exposure prophylaxis, or PrEP, and an existing hormonal contraceptive pill. By leveraging these two approved products, the regulatory burden is not as large, so it has a faster route to market.
That's only one of the MPTs under development, and that will address the needs of people who feel comfortable using a pill every day and feel comfortable with hormonal contraception and something to address HIV risk. But it isn't covering all the other sexually transmitted infections. I think you're not going to find one method that's going to address everything. But we need to offer opportunities for enough options to address the issues that are common in different communities and the concerns of different groups of people. Bottom line - why wouldn’t I want to protect myself from additional things if I’m not having to do any additional work?
NCTCFP: We recently talked with people from Evofem about their FDA-approved contraceptive gel, Phexxi®. They say they are collecting data now to submit an STI prevention indication for their product. Can you comment on this?
DR. HADDAD: Yes, I can. I do believe that through reducing the pH in the vagina, not only can you achieve contraception, there's also likely prevention of other sexually transmitted infections as well, including bacterial STIs and I think this is one opportunity. Now, again I think people want choices. We all want options, and what we've learned from the contraceptive field is, there is no one size that fits all. People are looking for different things, and different people feel comfortable integrating different things into their sexual life. Using a gel before sex and with each sexual act is good, and it is a great option for people who feel comfortable with that, and who maybe don't want a systemic method, or feel that they aren't necessarily needing that spontaneity. That situation - an ‘on-demand’ method - may not address everybody's needs though.
My goal and my hopes are that there would be the same diversity of choice for MPTs as there is for contraceptive methods - a variety to meet the needs of individuals in many different situations.
I do want to highlight that an additional burden for MPTS is showing effectiveness for multiple indications is challenging - a regulatory burden. It would be nice if there was a streamlined regulatory process that could enhance the ability to get those approvals for more products that have more than one indication.
I [also] want to highlight the funding challenges. Another issue is polarization of funding streams, so HIV funding is separate from family planning funding, and there's very little funding for sexually transmitted infections. That additionally complicates the research and development of MPTs. Unfortunately, it's not a major priority area for large pharmaceutical companies, and so it's often some of the smaller more mission-driven organizations that are driving this work.
NCTCFP: What is the estimated uptake for the products globally and in the US?
DR. HADDAD: What we know from multiple surveys is that people are interested in using a method that not only prevents pregnancy or prevents HIV but permits multiple indications. There are several studies in different settings that all present that hypothetical question of which product you would want to use, and overwhelmingly people indicate they want would want to use MPTs. At this time, though, this is with people responding to questions about hypothetical products. So we don't have the data on the real-world market use. And we know there are multiple reasons that people choose a product. For instance, people don't just look at efficacy as the only driving force for why they would use a method. They look at multiple attributes, including ease of use, privacy, side effects, and other characteristics.
NCTCFP: Where can people find more information and get updates about MPTs? What are some good resources?
DR. HADDAD: I recommend the Initiative for Multipurpose Prevention Technologies, or IMPT (theimpt.org). They are an unbiased organization committed to advancing products that simultaneously prevent HIV, other STIs, and/or unintended pregnancy. Then there are other organizations interested in MPT research and development, like the Population Council (www.popcouncil.org).
NCTCFP: Thank you so much, Dr. Haddad, for sharing all of this great information about multipurpose prevention technologies with us!
This interview is intended for informational purposes and does not constitute legal or medical advice or endorsement of a specific product. Opinions expressed herein are the views of the contributors and do not necessarily reflect the official positions of the Department of Health and Human Services (DHHS), Office of the Assistant Secretary of Health (OASH), or the Office of Population Affairs (OPA or the National Clinical Training Center for Family Planning (NCTCFP). No official support or endorsement by DHHS, OPA, or NCTCFP is intended or should be inferred.In Spring of 2021, we surveyed our mailing list as well as anyone who had taken one of our trainings over the past few years. 400 respondents from all 10 DHHS regions responded. Below is an infographic describing the results of that survey.
This data gives us insight on who our audience is, what they use from the NCTCFP, how they rate it, and whether or not the NCTCFP has met their clinical training needs through our products, events, and resources. Click on the images below to view the full-size pdf.
CDC's Sexually Transmitted Infections (STI) Treatment Guidelines, 2021 provides current evidence-based prevention, diagnostic and treatment recommendations that replace the 2015 guidance. The recommendations are intended to be a source for clinical guidance.
