Her Life Her Health Autumn 2020 by E4H Ltd

AUTUMN 2020

THE OFFICIAL PUBLICATION OF THE PRIMARY CARE WOMENâ&#x20AC;&#x2122;S HEALTH FORUM PCWHF.CO.UK

From challenge to opportunity

Outreach for vulnerable sex workers

Lichen sclerosus & vulval cancer

Non-hormonal menopause management

Question � Understand � Practice

17 –18 November 2020 virtual event

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From the Editor-in-Chief

Dr Anne Connolly SENIOR EDITOR

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A digital version of Her Life Her Health is available to download from www.pcwhf.co.uk The next issue will be published in January 2020.

WE KNOW HOW HARD YOU HAVE WORKED TO MAKE SURE THAT CARE FOR WOMEN HAS BEEN DELIVERED Look for this icon for free downloadable resources at www.pcwhf.co.uk/HLHH

s I write, further restrictions have been imposed and stricter ones could soon be on their way as we continue to navigate our way through the pandemic. The healthcare sector has been forced to transform over the past few months and an incredible amount has been achieved – but it is more important than ever before that we continue to work together to maintain healthcare provision over this time as we head into the difficult winter months in primary care. We have learnt from our recent member survey what fantastic work is being done in primary care and that our members are continuing to provide this excellent care in spite of the pressures of workload and priorities. We also have collected information about what people want to learn and will continue to provide a wide range of topics – as you can see in this edition – while also focusing on the highest priorities. Thank you to all of you who have taken the time to fill in the survey, it’s a vitally important piece of work for all of us working in primary care. We continue to learn how to deliver care remotely and our guides, webinars and other educational resources have proved extremely popular. The positive feedback we have received continues to encourage us to develop resources relevant to supporting the challenges of our daily work. Our ‘Fair pricing for LARC fitters’ survey results, from the survey performed in February before we were hit by the pandemic, were used to provide evidence in the recent APPG Inquiry and the recommendations include the need for co-commissioning and removal of hurdles, to provide more LARC in primary care by funding this properly and to encourage the development of working at scale by developing women’s health hubs. We are watching fantastic examples of work being developed around the country and would love to hear from you. You can read more about the launch of the report, Women’s Lives, Women’s Rights: Strengthening Access to Contraception Beyond the COVID-19 Pandemic, on page 10. It was great to see so many of you at our first virtual ‘Her Life, Her Health’ event in September. We received some fantastic feedback from delegates about the new format and the quality of the speakers and the content, and even though we didn’t get to debrief with colleagues and a large glass of something at the end of the day, so much learning was shared and gained. Building on the success of the event, our big news is that the PCWHF Annual Conference 2021 will be entirely virtual to ensure that you get everything you can out of the day while keeping safe. On the 24 February 2021, we will be presenting a mix of live streamed main stage sessions and small group workshops by experts in the field who are either delivering services in primary care, or working closely with those who do. Our speakers, including James Woolgar, Virginia Beckett, Caroline Gazet and Toni Hazell, will look at the evidence on a variety of women’s health issues, and translate this into practical guidance and useful tips for your own practice. Booking is now open at www.pcwhf.co.uk/events. I am very proud of this journal and the quality of submissions, and thank you once again to our wonderful contributors. It is great to share expertise and pragmatic advice. Please contact us at submissions@pcwhf.co.uk if you would like to share your interest with us, including any audit you have performed, large or small, that has improved the care of your women and would be useful to copy in other services. We hope you enjoy this issue, stay safe.

DR ANNE CONNOLLY EDITOR-IN-CHIEF, HER LIFE HER HEALTH & CHAIR OF THE PCWHF

Her Life Her Health | Autumn 2020 | 1

IN THIS ISSUE

Contributors

DR ANNE CONNOLLY, EDITOR-IN-CHIEF

Anne is Chair of the PCWHF and a GPSI in gynaecology, accredited as a hysteroscopist, colposcopist and FSRH trainer. She has been involved with commissioning for many years. Anne is also RCGP Clinical Champion for Women’s Health. MYRA ROBSON

Myra is a specialist pelvic health physiotherapist and clinical lead at Lewisham & Greenwich NHS Trust in South London. She co-founded the pelvic floor muscle training Squeezy app with the technology company ‘Living With’ and also co-founded the physiotherapy-led campaign group ‘Pelvicroar’. DR CLARE SPENCER

Clare qualified from Cambridge University in 1995. She initially followed a career in obstetrics and gynaecology, gaining her MRCOG, before changing to general practice. She is a GP partner, menopause specialist and GPwSI in gynaecology at the Meanwood Group Practice, Leeds.

DR JANE DAVIS

DR LUCY CHIDDICK

Jane is a GP based in Cornwall with a special interest in women’s health. She is a member of the PCWHF’s Executive Committee and spokesperson for the PCWHF’s public-facing menopause campaign, Rock My Menopause.

Lucy is Clinical Lead for Vulnerable Groups, Hull CCG and Health Inequalities at Leeds CCG. As a GP for the homeless in Leeds and Hull she is particularly interested in the mental wellbeing of marginalised women, and in 2005 co-founded a charity working with women in street prostitution in Leeds.

DR AMY TATHAM

Amy is a GP and FSRH trainer with a passion for women’s health working in a large teaching practice in Bradford and is also the Associate Clinical Director for Maternity care and women’s health for Bradford Districts and Craven CCGs.

DR KATE MACLARAN

Kate is a Trustee of Daisy Network. She has worked for several years as part of a menopause clinic team that has a specialist interest in premature ovarian insufficiency (POI) in the NHS and her hope is to raise awareness of POI within the primary care community.

IT IS TIME TO ACT TOGETHER – USE THIS OPPORTUNITY TO JOIN FORCES, TO PUSH FOR AN IMPROVEMENT IN SERVICE PROVISION

VICTORIA HOWELL

Victoria is a registered, independent menopause and women’s health nurse and a professional certified coach whose purpose is to educate, inform and empower women to enable them to have the best care possible.

LISA HALLGARTEN

DR URSULA MASON

DR ANATOLE MENON-JOHANSSON

Ursula is a GP principal in Carryduff, Northern Ireland. She has interests in prescribing, women’s health and GP education. She has worked as a Clinical Lead in the GP Elective Care Service (GPECS).

Lisa is Head of Policy and Public Affairs at Brook. She advocates for young people’s rights to accessible sexual and and reproductive health services, and champions inclusive, sex-positive Relationships and Sex Education.

Anatole is the Clinical Director for Brook, a Consultant in Sexual & Reproductive Health at Guy’s & St Thomas’ NHS Foundation Trust and Founder of http://SXT.Health.

DR JANE DAVIS, FROM CHALLENGE TO OPPORTUNITY, PAGE 36.

The information contained in this publication and/or any accompanying brochure is intended for medical professionals and not the general public. The content of and information contained in this magazine are the opinions of the contributors and/or the authors of such content and/or information. Events4Healthcare Ltd and PCWHF accept no responsibility or liability for any loss, cost, claim or expense arising from any reliance on such content or information. Users should independently verify such content or information before relying on it. The Publisher (Events4Healthcare) and its Directors shall not be responsible for any errors, omissions or inaccuracies within the publication, or within other sources that are referred to within the publication. The Publisher provides the features and advertisements on an ‘as is’ basis, without warranties of any kind, either express or implied, including but not limited to implied warranties of merchantability or fitness for a particular purpose, other than those warranties that are implied by and capable of exclusion, restriction, or modification under the laws applicable to this agreement. No copying, distribution, adaptation, extraction, reutilisation or other exploitation (whether in electronic or other format and whether for commercial or non-commercial purposes) may take place except with the express permission of the Publisher and the copyright owner (if other than the Publisher). The distribution of this publication includes to data from the Care Quality Commission. It is used in accordance with the Open Government Licence.

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IN THIS ISSUE

Contents

Her life

Her health

EARLY YEARS

ON THE GROUND

Locked down & locked out?

The impact of COVID-19 on young people & RSHE provision Lisa Hallgarten & Dr Anatole Menon-Johanssen

DIAGNOSIS, TREATMENT, & MANAGEMENT OF LICHEN SCLEROSUS & VULVAL CANCER, PAGE 27

Tips for cervical screening in transgender, non-binary and intersex communities

ESSENTIAL UPDATES News & Policy

Research & Guidelines

RIGHT PLACE, RIGHT TIME, RIGHT PERSON, PAGE 32

Improving the long-term outcomes of a population Dr Amy Tatham 18

POI charity Daisy Network supports women coping with early menopause Dr Kate Maclaran

PCWHF PROFILE

One specialist physiotherapist’s journey in pelvic health Myra Robson

Making a difference

Introducing the PCWHF’s latest Executive Committee member, Dr Aamena Salar

GOLDEN YEARS

How to spot the signs Victoria Howell

Bringing healthcare & support to vulnerable sex workers in the field Dr Lucy Chiddick

Holistic support

Alternatives to HRT Dr Clare Spencer

Diagnosis, treatment & management of lichen sclerosus & vulval cancer

Standing on the back of giants

CHARITY FOCUS

RENAISSANCE YEARS

Physiotherapy & pelvic health

Reflecting on how COVID has transformed women’s health services for the future Dr Jane Davis

PIONEERS IN WOMEN’S HEALTH

Advice for healthcare professionals from gynaecological cancer charity, The Eve Appeal.

Non-hormonal management of the menopause

Increasing access to primary care gynaecology services via a hub model Dr Ursula Mason From challenge to opportunity

FERTILE YEARS The long view of preconception care

Right place, right time, right person

RESOURCES 27

Top tips for managing HMB in primary care

How to manage heavy menstrual bleeding PCWHF Working Group

Her Life Her Health | Autumn 2020 | 3

ESSENTIAL UPDATE

News & Policy

DATES FOR YOUR DIARY THE PCWHF’S EDUCATIONAL PROGRAMME Booking is open for this year's educational events. To find out more and to register, go to www.pcwhf.co.uk/events. PCWHF Annual Conference The Primary Care Women’s Health Forum Annual Conference will be going virtual in 2021. Bringing together key expert speakers in women’s health, the conference aims to improve your practice in women’s health. Key topics include: • Abortion care • AUB guidance • Women and HIV • PMS and • Contraception • Menopause • Ovarian cancer • PCOS • Out of hospital care There will be an opportunity to network with colleagues virtually and CPD points available. Booking is now open. Date: 24 February 2021 | Venue: Online ► www.pcwhf.co.uk/pcwhf-events/ pcwhf-conference-2021

PCWHF-ENDORSED EVENTS Guidelines Live This two-day educational conference focuses on clinical guidance to meet the needs of busy healthcare professionals. Date: 17-18 November 2020 | Venue: Online ► www.guidelineslive.co.uk Special Skills in Menopause Special Skills in Menopause is organised by Dr Sarah Gray, who is joined by Dr Jane Davis for this course which will provide you with the knowledge and confidence to advise and treat women before, during and after menopause within your working environment. Date: 2-3 December 2020 | Venue: Online ► www.pcwhf.co.uk/external-events

PCRMM Virtual Conference 2020 The Primary Care Rheumatology and Musculoskeletal Medicine Society Annual Conference 2020 with be held virtually. The two-day event will focus on First Contact Practitioners and the Evolving MSK Workforce. Date: 12-13 November 2020 | Venue: Online ► www.pcrmm.org.uk/conference

STUDIES SHOW TARGETED INTERVENTION TO REDUCE SEVERE TEARING IN CHILDBIRTH ‘PROMISING’

wo new evaluation papers exploring the impact of the Royal College of Obstetricians and Gynaecologists’ (RCOG) and Royal College of Midwives’ (RCM) OASI Care Bundle have been published in BJOG: An International Journal of Obstetrics and Gynaecology and BMJ Open. Third- or fourth-degree perineal tears, also known as an obstetric anal sphincter injury (OASI), can occur in 6 out of 100 births (6%) for first-time mothers and less than 2 in 100 births (2%) of births for women who have had a vaginal birth before. These injuries can have severe, life-long implications for a woman’s mental and physical health. The OASI Care Bundle, a Health Foundation-funded quality improvement project, aimed to reduce the rate of these severe perineal tears in 16 maternity units in England, Scotland and Wales between January 2017 and March 2018.

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The care bundle was evaluated for clinical effectiveness as well as barriers and enablers to uptake. The clinical results, published in BJOG, compared 28,000 singleton vaginal births that took place before implementation of the care bundle with 27,000 singleton vaginal births that took place after implementation of the care bundle. The authors found that the OASI Care Bundle reduced rates of severe perineal tearing from 3.3% to 3.0%, without affecting rates of caesarean section or episiotomy. The estimated reduction in severe perineal tearing was 20% when women’s characteristics were taken into account. The barriers and successes identified by the qualitative evaluation published in BMJ Open, and results of the OASI Care Bundle will be used to inform the next phase of the work.

THIRD- OR FOURTH-DEGREE PERINEAL TEARS CAN OCCUR IN 6 OUT OF 100 BIRTHS FOR FIRST-TIME MOTHERS

ESSENTIAL UPDATE

THE AUTUMN ISSUE

FSRH & partner organisations call for menstrual teaching to be compulsory in Wales’ schools The Women’s Health Cross Party Group in Wales, Endometriosis UK, and Fair Treatment for the Women of Wales (FTWW), together with FSRH and over 20 other partner organisations, have written a letter to the Welsh Government to request that menstrual teaching is made a compulsory component of the school curriculum. The curriculum currently offers schools and teachers the flexibility to decide whether or not to teach menstrual wellbeing. The alliance requests two amendments to the new Wales school curriculum’s Health and Wellbeing Area of Learning and Experience: • should understand the concept of menstrual wellbeing, including the key facts about the menstrual cycle. • P upils will be given the knowledge, confidence, and skills to seek help if they are concerned they have a menstrual health condition.

New menopause patient podcasts

series of new podcasts has launched for Rock My Menopause, the PCWHF’s patient-facing campaign, Facebook group and website for women going through menopause. Hosted by menopause specialist and GP Dr Jane Davis and Editor of Her Life Her Health Amy Schofield (both of whom are perimenopausal women themselves) the podcasts cover Sex and Perimenopause; HRT in a Nutshell; How Do You Know If You’re Perimenopausal?; Coping With Menopause in Lockdown, and The Rollercoaster Effect of Hormones. Warm and chatty, with plenty of humour thrown in, the podcasts can be shared with your patients to help them to recognise when they need help, and how to find it. They can be found at www.RockMyMenopause.com/resources, under Podcasts. Do also point your patients in the direction of the Rock My Menopause Facebook group – it’s a welcoming community of over 2000 women all sharing tips, advice, worries and reassuring shoulders. ► www.RockMyMenopause.com/resources

THE PODCASTS CAN BE SHARED WITH YOUR PATIENTS TO HELP THEM TO RECOGNISE WHEN THEY NEED HELP, AND HOW TO FIND IT

Her Life Her Health | Autumn 2020 | 5

ESSENTIAL UPDATE

News & Policy

RCGP calls NHSE’s letter to GPs on access to services an ‘insult’

THE APPARENT U-TURN FRUSTRATED GPS WHO HAVE CONTINUED TO STAY OPEN TO PATIENTS THROUGHOUT THE PANDEMIC

hile many services have been forced to transform almost overnight to a remote model during the pandemic, NHS England has attracted criticism from GPs in response to a letter instructing them to give face-to-face appointments to vulnerable patients during the coronavirus pandemic. GPs were reportedly left feeling ‘undervalued’ and ‘demoralised’ by the letter, which was sent to practices saying it was ‘important’ that the public was aware they could still access face-to-face appointments with their doctor. Health Secretary Matt Hancock previously told surgeries that all GP consultations must be held over the phone or virtually unless there was a ‘compelling’ clinical reason for face-to-face consultations. The apparent U-turn frustrated GPs who have continued to stay open to patients throughout the pandemic, working hard to adapt their services to provide the care that all their patients need, in accordance with government guidance. Professor Martin Marshall, Chair of the Royal College of GPs, responded to NHS England’s latest letter by saying: “General practice is open and has been throughout the pandemic. GPs have been delivering a predominantly remote service in order to comply with official guidance and help stop the spread of Covid-19. “Any implication that they have not been doing their job properly is an insult to GPs and their teams who have worked throughout the pandemic, continued delivering the vast majority of patient care in the NHS, and face an incredibly difficult winter ahead.” Data from the College’s Research and Surveillance Centre shows that routine GP appointments are back to near-normal levels for this time of the year, following a slump around the peak of the pandemic. The proportion of face-to-face appointments being delivered has also increased since the peak of the pandemic.

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ABORTION STATISTICS IN ENGLAND AND WALES SHOW BENEFIT OF TELEMEDICINE

ACCESS TO ABORTION HAS BEEN NOT ONLY MAINTAINED BUT IMPROVED THROUGH THE INNOVATIVE USE OF TELEMEDICINE

ESSENTIAL UPDATE

THE AUTUMN ISSUE

tatistics from the Department of Health and Social Care showing the number of abortions between January and June 2020 indicate that access to abortion has benefitted from the use of telemedicine. To that date there have been 109,836 abortions carried out in 2020, a small increase on the same period in the previous year. This demonstrates that while many essential healthcare services have had to pause activity due to the impact of the COVID-19 pandemic, access to abortion care has been unaffected due to the innovative use of telemedicine. The statistics show a significant reduction in average gestation, with 86% of abortions performed before 10 weeks (compared to 81% the previous year) and 50% of abortions performed before 7 weeks (compared to 40% the previous year). Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “While many healthcare services have

paused during the pandemic, access to abortion has been not only maintained but improved through the innovative use of telemedicine.” Dr Tracey Masters, Abortion Care Lead at the Faculty of Sexual and Reproductive Healthcare (FSRH), said: “In my clinic I have directly experienced the benefits of providing telemedicine for abortion care and I sincerely hope this will be allowed to continue. In these uncertain times, it is more vital than ever that all women should be supported to take control of their own reproductive health through easy access to the contraceptive care they all deserve.”

Her Life Her Health | Autumn 2020 | 7

ESSENTIAL UPDATE

Research & Guidelines

BBC WOMEN'S SPORT SURVEY:

Periods, the pill and the effect on female athletes

survey of elite female athletes carried out by the BBC found that 60% of sportswomen say their performance is affected by their period. These respondents also said that their period had caused them to miss training or competitions. Problems that female athletes face include wearing white clothing, no sanitary bins available, having to wear the same tampon or pad for hours on end or having to double up, enduring cramps and bloating. Some even reported there being no toilet roll in sporting facilities. Despite the obvious problems, 40% said that they didn’t feel comfortable discussing their period with coaches, with some taking the contraceptive pill to control their menstrual cycle because competing while menstruating was too painful or inconvenient. One said: “It’s really horrifying, when you’re on your period, to be thinking: ‘Oh, am I sweating or have I leaked?’ You’re running to the toilet between contests. It’s not something you want to think about but it is in your mind.” Another said: “When I was younger, doing the junior rounds, it was a huge problem. I would have to take toilet paper to every competition I went to. Often there were toilets that didn’t have locks on the doors which, if you’re trying to change a tampon, is a nightmare." The use of the pill also has its downsides in athletes, with one reporting that her bones were made denser, another found it hard to lose weight, and others said that the

mental effect of the extra hormones were too much to cope with. When publishing the survey results, BBC Sport stated: ‘We live in a world largely designed by men, for men. Sporting laws and stadiums are designed with men in mind, whether or not those in charge realise it.” For example, according to cricket rules, you cannot leave the field to go to the toilet, which is a terrible restriction for women who are menstruating. Scotland’s Katie McGill said: “In a 50-over game, you’re out there for three hours or more. A lot of us will double up with a tampon and a pad. It’s not great…quite often we’ll go and play and there won’t be a changing room. You’ll be using the toilet because there’s men in the changing room. There won’t always be the correct disposal units or stuff like that.” The survey also found: • 4 8.5% of female elite athletes believe that their governing body does not support them equally, compared with male colleagues. • 59.8% of respondents’ performance has been affected by their period or missed training/competition because of their period. • 39.9% don’t feel comfortable discussing their period with coaches. • 3 4.3% of respondents have delayed starting a family because of their sporting career. • 35.6% don’t feel supported by their club/governing body to have a baby and continue to compete.

Download these resources at www.pcwhf.co.uk/HLHH

8 | Primary Care Women’s Health Forum | pcwhf.co.uk

ESSENTIAL UPDATE

THE AUTUMN ISSUE

JULIE AND TRACEY SHARE THEIR OPINIONS, EXPERTISE AND EXPERIENCE ON FITTING PESSARIES FOR PROLAPSE

PCWHF MEMBERS SURVEY FINDINGS

PCWHF WEBINAR RECORDING

To date, we have had over 200 responses to our latest PCWHF survey, ‘Shape the Future of Women’s Health’, which are helping us to understand the future learning needs of our primary and community care clinicians to better support the women we care for. Everyone’s role in women’s health is important, and we have been hearing the views of all members of the multi-disciplinary workforce. All the information we gain from your responses will not only be used confidentially to help us in developing the right resources for those working in primary care, but also to use as evidence when working with other national bodies to help shape how we can support you in your work now and in the future.

USING SUPPORTIVE VAGINAL PESSARIES IN PRIMARY CARE

his ‘Ask the Experts’ webinar with speakers Dr Julie Oliver and Advanced Nurse Practitioner Tracey Elliott tells you all you need to know about using supportive vaginal pessaries in primary care. Julie and Tracey share their opinions, expertise and experience on fitting pessaries for prolapse. Aimed at those who are currently fitting vaginal pessaries and those wanting to train to fit pessaries, the webinar is packed with useful, actionable information. ► Listen at www.pcwhf.co.uk/resources.

Our findings so far show: • Impressive work being done by all members of the MDT • Variable training undertaken • Some exciting new models of care developing. Training requested: • Menopause, menopause, menopause • R ing pessary • Adolescent concerns • Contraception updates • Advice on supporting commissioning / service development • Mentoring. ► There is still time to add your voice to the

development of this important work – the survey takes just 10 minutes to fill in and you can find it at www.pcwhf.co.uk/ pcwhf-subscriber-survey.

THE STAIR-STEP APPROACH IN TREATMENT OF ANOVULATORY PCOS PATIENTS

lomiphene citrate (CC) is a widely accepted first-line treatment for anovulatory patients with polycystic ovarian syndrome (PCOS). The current practice is to prescribe CC with gradual dose increments until ovulation is achieved. The objective of the publication was to review the world literature on the CC-SS protocol and to summarise the authors’ experience with extending the CC-SS approach to initiation of gonadotropin therapy. ► https://tinyurl.com/yxpqbm6e

Her Life Her Health | Autumn 2020 | 9

ESSENTIAL UPDATE

Research & Guidelines

APPG Inquiry reveals impact of COVID-19 on women’s access to contraception Report reveals increasing difficulties for women in accessing contraceptive services.

A WORDS BY AMY SCHOFIELD

CUTS TO PUBLIC HEALTH GRANT HAVE MEANT A £25.9 MILLION (13%) CUT TO CONTRACEPTIVE BUDGET

report resulting from an Inquiry by the All Party Parliamentary Group on Sexual and Reproductive Health (APPG SRH), a group of cross-party MPs and Peers, has been published, highlighting a marked reduction in services offering contraception which leaves many women out in the cold. Women’s Lives, Women’s Rights: Strengthening Access to Contraception Beyond the COVID-19 Pandemic, found that women in England are facing difficulty in accessing contraception, with many being “bounced from service to service”. The worst outcome of these circumstances, and the provision gap which has been exacerbated as a result of the closure of many women’s health services due to the COVID-19 pandemic, could mean more unplanned pregnancies and increased demand for maternity and abortion care. The Inquiry found that due to a combination of funding cuts and a fragmented commissioning system which creates unnecessary silos in healthcare, women are facing increasing difficulty in accessing the contraception that meets their needs.

Key findings: • 13% cuts to the contraceptive budget between 2015 and 2018 have likely obstructed and reduced access to services, resulting in long waiting times for women, leaving them at risk of unplanned pregnancies. • Underfunding of long-acting reversible contraceptives (LARCs) in primary care has led to a reduction in GPs offering women the most effective methods to prevent pregnancy. Issues around accessing contraception have been worsened by pandemic lockdown restrictions, which caused many providers to significantly reduce their services or cease them altogether. Despite the bleak scenario, women’s health service providers rapidly rose to the challenge to improve service provision and are now building on the remote service provision used during the pandemic. The APPG is now calling on the Department of Health and Social Care to consider introducing an integrated commissioning model for sexual and reproductive healthcare as it develops the new Sexual and Reproductive Health Strategy.

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The Inquiry into Access to Contraception first opened for submissions in 2019, however this closed as lockdown hit, then reopened to responses for COVID-19 from May-June 2020. The Inquiry received a total of 60 written, and 13 oral responses. Data from the Advisory Group on Contraception (AGC) found that overall spending power on contraception has been slashed by 18% since 2015/16 (MHCLG figures), and according to FOI findings, the rate at which services are being closed or redistributed is accelerating: • 18% of councils had planned closure for 2019/20 prior to the pandemic • O verall, 39% of councils commissioned fewer sites to deliver contraceptive services in 2018/19 than they did in 2015/16. Reasons behind these decisions include funding and workforce pressures; service quality issues; pressure on primary care; changing models of service delivery. The AGC concluded that there is mounting pressure on services to deliver more with less and that services hit by the consequences of the pandemic must be supported to recover and improve. The PCWHF’s Dr Anne Connolly contributed to the Inquiry, and at the report launch she provided evidence of how funding cuts increase pressure on services and obstruct and reduce access for patients. Cuts to the public health grant have meant a £25.9 million (13%) cut to contraceptive budget, while underfunding of LARC in primary care means that GPs are not incentivised to provide services.

ESSENTIAL UPDATE

THE AUTUMN ISSUE

Overview of findings: • Women in England are facing increasing difficulty in accessing the contraception which best suits their needs • T his is due to a combination of funding cuts and a fragments commissioning system that creates unnecessary silos in healthcare • T he pandemic has compounded access issues, causing many providers to cease or significantly reduce provision • T here are many areas of opportunity to improve service provision and to build on remote service provision used during the pandemic. Meanwhile, the current commissioning structure has fragmented contraceptive provision and simultaneously created a lack of accountability. Dr Anne Connolly spoke about how the pandemic has compounded access issues, especially for marginalised and underserved groups: • Cuts to the public health grant have led to reduced service capacity for marginalised and underserved groups • Drop in number of young and BAME people requesting care during the pandemic • Digital and telephone services improve access for some groups, but cause additional barriers for others. Recommendations The APPG recommends a series of steps to improve care pathways and better integrate contraceptive care with other forms of sexual and reproductive healthcare. These include: • Mandate co-commissioning to improve care pathways • Consider bringing all sexual and reproductive health commissioning under one body with ultimate responsibility for oversight • Consider opportunities of Primary Care Networks (PCNs).

Dr Asha Kasliwal, President of the Faculty of Sexual and Reproductive Healthcare (FSRH), said: “Funding and commissioning challenges have led to an overstretched and underfunded Sexual and Reproductive Healthcare service that was not sustainably supported to provide care to women and girls either before or during a pandemic. COVID-19 made a difficult situation worse. “Many specialists and GPs feel unable to meet the needs of their patients due to obstacles such as insufficient funding, disjointed commissioning and training limitations. It is frustrating for me as a doctor and unfair for women, who have to navigate a complex system just to access basic healthcare.” Dame Diana Johnson DBE MP, CoChair of the All Party Parliamentary

Group, said: “Our Inquiry found that for many women, getting access to contraception is difficult and timeconsuming. Due to the unnecessary complexity of the system, many women are being bounced from service to service, undergoing multiple, intimate consultations and spending months on waiting lists to access their preferred contraceptive method.” Baroness Barker, Co-Chair of the All Party Parliamentary Group, added: “The report underscores the importance of better understanding the needs of marginalised and underserved groups. That’s why we’re calling for the collection of fit-forpurpose data on ethnicity, gender, age and socioeconomic status to ensure that essential healthcare is accessible to everyone.” ► The full report is available on the FSRH website at https://tinyurl.com/yxaulcfg.

Her Life Her Health | Autumn 2020 | 11

EARLY YEARS

WORDS BY LISA HALLGARTEN & DR ANATOLE MENONJOHANSSON

Locked down & locked out? The real impact of lockdown on young people is now emerging. Mandatory RSHE is needed now more than ever, but the Government is proposing a delay until June 2021. What does this mean for our young people?

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EARLY YEARS

TEACHERS WILL BE PICKING UP THE EMOTIONAL PIECES FOR MONTHS

I AT A POINT WHERE RSHE IS MOST NEEDED THE GOVERNMENT IS CONCERNED THAT IT WILL PLACE A FURTHER ADDITIONAL BURDEN ON SCHOOLS

n the week that this article was written, young people became the focus of the Government’s COVID-19 response with Health Secretary Matt Hancock telling them to behave more responsibly so that they “Don’t kill your gran”. Yet we are only beginning to understand the impact of lockdown on young people’s own health and wellbeing. Like many GP practices Brook was able, rapidly, to adapt its provision to continue seeing young people remotely throughout lockdown. However, the closure of many other services around the country has resulted in a reduction in contraception provision with a resultant increase in emergency contraception usage. Likewise, testing for sexually transmitted infections has been curtailed and this limits case finding for infections, such as chlamydia, that affect around one in ten young people. This takes place in the context of new figures from Public Health England showing a 5% increase in STIs from 2018-2019, with young people amongst the most at risk groups. Research is needed to understand more about which young people were

advantaged or disadvantaged by a move to an online and telehealthfirst approach to sexual health provision; what the implications are for safeguarding of vulnerable young people via remote access; whether sexual and reproductive health inequality has been exacerbated; or whether new ways of working can help us to reach those at greatest risk more effectively. Adolescence is a key period to acquire life skills through social interactions and the healthy development of these skills has been severely disrupted by the limitations on movement and closure of educational establishments. Questions from young people to Brook answered during this time covered sex and sexual health, dealing with relationships, staying safe online and how to look after their mental health. It is not clear what half a year of social isolation will have on mental health; in a survey of young people carried out by Brook, 72% said their mental health had been negatively impacted by lockdown1. The National Youth Agency and Brook report2 highlights that youth service access should be classified as essential to support vulnerable youth, youth workers have a key role; to identify food poverty, addiction and mental health issues; and to provide clear health (including sexual health) messaging. As a universal service, schools play a key role in all these areas for children from early years to young adulthood. Teachers are bringing children and young people back after 6 months of what for all of them has been at the very least extremely strange and at worst nothing short of traumatic. They need to get back into some kind of routine at the same time as introducing new rules and new ways of interacting (or reducing interaction). It is a huge challenge. Teachers will be picking up the emotional pieces for months. The Government recognises the need for additional pastoral care within schools 3 .Teachers have been calling

for schools to be able to focus on the broader needs of students ensuring they are well enough to learn and not launch head first into the conventional examdriven academic timetable. In this context the introduction of mandatory Relationships, Sex and Health Education (RSHE) in all schools – something Brook has lobbied for for decades – is more important than ever. For many young people the everyday relationships within their households will have taken on a new intensity during lockdown. Over 50% of young people Brook surveyed said their family relationships had become more difficult1. Other relationships such as with their friends, romantic partners, wider family, teachers and other adults, may be seen as more or less important than they were before. These are all rich areas for thinking about what we value about different relationships. Meanwhile there is an unprecedented imperative to promote safeguarding messages, understand personal hygiene and to learn to value and look after our bodies. At a point where RSHE is most needed the government is concerned that it will place a further additional burden on schools and has told them that they can delay the start of implementing their new curricula until June 2021. Amidst so much change we understand the instinct to delay introducing this topic in schools that haven’t really tackled it before. However, we hope that many will see RSHE as the answer to some of their problems and not just an additional problem to deal with. At whatever point schools begin implementing RSHE this academic year, Brook along with many national and local experts and organisations are there to help. ► Lisa Hallgarten is Head of Policy and Public Affairs, Brook, and Dr Anatole Menon-Johansson is Clinical Director, Brook. Go to www.brook.org.uk.

REFERENCES 1. Brook: Life under lockdown, survey July 2020 2. Inside Out - Young People’s Health and Wellbeing: A response to Covid-19. National Youth Agency (www.nya.org.uk) and Brook (www.brook.org.uk) August 2020 3. https://www.gov.uk/guidance/pastoral-care-inthe-curriculum

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FERTILE YEARS

WORDS BY DR AMY TATHAM

The long view of preconception care

IT IS IMPORTANT TO RECOGNISE THAT MANY WOMEN HAVE MULTIPLE RISK FACTORS AS THEY OFTEN CO-EXIST

Improving the long-term pregnancy outcomes of a population

e often focus on short term outcomes as a marker of a successful pregnancy and delivery. It could be argued that a successful pregnancy is one which occurs at a time when a woman is physically, socially and emotionally optimised for the challenges of pregnancy and motherhood, thus reducing the chance of perinatal morbidity and mortality and which affords her baby the best possible chances of physical and emotional development. But how best can we improve the long-term pregnancy outcomes of a population? This article looks at factors that can be considered to empower women to have the best chance they can of a successful pregnancy. Effective preconception care aims to improve maternal and child outcomes through improving pre-pregnancy health and fitness and adequate planning for the first pregnancy and for subsequent pregnancies. It is about reducing risks to mother and baby,

and also about promoting healthy behaviours that will benefit young people, male and female, regardless of their plans to become parents. It is a busy morning surgery and your next patient is Lisa, an 18-year-old. Lisa has one child aged 9 months. She is a single parent, having fled an abusive relationship. She is taking medication for depression. She has recently started in a new relationship. She has a contraceptive implant but has had some problematic bleeding. She wants it removed and will use condoms instead. She would like a further pregnancy in the future but not yet. • Is it in her best interests to remove the implant now or are there other options to discuss and help with the bleeding problems? • What issues should be addressed? The contraceptive implant is a reliable and effective long acting method of contraception in comparison to condoms with typical use. 45% of pregnancies and a third of births are unplanned or ambivalent 1. Unplanned

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births are associated with a higher risk of poor outcomes that may impact on the woman and child with increased risk of obstetric complications and poor mental health. Additionally, one third of women will get pregnant within a month of stopping contraception and 80% within 6 months2 . This highlights the importance of women pre-planning and being fit for pregnancy and if a pregnancy is unplanned then reliable and effective contraception is vital in order to plan for the best possible outcome for mother and baby. Poor preconception care will impact on the safety of pregnancy and childbirth for both mothers and babies and has potentially long-term impacts on child health. Care and consideration should be given to teenage mothers: 12% of teenage mothers already have a baby and they have a significant higher risk of still birth (24%) and infant mortality (56%2). It is important to address Lisa’s mental health. We are aware of her use of antidepressants. We need to consider the safety of the medication

▲ Portrait by Emily Tatham REFERENCES 1. https://www.gov. uk/government/ publications/healthmatters-reproductivehealth-andpregnancy-planning/ health-mattersreproductive-healthand-pregnancy-planning 2. https://assets. publishing.service. gov.uk/government/ uploads/system/ uploads/attachment_ data/file/729018/ Making_the_case_for_ preconception_care.pdf 3. https://www.fsrh. org/standards-andguidance/documents/ contraception-afterpregnancy-guidelinejanuary-2017/

FERTILE YEARS

and the benefits versus the risks. There is an increased prevalence of mental health problems during pregnancy and for the first year after delivery, with a prevalence of up to 20% in women. 10% of men also suffer postnatal depression2. Poor parental mental health can adversely affect the infant’s behavioural, emotional and cognitive development. It may adversely affect bonding and the quality of parenting. Additionally, suicide is a leading cause of maternal death in the UK. It is important to make sure Lisa’s mental health is optimised and that she has the necessary planning and support in place and an understanding and recognition of her mental health prior to planning a pregnancy 3. We determine more of Lisa’s history and examination. Lisa has a BMI of 36, she is a smoker and she has a strong family history of diabetes. Maternal obesity and smoking result in a higher risk of poor birth outcomes. Obesity increases the risk of gestational diabetes, birth complications and subsequent development of diabetes later in life. In turn, the risk of obesity and diabetes in children of obese and diabetic mothers is also increased. Obesity results in a higher incidence of birth defects and metabolic abnormalities in the infant. Smoking in pregnancy negatively affects the placenta and results in an increased risk of miscarriage, stillbirths and premature deliveries. 13.7% of women smoke during pregnancy2. Many of the health behaviours and risk factors for poor birth outcomes are established before pregnancy and in the UK 11% of women continue to smoke through pregnancy2. With effective counselling and support we can encourage women to stop smoking before they are pregnant and this will have a positive impact on child health by reducing the risk of a low birth weight, respiratory conditions, obesity in childhood, diabetes and problems with the ears, nose and throat. Folic acid supplements should be taken for at least three months before trying to conceive in order to

reduce the risk of neural tube defects. In Lisa’s case she should be given a 5mg dose of folic acid/day with her higher BMI (>30). There has been a reduction in the number of women taking supplements in recent years, particularly in younger mothers and those of lower socioeconomic status2 . Being fit for pregnancy is not about the week before conception but it is about optimising physical and mental health throughout adolescence and into the reproductive years to achieve a healthy and successful pregnancy for mother and baby. Ideally this information is best delivered in the years before the commencement of sexual relationships. Other opportunities may be contraceptive counselling consultations, as part of sexual health discussions and at postnatal reviews to avoid interpregnancy intervals of less than 12 months2 .

BY ADDRESSING RISK FACTORS AND PROVIDING ADEQUATE PRENATAL EDUCATION WE ARE GIVING THE NEXT GENERATIONS THE BEST POSSIBLE START IN LIFE

It is important to recognise that many women have multiple risk factors as they often co-exist. By addressing risk factors and providing adequate prenatal education we are giving the next generations the best possible start in life. There needs to be a whole system approach to providing education across the population before the age of first pregnancy. It is important to recognise opportunities within primary care to promote fitness for pregnancy at contraceptive consultations, after miscarriage, abortion and postnatally and opportunistically at cervical screening and sexual health screening appointments. Contraception should no longer be seen solely as a means of avoiding pregnancy until chronologically the right time, but additionally a tool with which women can remain unpregnant to facilitate a period of nutritional, physical and emotional optimisation.

HOW DO WE TACKLE PRENATAL DISCUSSIONS AND WHAT SHOULD WE CONSIDER DISCUSSING? HEALTHY BEHAVIOURS Optimal nutritional intake, regular exercise, folic acid supplementation, promoting emotional well-being, ensuring immunisations, cervical screening and sexual health screening RISK FACTORS Smoking, alcohol, substance misuse, obesity, long term mental health conditions, genetic risks, maternal age, domestic abuse and adverse childhood experiences, migrant factors ADDRESS SOCIAL FACTORS Relationship support, education, housing, employment and financial support

Her Life Her Health | Autumn 2020 | 15

FERTILE YEARS

Top Tips for managing HMB in primary care WORDS BY DR ANNE CONNOLLY, DR JULIE OLIVER, DR AAMENA SALAR & DR VICTORIA COGGER

Do not quantify, but ask how it affects her Heavy menstrual bleeding (HMB) affects a woman’s physical, psychological and social health and wellbeing. Any intervention for HMB should aim to improve the woman’s quality of life rather than focusing on blood loss.1 HMB is a common concern but there remains a stigma and unappreciation of the impact on a woman’s life, and it is under-reported to healthcare providers. 1 in 5 women suffers with HMB1, 43% of women have taken time off work due to their heavy period, and 50% of affected women have never been to see a GP about their condition.2 So when a woman complains of heavy periods then it matters to her and it needs actioning. It is the impact on her quality of life that matters; the amount of blood loss does not need to be quantified.

Clarify the bleeding pattern & pressure symptoms It is essential to clarify the history of the woman’s problem to decide on examination and investigation requirements. In addition to her complaint of heavy menstrual bleeding, it is important to determine the pattern of bleeding and whether there are any pressure symptoms suggestive of large fibroids or pain suggesting adenomyosis. Note: women often complain of short cycle length rather than inter-menstrual bleeding (bleeding at a point of the cycle other than during the normal period) or erratic bleeding, which are symptoms of endometrial pathology.

Risk factors/When to worry HMB is common and is usually a result of dysfunctional uterine bleeding but may be caused by endometrial hyperplasia and endometrial cancer. Risk factors include: • Increasing age • Obesity (BMI>35).

Plus any condition causing oestrogen excess/unopposed oestrogen including: • Inadvertent use of oestrogen-only HRT • Polycystic ovary syndrome with chronic anovulation • Insulin resistance • Tamoxifen use. When to examine Abdominal examination may reveal large fibroids and is usually expected by women when complaining of HMB. Speculum and pelvic examination should be considered if there are additional relevant symptoms of pelvic pressure, tenderness, or of post-coital bleeding, but may not be necessary if the symptom is of HMB only.

Basic laboratory investigations recommended • F ull blood count (FBC) for all • Testing for coagulation disorders only if HMB since menarche or personal/FH of coagulation disorder • Consider sexual health screening • C ytology if due.

No indication for testing thyroid function, hormone levels, prolactin or ferritin without the presence of additional symptoms.

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When to scan Ultrasound (US) scans are overused, do not change management, and often lead to further unnecessary investigations. Consider what findings would be expected from an ultrasound scan to influence management. If a scan is indicated, remember to request a trans-vaginal US scan in addition to a pelvic scan to allow improved imaging of endometrium and ovaries – and warn the woman to expect an ‘internal’ probe. Consider: • US scan if she has pressure symptoms, dyspareunia, or anything to suggest uterine enlargement • US scan if unable to assess uterine size if obese or difficult examination • Direct endometrial visualisation by hysteroscopy if she has persistent intermenstrual bleeding or endometrial risk factors • No investigations required if none of above apply.

When to hysteroscope/Refer Refer for hysteroscopy or expert opinion if endometrial assessment required in women presenting with a history of persistent intermenstrual bleeding, fibroid or polyp suggested on US scan, endometrial risk factors, failed medical or surgical management. List any identified risk factors on the referral letter to help the hospital team triage the referral directly into the hysteroscopy clinic if required and possible. Hysteroscopy is usually performed in the outpatient setting with women awake. It is a short procedure which is usually tolerated very well. Local anaesthetic is used if required or requested. Most diagnostic hysteroscopes used allow endometrial samples to be taken directly from endometrial pathology or by a global suction using a pipelle. It is also possible to progress to treatment procedures in the outpatient setting when required to insert LNG-IUS, perform morcellation of endometrial polyps and small fibroids or endometrial ablation.

FERTILE YEARS

Download these resources at www.pcwhf.co.uk/HLHH

Treat on that day/Don’t let the woman leave your room without • T reat with tranexamic acid +/- analgesia at first visit, including while waiting for further investigations or referral. • Tranexamic acid is well tolerated but requires a 1-1.5g tds dose to be effective. • Myth buster: Tranexamic acid does not increase thrombotic risk or cause peptic ulceration.

Pathway of management – remember you can’t go back following an irreversible procedure Treatments depend on investigation findings, imminent fertility requirements, risk assessment and informed patient choice. A useful resource is the NICE-endorsed ‘Shared decision making aid for heavy menstrual bleeding’. Heavy periods: what are my options?3 For HMB where no abnormal pathology is found or considered likely, NICE recommends the use of levonorgestrel-releasing intrauterine system (LNG-IUS) as first line treatment. This can be offered in primary care where possible.

Endometrial ablation NICE recommends second-generation endometrial ablation techniques. These deliver radio-frequency energy to ablate the endometrium and reduce or stop endometrial regrowth. Further information about the procedure for clinicians and patients is available on the Wear White Again website. www.wearwhiteagain.co.uk

Option if:

• LNG-IUS not acceptable or effective • Patient choice • Family complete. Pros:

LNG-IUS Pros: • 80-90% reduction in bleeding at 12 months1 • Contraceptive & can be used as part of HRT if needed • Reversible • Licensed for use for HMB • Long lasting • P rotection against endometrial hyperplasia (off – license). Cons:

• M inor procedure for insertion • Unpredictable bleeding – usually improves with time • Hormonal side effects – but these usually subside after a few months • Insertion risks; perforation, infection. Alternative medical options include:

° Hormonal; combined hormonal contraception, long-cycle progestogens (consider use of medroxyprogesterone acetate rather than norethisterone because of thrombotic potential of NET). Non-hormonal: tranexamic acid, any NSAID. °

• Minimally invasive surgery, easy to perform in the outpatient setting with women awake using local anaesthetic and analgesia • No pre-treatment required • Can be performed at any time of the menstrual cycle including during menstruation • P rocedure takes an average 60-90 secs with 15 minutes set up time • O ption for general anaesthetic day case procedure if requested • Good outcome with 97% not requiring further surgical treatment within 5 years 4 • Well tolerated with women returning to daily activities within 24 hours. Cons:

• R isks of procedure include uterine perforation and post-procedure infection • Permanent procedure that cannot be reversed • Reliable contraception still required after ablation & IUCD difficult/impossible to fit unless included as part of the procedure • Combined HRT preparations required for menopausal symptoms • I f unsuccessful, more invasive interventions required.

Hysterectomy Hysterectomy for treatment of HMB should not be offered as a first line and was included in the list of inappropriate interventions produced by the Evidence-Based Intervention Programme published by NHS England5. The primary goals of the Evidence-Based Interventions programme are to avoid needless harm to patients and free up scarce professional time for performing other interventions.

Pros:

• A menorrhoea guaranteed • H igh satisfaction rates. Cons:

• Major surgery with associated risks • Requires general anaesthetic • Post-operative infection/DVT • Can cause premature menopause • 4-8 weeks post-op recovery time and delayed return to activities of daily living • Long term possible pelvic pain, continence problems, sexual problems, psychological impact • Death: mortality rate 0.4-1.1/1000.6

REFERENCES 1. nice.org.uk/guidance/ng88 2. Data on file: MISC-05658-GBR-EN Rev 001 3. www.wisdom.wales.nhs.uk/sitesplus/documents/1183/ HMB_Shared_Decision_Making_Aid_Updated_ version_Mar-2020.pdf 4. J Reprod Med 2007 Jun:52(6);467-72 5. www.england.nhs.uk/wp-content/uploads/2018/ 11/ebi-statutory-guidance-v2.pdf 6. BJOG Vol 111 Issue 7, July 2004 688-694 DECLARATION Hologic has provided an educational grant to fund this top tips resource. Hologic has no editorial control over the content.

Her Life Her Health | Autumn 2020 | 17

FERTILE YEARS

Tips for cervical screening in transgender, non-binary and intersex communities Advice for healthcare professionals from gynaecological cancer charity, THE EVE APPEAL.

Preparation Make the offer: Trans men and non-binary people may not receive an invitation letter to go to a cervical screening so do keep in mind when seeing them whether they may need a screening test, make them aware they are due and chat them through what the test is and why they might want to have one. Don’t assume: If you don’t already know, check with your patients what their preferred pronouns are. Check what gender reassignment genital surgeries your patient has had, if any. Also ask your patient what they prefer their genitals to be called, avoid words like vagina/vaginal unless told otherwise.

Download this resource at www.pcwhf.co.uk/HLHH

18 | Primary Care Women’s Health Forum | pcwhf.co.uk

FERTILE YEARS

Photograph from The Gender Spectrum Collection www.genderphotos.vice.com

Set expectations: Let your patient

know that there is no pressure to have their screening done in your first appointment together. Sometimes multiple appointments are needed so that trust is built up and your patient can prepare themselves in whatever way they need to, before a sample can actually be collected from their cervix. Try to avoid language such as ‘successful’, ‘inadequate’ and so on. Show and tell: Show your patient the equipment you will be using first. Knowing what to expect can help make things seem less scary. Show them the speculum and brush you plan to use and talk them through the procedure step-by-step before you begin. Be aware: That your patient may not have experienced any vaginal penetration, which includes vaginal intercourse, using sex toys or tampons. Therefore they may find a speculum painful. Try the smallest size speculum, and make sure it is lubricated. Relaxation is key: As humans, when we hear the words ‘just relax’, we often do the exact opposite! But if you can, let your patient know before your appointment together that being relaxed is important and will make the screening process easier. What normally relaxes them? Let them know they can bring in their favourite music, a stress ball, or a friend or partner for support. Whatever they can do to try and feel as calm as possible. Testosterone: May affect the results of a cervical screening test, so be sure to check with your patient whether or not they are currently taking testosterone. Testosterone can cause changes to the cervix that can mimic cervical dysplasia (abnormal cells). Using an extended brush can help to get a better sample of cervical cells. Someone taking testosterone is more likely to receive an abnormal cervical screening result, and be referred for a colposcopy. Let your patient know that this is the case and reassure them that taking testosterone isn’t increasing their risk of cervical cancer.

LET YOUR PATIENT KNOW THAT THERE IS NO PRESSURE TO HAVE THEIR SCREENING DONE IN YOUR FIRST APPOINTMENT TOGETHER

IF YOUR PATIENT IS TAKING TESTOSTERONE, THEY WILL HAVE LESS NATURAL VAGINAL LUBRICATION

Performing the screen Control: Throughout the appointment remind your patient that they are in control, and that they can tell you to stop or change their mind at any time. Some patients can feel very vulnerable during a screening appointment, so letting them know that everything is on their terms can help balance this. Letting them know that if it is easier for them they can help you guide in the speculum. Get informed and explicit consent, and double or triple check! Moisture: If your patient is taking testosterone, they will have less natural vaginal lubrication, which can make a cervical screening test more uncomfortable for them and harder for you in terms of inserting the speculum. Advise them to use a natural vaginal moisturiser before the appointment to make using a speculum easier and more comfortable. An oestrogen cream is also something that is helpful in this situation, but understandably many trans men will not want to use anything oestrogen-based, even if it is a localised product, i.e. it won’t do anything to the body other than make the vaginal wall more moisturised.

Patients first: If your patient is finding the appointment really difficult, or taking the sample is causing a lot of discomfort or pain, it may be better for your patient to not go through with the screening test at this moment. It might be better to recommend trying again at another appointment. Sometimes, after thinking about their risk of having HPV, i.e. their sexual activity/history (if any), a patient may decide against completing their screening. Their overall wellbeing is a priority, particularly if the risk of cervical cancer is low.

Follow up Plan b: Sometimes it just isn’t possible to finish the cervical screening test, either because you can’t take the sample or your patient would prefer not to go ahead with the appointment. If appropriate, you might want to tell your patient about self-testing kits that can be done at home. It will come at a financial cost to them, and the chances of a poor sample or inaccurate result are higher, but is better than no test at all. ► The Eve Appeal raises awareness and funds research for the prevention, risk prediction and early diagnosis of the five gynae cancers, and they want to support everyone with a cervix to get screened. Go to eveappeal.org.uk/tnbiinfo

Her Life Her Health | Autumn 2020 | 19

WIDE AWAKE AT

NIGHT?

Isolation and loneliness can affect our quality of sleep1

• • •

Provides clinically meaningful improvements in quality of sleep and morning alertness2 No common or very common undesirable effects2 Treatment can be continued for up to 13 weeks2

Circadin® 2mg (prolonged-release melatonin) Tablets Prescribing Information: Please refer to the Summary of Product Characteristics before prescribing. Presentation: Circadin 2mg prolonged-release tablets containing 2mg melatonin. Indication: Monotherapy for the short-term treatment of primary insomnia characterised by poor quality sleep in patients aged 55 or over. Dosage and administration: 2mg orally once daily, 1-2 hours before bedtime and after food. Swallow whole, do not crush or chew. This dosage may be continued for up to thirteen weeks. Children and adolescents (<18 years): Safety and efficacy not yet established. Contraindications: Hypersensitivity to the active substance or to any excipients. Special warnings and precautions for use: Use caution when administered to patients with renal insufficiency. Not recommended for use in patients with hepatic impairment. Circadin may cause drowsiness, therefore use with caution if the effects of drowsiness are likely to be associated with a risk to safety. Not recommended in patients with autoimmune diseases. Patients with rare hereditary problems of galactose intolerance, the LAPP lactase deficiency or glucose-galactose malabsorption should not take this medicine. Fertility, pregnancy and lactation: Circadin use in pregnancy and in women intending to become pregnant is not recommended and breast-feeding is not recommended in women receiving melatonin. Driving: Circadin has moderate influence on the ability to drive and use machines. Interactions: Fluvoxamine should be avoided. Caution should be used in patients on 5- or 8-methoxypsoralen (5- and 8-MOP), cimetidine and oestrogens. Cigarette smoking may decrease melatonin levels. CYP1A2 inhibitors such as quinolones may give rise to increased melatonin exposure. CYP1A2 inducers such as carbamazepine and rifampicin may give rise to reduced melatonin exposure. Alcohol should not be taken with Circadin. Sedative properties of benzodiazepines and non-benzodiazepine hypnotics may be enhanced. Undesirable effects: In clinical trials the rate of patients with adverse events per References 1. Simon, E.B. and Walker, M.P. (2018) Nature Communications 9; 3146. 2. Circadin SmPC August 2019.

100 patient weeks was higher for Placebo than Circadin (5.743 placebo vs. 3.013 Circadin). There are no very common (≥1/10) or common (≥1/100 to <1/10) adverse reactions. Uncommon (≥1/1,000 to <1/100) adverse reactions include hypertension, chest pain, migraine, headache, irritability, abnormal dreams, nightmares, dermatitis, menopausal symptoms, abdominal pain, abnormal liver function test and asthenia. Rare (≥1/10,000 to <1/1,000) adverse reactions include loss of consciousness, angina, palpitations, depression, visual impairment, disorientation, vertigo, haematuria, leukopenia, thrombocytopenia and abnormal laboratory test. Prescribers should consult the full Summary of Product Characteristics for further information on adverse reactions. Legal category: POM. Packs and Prices: Circadin 2mg, 30 tablets, £15.39. Marketing Authorisation number: EU/1/07/392/003. Marketing Authorisation holder: RAD Neurim Pharmaceuticals EEC SARL, 4 rue de Marivaux, 75002 Paris, France. Further information available from: Flynn Pharma Ltd. Hertlands House, Primett Road, Stevenage, Hertfordshire, SG1 3EE. Date of last revision of PI: March, 2019.

Information about this product, including adverse reactions, precautions, contraindications and method of use can be found at http://www.medicines.org.uk/emc/

Date of preparation April 2020

UK/CIR/2020/966

RENAISSANCE YEARS

Non-hormonal management of the menopause Not all women can, or wish to take hormone replacement therapy. What alternatives can you offer those women?

THERE ARE PRESCRIBABLE MEDICATIONS THAT ARE NOT HORMONES THAT CAN HELP RELIEVE SYMPTOMS OF THE MENOPAUSE WORDS BY DR CLARE SPENCER

any women suffer debilitating menopause symptoms. The median length of time for symptoms to resolve is 7 years, though for some women it may longer. There is good evidence that hormone replacement therapy (HRT) can help relieve many of these symptoms, but it is not always the answer. Many women do not want to take HRT because of side effects. Many have concerns about real or perceived risks. Some women will have been advised not to take HRT by their doctors because of underlying medical conditions or malignancy. Some women prefer to get through without medicine as, for many, symptoms resolve naturally with time. It is therefore important to know how to help women manage menopause symptoms in alternative ways to taking HRT. Many of the options and issues discussed in this article are also useful for women on HRT. The lifestyle changes discussed cannot only help manage symptoms, but help prevent the long term health consequences of the menopause; cardiovascular and osteoporosis. There are therefore health benefits to women going forward in their lives during the menopause and beyond.

EXERCISE Regular exercise can help sleep quality, insomnia and depression1 and may help hot flushes in some women2. Regular weight bearing exercise (such as running or brisk walking) can help prevent osteoporosis. Smoking cessation is important. There is evidence to suggest that smoking increases the risk, severity and frequency of experiencing hot flushes; all parameters can improve after smoking cessation3. The severity of menopausal symptoms is higher among obese women as compared to nonobese women, and clinically significant weight loss results in marked improvement of these symptoms, especially hot flushes, mood disorders, and sleep disturbances4.

DIET There is no one ‘best menopause diet’. Caffeine, alcohol and spicy foods can increase the severity of hot flushes so it makes sense to avoid them. A Mediterranean diet is associated with lower risk of cardiovascular disease. Ensuring optimal vitamin D and calcium can help prevent osteoporosis, alongside regular weight bearing exercise. During the spring and summer, the sunlight is sufficient to help our bodies make enough vitamin D, but there is a recommendation to take a vitamin D supplement containing at least 10 micrograms or 400 international units of vitamin D during the autumn and winter. If you’re at risk of having low vitamin D, it’s recommended you take a daily supplement throughout the year5.

Her Life Her Health | Autumn 2020 | 21

RENAISSANCE YEARS

MENTAL HEALTH In terms of trying to keep on an even keel, women may find mindfulness, yoga and mediation really helpful, with evidence that it can also help hot flushes6. Cognitive behaviour therapy (CBT) is a psychological talking therapy where problems are managed by changing the way that thoughts are processed and changing behaviour. It is recommended by NICE as a method of managing menopause symptoms7. For women in the perimenopause and menopause, CBT can help anxiety and low mood, hot flushes and night sweats, and can help sleep problems8. It is based on the premise that negative feelings toward hot flushes and night sweats can both cause and maintain them. CBT can work as individual or group therapy 9. Resources for women can be found on the Women’s Health Concern website10.

COMPLEMENTARY THERAPIES Complementary and alternative therapies can help some, though there is a general lack of good quality randomised control trials. Some women prefer to try herbal preparations and isoflavones – plant oestrogens. Natural does not equate to safety or risk-free however. For example, St John’s Wort can help hot flushes but can also potentially seriously interact with other drugs (including tamoxifen, anticoagulants and anticonvulsants). NICE advises that quality, purity and constituents of these products may be unknown. Herbal preparations and isoflavones are not regulated by the European Medicines Authority and in most instances are not subject to any quality control or research studies of sufficient power or quality. The Medicines and

Healthcare products Regulatory Agency (MHRA) runs the Traditional Herbal Registration (THR) scheme which requires every herbal medicine marketed in the UK to hold a THR. THR registered preparations have patient information advising how to take the medication, plus possible interactions with other medicines.

PRESCRIBABLE ALTERNATIVES There are prescribable medications that are not hormones that can help relieve symptoms of the menopause11. Clonidine is an alpha receptor agonist and is a treatment for hypertension. This is licensed for the management of menopausal flushes. The most common side effects include a dry mouth and drowsiness, and this may result in poor tolerance. All other prescribable alternatives are not licensed for the management of menopause symptoms, but there is evidence for efficacy. Gabapentin and prebabalin can improve hot flushes and quality of life. Serotonin reuptake inhibitors (SSRIs) can all improve quality of life, psychological symptoms and many can improve hot flushes – paroxetine having the best evidence base12. Many – paroxetine, fluoxetine and sertraline particularly – can interfere with the enzyme cytochrome 450. This is important for women taking tamoxifen as it become less effective as a result. Care should therefore be taken when prescribing. Venlafaxine can also be effective in reducing hot flushes and improving quality of life13 . In summary, there are many alternative options to HRT for women to choose from. Lifestyle changes can be effective. Careful, motivational consulting can encourage changes which can help relieve menopausal symptoms, improve wellbeing and help prevent the long term health consequences of the menopause.

22 | Primary Care Women’s Health Forum | pcwhf.co.uk

MANY HAVE CONCERNS ABOUT REAL OR PERCEIVED RISKS

REFERENCES 1. Sternfeld B, Guthrie KA, Ensrud KE, et al. Efficacy of exercise for menopausal symptoms: a randomized controlled trial. Menopause. 2014;21(4):330-338 2. Elavsky S, Gonzales JU, Proctor DN, Williams N, Henderson VW. Effects of physical activity on vasomotor symptoms: examination using objective and subjective measures. Menopause. 2012 Oct;19(10):1095–103 3. Smith RL, Flaws JA, Gallicchio L. Does quitting smoking decrease the risk of midlife hot flashes? A longitudinal analysis. Maturitas. 2015;82(1):123-127. doi:10.1016/j.maturitas.2015.06.029 4. Obesity associates with vasomotor symptoms in postmenopause but with physical symptoms in perimenopause: a cross-sectional study. Koo S, Ahn Y, Lim JY, Cho J, Park HY BMC Womens Health. 2017 Dec 8; 17(1):126 5. www.nhs.uk 6. Carmody JF, Crawford S, Salmoirago-Blotcher E, Leung K, Churchill L, Olendzki N. Mindfulness training for coping with hot flashes: results of a randomized trial. Menopause. 2011;18(6):611-620. doi:10.1097/gme.0b013e318204a05c; Cramer H, Lauche R, Langhorst J, Dobos G. Effectiveness of yoga for menopausal symptoms: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2012;2012:863905. doi:10.1155/2012/863905 7. https://www.nice.org.uk/guidance/ng23 8. Mann,E., Smith,M.J., Hellier,J., Balabanovic,J.A., Hamed,H., Grunfeld,E.A., Hunter,M.S,. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial, Lancet Oncology, 13, 309-318, 2012 9. Managing Hot Flushes with Group Cognitive Behaviour Therapy Myra Hunter and Melanie Smith. Published Routledge 2015 10. https://www.womens-health-concern.org/ help-and-advice/factsheets/cognitive-behaviourtherapy-cbt-menopausal-symptoms/) 11. https://thebms.org.uk/wp-content/ uploads/2018/03/Prescribable-alternatives-to-HRT01EE.pdf. Accessed July 2020 12. Carroll DG, Lisenby KM, Carter TL. Critical appraisal of paroxetine for the treatment of vasomotor symptoms. Int J Womens Health. 2015;7:615-624 13. Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD004923. DOI: 10.1002/14651858.CD004923.pub2

ESTRIOL 50 micrograms/g VAGINAL GEL

A drop of bliss

Sometimes a topical discussion is diﬃcult to start

The only strongly hydrating mucoadhesive, clear aqueous gel for the topical treatment of vaginal atrophy 1,2 For women with urogenital atrophy, oﬀer low-dose vaginal oestrogen 3

References 1. Blissel SmPC, April 2019 2. Cano et al. 2012 3. NICE CKS Guidelines. Menopause. March 2017 BLISSEL® (ESTRIOL 50 micrograms/1g) VAGINAL GEL PRESCRIBING INFORMATION: Please refer to Summary of Product Characteristics (SmPC) before prescribing. ACTIVE INGREDIENT: 1g vaginal gel contains 50 micrograms estriol. INDICATIONS: Local treatment of vaginal dryness in postmenopausal women with vaginal atrophy. DOSAGE AND ADMINISTRATION: Use the lowest effective dose for the shortest duration. Treatment initiation or reinstitution: One applicator-dose per day for 3 weeks at bedtime. Only initiate local estrogen therapy for symptoms that adversely affect quality of life. Take a complete personal and family medical history. Use this, and the contraindications and warnings for use, to guide physical (including pelvic and breast) examination. Treat vaginal infections before starting therapy. Maintenance treatment: One applicatordose twice weekly at bedtime. Evaluate treatment continuation after 12 weeks. Conduct periodic check-ups and investigations, adapted to the individual, including mammography, in accordance with accepted screening practices. Advise of breast changes that should be reported. Appraise the risks and benefits at least annually and continue only if the benefit outweighs the risk. Administer a missed dose as soon as remembered. Skip doses 12 hours or more overdue and administer the next dose at the normal time. Administration: Apply into vagina using dose-marked applicator in accordance with instructions in the information leaflet. CONTRAINDICATIONS: Known, past or suspected breast cancer, known or suspected estrogen dependent malignant tumour, undiagnosed genital bleeding, untreated endometrial hyperplasia, previous idiopathic or current venous thromboembolism, active or recent arterial thromboembolic disease, known thrombophilic disorders, acute liver disease or a history of liver disease as long as liver function tests have failed to return to normal, porphyria, hypersensitivity to the active substance or to any of the excipients. SPECIAL WARNINGS AND PRECAUTIONS: Do not combine with estrogen preparations for systemic treatment. Risk of endometrial hyperplasia and carcinoma in oral treatment solely with estrogen is dependent on treatment duration and estrogen dose. Increased risk of endometrial hyperplasia or uterine cancer has UK/BLS/2020/965 Date of preparation: May 2020

not been attributed to treatment with estriol by vaginal use; if continued treatment is required periodic revisions are recommended, with special consideration to symptoms suggestive of endometrial hyperplasia or endometrial malignancy. Investigate breakthrough bleeding or spotting occurring at any time on therapy to exclude endometrial malignancy. Caution in women who have undergone hysterectomy because of endometriosis, especially if there is residual endometriosis. Increased risk of certain types of cancer (in particular uterine, ovarian and breast cancer),venous thromboembolism, stroke and coronary artery disease associated with systemic hormone replacement treatment. Blissel vaginal gel administered locally is not expected to increase the risk of cancer, VTE, stroke and coronary artery disease. Generally recognised risk factors for VTE include a personal history or family history, severe obesity (BMI > 30 kg/m2) and systemic lupus erythematosus . No consensus about the possible role of varicose veins in VTE. Close supervision is recommended in these patients. Estrogens with systemic effects may cause fluid retention or increase of plasma triglycerides. Therefore, careful observation of patients with heart diseases or impaired renal function or with pre-existing hypertriglyceridemia during the first weeks of treatment is recommended. No systemic effects expected with local treatment using a low dose estriol vaginal gel. Careful observation in severe renal insufficiency as levels of circulating estriol may be increased. Close supervision of patients with current, previous, or where the condition has been aggravated during pregnancy, or previous hormone treatment: Leiomyoma or endometriosis, risk factors for thromboembolic disorders or estrogen-dependent tumours, hypertension, liver disorders, diabetes mellitus with or without vascular involvement, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of endometrial hyperplasia,epilepsy,asthma,otosclerosis. Intravaginal applicator may cause minor local trauma, especially in women with serious vaginal atrophy. Discontinue immediately if a contraindication is discovered and in cases of jaundice or deterioration in liver function,significant increase in blood pressure, new onset

of migraine-type headache or pregnancy. INTERACTIONS: No interaction studies have been performed. No clinically relevant interactions expected. FERTILITY, PREGNANCY, LACTATION: Not indicated during pregnancy. Withdraw treatment immediately if pregnancy occurs. No data available on exposed pregnancies. Not indicated during lactation. DRIVING: No influence on ability to drive and use machines. UNDESIRABLE EFFECTS: Very common: None. Common: Pruritus genital, application site pruritus, pruritus. Consult SmPC in relation to less common side effects. PHARMACEUTICAL PRECAUTIONS: Store below 25°C. LEGAL CATEGORY: POM. Product

NHS List Price

Pack Size

Marketing Authorisation Number

Blissel

£ 18.90

30g

PL 20663/0003

MARKETING AUTHORISATION HOLDER: Italfarmaco S.A., San Rafael 3, 28108 Alcobendas (Madrid), Spain. Marketed in the UK by Flynn Pharma Limited, Hertlands House, Primett Road, Stevenage, Herts, SG1 3EE, Tel: 01438 727822, E-mail: medinfo@flynnpharma.com.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to Flynn Pharma Ltd. Medical Information: Tel 01438 727822, E-mail medinfo@flynnpharma.com. Information about this product, including adverse reactions, precautions, contraindications and method of use can be found at http://www.medicines.org.uk/emc/. DATE OF REVISION OF PRESCRIBING INFORMATION: May 2019. Blissel® is a registered trademark of Italfarmaco S. A., San Rafael 3, 28108 Alcobendas (Madrid), Spain.

RENAISSANCE YEARS

Physiotherapy & pelvic health How a chance conversation in the school playground led a specialist pelvic health physiotherapist to create an award-winning app and pelvic health campaign group that has transformed the lives of many women.

M WORDS BY MYRA ROBSON

y journey in pelvic health started in 1996, when my senior went on maternity leave and asked me to cover the small cohort of women with stress urinary incontinence. I had no clue what to do and took a one-day course. This day was transformational, and my career path changed. Fast forward to 2012 and a chat with another parent in the playground. He was a co-founder of a small technology company involved in publishing and knew nothing about pelvic health physiotherapy. He asked what the most challenging part of my job was. “Enabling women to remember to do their pelvic floor exercises regularly enough,” I said. “You could make an app for that,” came the reply. We brainstormed it, and a few months later had a prototype and potential funding. The funding fell through, but the company decided to

launch the app anyway, in September 2013. The response was incredible, and we have won various awards and kept a top spot on the paid medical app chart for some years. Squeezy is simple to use and has evidence-based and peer-reviewed content on pelvic floor exercises and how to do them. It comes pre-set with the basic maintenance programme: • 3 sets of exercises a day • 10 slow squeezes of 10 seconds each • 10 fast squeezes at a rate of 1 per second. The user can set a reminder schedule, and Squeezy will notify them that their exercises are due. It has various options such as snooze button, vibrate mode and a record of exercises completed. There is also a ‘professional mode’, designed to be used in conjunction with a pelvic health physiotherapist. This includes the sub-maximal exercise option (a sustained half squeeze, useful for prolapse management in particular), and the ability to change the settings further for the fast and slow exercises. Pelvic floor exercises have an excellent evidence base: • Reduce incidence of stress urinary incontinence post childbirth • 8 4% success rate in stress urinary continence resolution • Helps reduce urge in overactive bladder • Helps treat anal incontinence • Improves premature ejaculation, erectile dysfunction and postprostatectomy incontinence in men • Reduces early stage pelvic organ prolapse.

24 | Primary Care Women’s Health Forum | pcwhf.co.uk

The company, Living With, has also developed a clinician platform to work alongside Squeezy and their other apps. This allows clinicians to send an app free to the patient, along with outcome measures and symptom diaries, content, exercise videos and so on. The clinician can view the diaries and outcomes and follow progress remotely. The increased profile from Squeezy has enabled me to have a stronger voice in other areas of pelvic health. 2 years ago, I co-founded the collaborative campaign group ‘Pelvicroar’ with my colleagues Elaine Miller and Emma Brockwell. Pelvicroar is active on all key social media platforms and aims to amplify and unite the various voices in pelvic health, including health care professionals, expert patients, fitness professionals, product companies and any interested parties. We focus on evidence, expert opinion, critical thinking, and best practice. We have run various campaigns and have a website designed and run by my 16-year-old son, who is very knowledgeable about the topic now…. and way past any awkwardness when discussing vaginas! There is also a closed Facebook group for anyone interested in pelvic health. We do this in our own time, which makes progress somewhat ad hoc, but our aim is to become a one-stop resource for pelvic health issues by bringing together all the best resources in the field. We want to empower everyone to understand pelvic health, identify issues, seek treatment or advice, and break down taboos.

RENAISSANCE YEARS

What can you do to support your patients with their pelvic health? • OPEN THE DISCUSSION WITH EVERY RELEVANT PATIENT IF TIME ALLOWS! For example, if you see a woman for a post-natal check, make sure to ask if they have any issues controlling their bladder or bowels. Or reviewing an older person following a fall might prompt a question about whether they need to rush to get to the toilet on time. I accept that asking a male patient, presenting with knee pain, about their erectile function may seem odd but there are so many clinical scenarios that can connect to pelvic health that it is worth having it in your mind! • HAVE A SPACE IN YOUR CLINIC FOR SIMPLE, QUALITY INFORMATION ON PELVIC HEALTH. We know people get overloaded with information but something that says, ‘Do you experience any of the following…rushing to make the toilet on time, leaking urine, leaking faeces….etc’ with a link to suitable websites or a nudge to book an appointment can be very useful. A mention of Squeezy wouldn’t go amiss either! • TEACH EVERYONE TO DO SUITABLE CHECKS – TESTICULAR, BREAST AND VULVAL CHECKS ONCE A MONTH. Pelvicroar has run campaigns on vulval checks with the producer of a vaginal lubricant, and there are resources on our website. • PLEASE DO REFER PATIENTS TO PELVIC HEALTH PHYSIOTHERAPISTS. You can find ones near you (NHS and private) by searching the directory at www.squeezyapp.com/directory.

WE WANT TO EMPOWER EVERYONE TO UNDERSTAND PELVIC HEALTH, IDENTIFY ISSUES, SEEK TREATMENT OR ADVICE, AND BREAK DOWN TABOOS

During COVID-19, many physios have made a move to telephone and online consultations. I think there will continue to be some of these services long-term, at least as part of an initial assessment and advice process, and this may suit patients who feel embarrassed about seeking help. Do join our Pelvicroar closed Facebook group and become part of our community. Let us know if we can help you in any way, and contact the team at www.livingwith.health if you are interested in the technology. ► Myra Robson is a specialist pelvic health

physiotherapist and clinical lead at Lewisham & Greenwich NHS Trust in South London.

Her Life Her Health | Autumn 2020 | 25

As seen on BBC Breakfast

OVER HALF THE POPULATION WILL BE AFFECTED BY MENOPAUSE. WHY DON’T WE TALK ABOUT IT MORE?

Rock My Menopause’s campaign mission is to stamp out the taboo around menopause and encourage women to recognise their symptoms and have the confidence to speak to their doctor if they are affecting their quality of life. The menopause is inevitable; get ready to rock it.

ROCKMYMENOPAUSE.CO.UK @RockMyMenopause # RockMyMenopause

EXPERTISE FROM PCWHF

GOLDEN YEARS

DIAGNOSIS, TREATMENT, & MANAGEMENT OF

lichen sclerosus & vulval cancer Lichen sclerosus (LS) and vulval cancer (VC) are often misdiagnosed in primary care, and consequently women can suffer for years in pain and discomfort. LS can lead onto vulval cancer, therefore prompt diagnosis is essential.

W WORDS BY VICTORIA HOWELL

VULVAL SKIN CHECKS ARE NOT ROUTINELY UNDERTAKEN IN PRIMARY CARE. MY AIM IS TO INTRODUCE CHECKS INTO NICE CLINICAL GUIDELINES

hen seeking help for symptoms of LS and VC, some women report they were made to feel it was ‘all in your head’ and stopped seeking medical help. It is considered that if primary care clinicians are trained in recognising vulval skin conditions, women will receive improved treatment, improving quality of life and ultimately saving lives.. Vulval skin checks are not routinely undertaken in primary care. My aim is to introduce checks into NICE clinical guidelines. There is a lack of education in primary care around the importance of vulval skin examination. An opportune time to examine the vulva and ask questions regarding vulval health is during a routine cervical screening test, suspected thrush, cystitis and during contraception checks. This will give patients the chance to talk to you about any

concerns. For post-menopausal women, introduce into annual checks in the clinic setting. It takes minutes and promotes better practice outcomes. What is lichen sclerosus? LS is a chronic inflammatory skin disorder that can appear anywhere on the skin, however the vulval area is the only site that can lead onto cancer. 5% cases will lead onto cancer (Dermnet. NZ) however, this figure could be higher, due to misdiagnosis. Women are not being routinely examined for symptoms and are often incorrectly diagnosed with cystitis or thrush. Symptoms (may include some or all):

• Itching • D ysuria • D yspareunia • Porcelain white papules • Shiny/crinkled bruised skin • Splits/tears • Clitoris buried under skin • F usion of labia majora with labia minora.

What is vulval cancer? VC is a rare type of cancer that affects the vulva. There are around 1300 new vulval cancer cases in the UK every year, that’s more than 3 a day (Cancer Research UK). Around 80% are diagnosed in women over 60. However, increasingly more women are being diagnosed at a younger age (Eve Appeal). Some women are incorrectly diagnosed with herpes when in fact it is VC. The human papilloma virus (HPV), is common and infects the vulval skin and is a factor in the development of some vulval cancers. So be mindful of this when assessing your patient. It is thought that around 50% of vulval cancers related to HPV occur in women between 35 and 55. Vulval intraepithelial neoplasia (VIN), LS, and smoking are also risk factors. Symptoms include:

• Ecchymosis • Vulval pain • Ulcers/sores lasting 1 month + • Changes to the appearance of the vulva • Lump • Unusual discharge • White/purple patches • Bleed between periods • Lasting itch • Bleed post menopause.

Her Life Her Health | Autumn 2020 | 27

GOLDEN YEARS

▼ Source: Lichen Sclerosus UK Awareness, Vulval Cancer UK Awareness www.lsvcukawareness.weebly.com

LICHEN SCLEROSUS SYMPTOMS  White patches  Itching  Burning Clitoris Inner Labia Outer Labia

Clitoris Hood

 Splitting/tearing  Fusing of labias

Urethral Opening

 Clitoris buried under skin

Vagina

 Shiny/crinkly/bruised skin  Paper thin skin  Painful intercourse You don't have to have all the symptoms

28 | Primary Care Women’s Health Forum | pcwhf.co.uk

GOLDEN YEARS

WHEN DIAGNOSIS IS CONFIRMED A PROGRAMME OF STEROID TREATMENT WILL BE PRESCRIBED AND PATIENTS WILL NEED PSYCHOLOGICAL, EMOTIONAL, AND PRACTICAL SUPPORT

VULVAL CANCER SYMPTOMS  A persistent itch on the vulva  Pain, soreness or tenderness on the vulva  Raised and thickened patches of skin  A lump or wart-like growth on the vulva  Bleeding from the vulva or blood-stained vaginal discharge between periods  An open sore in the vulva  A burning pain with passing urine  A mole on the vulva that changes shape or colour You don't have to have all the symptoms

Diagnosis in primary care To identify LS in a patient, it’s important to examine the vulva and clinically assess, document symptoms presented and take a verbal history from the patient. If unsure, refer to a vulval dermatologist consultant (bad.org), for correct confirmed diagnosis. A biopsy may be necessary. When diagnosis is confirmed a programme of steroid treatment will be prescribed and patients will need psychological, emotional, and practical support. A sample guide with flow chart is available at www.bssvd.org. A fast track referral cancer pathway is advised for suspicion of vulval cancer, when on examination a woman presents with an unexplained vulval lump, ulceration, or bleeding (NICE). A biopsy will be taken and if positive for cancer, options on surgery, radiotherapy and chemotherapy will be discussed with the patient. Women report feeling scared and alone, some are too embarrassed to talk to their family about vulval cancer, and as a result may end up with no support at home. RESOURCES www.bssvd.org/wp-content/uploads/2019/04/ Lichen-Sclerosus-management-vs-6.pdf www.eveappeal.org.uk/gynaecological-cancers/ training-resources-for-gp-and-community-nurses/ www.lsvcukawareness.weebly.com/ www.vulvalpainsociety.org/vps/ REFERENCES www.bad.org.uk/ www.dermnetnz.org/topics/lichen-sclerosus/ www.eveappeal.org.uk/gynaecological-cancers/ training-resources-for-gp-and-community-nurses/ www.nice.org.uk/guidance/ng12/chapter/1Recommendations-organised-by-site-ofcancer#gynaecological-cancers www.cancerresearchuk.org

Management in primary care It is important to support your patient emotionally and practically. Support by educating regarding the daily care they need to administer to the vulva each day, for example the right emollient wash in place of soap, moisturiser, and topical steroid treatment regime. Guide them explicitly on where and how to apply the steroid cream. Patients report feeling very alone during this time, so it is important to give them to time to talk and to signpost to support groups and reiterate the importance of coming back to you at the onset of any changes. Educate them on how to check their vulva. It is advised that those with VC and LS check weekly; there are apps which allow safe storage of photos, this helps to identify changes and allows the patient to get prompt help. In patients that do not appear to have LS or VC it is advisable to promote health with your patients by educating them on how to check their own vulva once a month, by making it routine, much like breast checks. Provide leaflets on LS and VC in clinics and display infographics that are clear and easy to read, available on the LSVCUK Awareness website. Further training is available on the Eve Appeal website. Clare Baumhauer and Emma Norman are patient advocates for LS and VC and provide an excellent range of patient support and resources at www.lsvcukawareness.weebly. com. They also have a private Facebook group where women can access support.

Her Life Her Health | Autumn 2020 | 29

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September 2020

Abbreviated Prescribing Information: EVOREL® 25,50,75,100 (estradiol/patch) Presentation: Evorel 25: 1.6mg estradiol patch; Evorel 50: 3.2mg estradiol patch; Evorel 75: 4.8mg estradiol patch; Evorel 100: 6.4mg estradiol patch. Indication: HRT for oestrogen deficiency symptoms in peri- and post-menopausal women. Evorel 50, 75 and 100 only: Prevention of osteoporosis in post-menopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage & administration: Adults: Evorel is an oestrogen-only HRT patch applied to the skin twice weekly. For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose for the shortest duration should be used. For women with an intact uterus progestogen should normally be added to Evorel for the prevention of adverse endometrial effects, e.g. hyperplasia and cancer. The regimen may be either cyclic or continuous sequential. Only progestogens approved for addition to oestrogen treatment may be prescribed (e.g. oral norethisterone, 1mg/day or medroxyprogesterone acetate, 2.5mg/day) and should be added for at least 12-14 days every month/28- day cycle. Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women. Treatment of oestrogen deficiency symptoms: Therapy should be started with one Evorel 50 patch (delivering 50 μg of estradiol/24 hours) and the dose adjusted after the first month if necessary, depending on efficacy and signs of over-oestrogenisation. For maintenance therapy the lowest effective dose should be used; a maximum dose of 100 μg of estradiol/24 hours should not be exceeded. Evorel 50, 75, 100: Prevention of post-menopausal osteoporosis: Therapy should be started with Evorel 50. The dose may be adjusted depending on efficacy and signs of over-oestrogenisation. The efficacy of Evorel 25 for the prevention of post- menopausal osteoporosis has not been demonstrated. For maintenance therapy, the lowest effective dose should be used. A dose of 100 μg of estradiol/24 hours should not be exceeded. Guidance on how to start therapy: Post-menopausal women currently not on HRT may start Evorel at any time. Peri- menopausal women who are still having regular menstrual cycles and are not currently on HRT should start Evorel within 5 days of the start of bleeding. Peri-menopausal women with irregular menstrual cycles, for whom pregnancy has been excluded, can start Evorel at any time. Switching from other HRT: The switch from another oestrogen-only therapy in post-menopausal women to Evorel may occur at any time. Women on a continuous combined regimen wishing to switch from another oestrogen to Evorel may do so at any time. Women on a cyclic or continuous sequential regimen wishing to switch from a sequential combined HRT preparation to Evorel may do so at the end of a cycle of the current therapy or after a 7-day hormone free interval. Method of Administration: Evorel should be applied to the skin as soon as it is removed from the wrapper. Recommended application sites are on clean, dry, healthy, intact skin and each application should be made to a slightly different area of skin on the trunk below waistline. Should not be applied on or near the breasts. Only one patch should be applied at a time. There is an increased likelihood of break-through bleeding and spotting when a patch is not replaced at the normal time. Children: Not indicated in children. Elderly: Data are insufficient in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: Known, current or past or suspected breast cancer. Known or suspected oestrogen-dependent malignant tumours or pre- malignant tumours. Undiagnosed genital bleeding. Previous idiopathic or current VTE. Active or recent past ATE disease. Acute liver disease, or a history of liver disease if liver function tests have failed to return to normal. Known thrombophilic conditions. Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal and family medical history should be taken. Conditions which need supervision: If any of the following conditions are present, occurred previously, have been aggravated during pregnancy or previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, thromboembolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of endometrial hyperplasia, epilepsy, asthma, otosclerosis, hereditary angioedema and mastopathy. Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication is discovered and in the following situations: jaundice/deterioration in liver function, significant increase in blood pressure, new onset of migraine-type headache, pregnancy. For Evorel 75 and 100 the endometrial safety of added progestogens has not been studied. Interactions: The metabolism of oestrogens (and progestogens) may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and bosentan. Ritonavir, nelfinavir and herbal preparations containing St. John’s Wort may induce the metabolism of oestrogens and progestogens. Clinically, an increased metabolism of oestrogens and progestogens may lead to decreased effect and changes in the uterine bleeding profile. Oestrogen- containing oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine when co-administered due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose adjustment of lamotrigine may be necessary. Pregnancy and lactation: Not indicated, treatment should be withdrawn immediately. Side effects: Adverse reactions observed in clinical trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the available clinical trial data). Very common: Application site pruritus, Application site rash. Common: Depressed mood, Migraine, Dizziness, Headache, Abdominal pain, Diarrhoea, Nausea, Pruritus, Rash, Arthralgia, Breast pain, Metrorrhagia, Pain, Application site erythema, Application site oedema, Application site reaction, Weight increased. Uncommon include: Genital candidiasis, Hypersensitivity, Palpitations, Myalgia, Dysmenorrhoea, Oedema, Oedema peripheral. Rare: Breast cancer, Epilepsy, Thrombosis, Abdominal distension, Cholelithiasis. Frequency not known: Endometrial cancer, Cerebrovascular accident, Myocardial infarction, Deep vein thrombosis, Pulmonary embolism, Angioedema. Package Quantities & Cost: Each Evorel patch size is presented in a sealed protective pouch. The pouches are packed in a cardboard carton. Cost: 25 (1x8) £3.42; 50 (1x8) £3.88; 50 (1x24) £11.66; 75 (1x8) £4.12; 100 (1x8) £4.28. Marketing authorisation number: Evorel 25 PL 49105/0005; Evorel 50 PL 49105/0006; Evorel 75 PL 49105/0007; Evorel 100 PL 49105/0008. Marketing authorisation holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: THX_GB_PI_001472.

Please consult the Summary of Product Characteristics for other adverse reactions and full prescribing information Abbreviated Prescribing Information: EVOREL® Conti (estradiol hemihydrate/norethisterone acetate) Presentation: Evorel Conti 3.2 mg of estradiol hemihydrate, 11.2 mg of norethisterone acetate transdermal patch. Indication: HRT for oestrogen deficiency symptoms in post-menopausal women more than 6 months post-menopause (or 18 months since last period). Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage & administration: Adults: Evorel Conti is a continuous combined HRT preparation. Patches are applied to the skin twice weekly. One Evorel Conti patch should be worn at all times, without interruptions. For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose for the shortest duration should be used. Guidance on how to start therapy: Post-menopausal women currently not on HRT may start Evorel Conti at any time. Switching from other HRT: Women on a continuous combined regimen wishing to switch from another oestrogen to Evorel Conti may do so at any time. Women on a cyclic or continuous sequential regimen wishing to switch from a sequential combined HRT preparation to Evorel Conti may do so at the end of a cycle of the current therapy or after a 7-day hormone free interval. Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women. Method of Administration: The sachet containing one Evorel Conti patch should be opened and one part of the protective foil removed at the S- shaped incision. The patch should be applied to clean, dry, healthy, intact skin as soon as it is removed from the sachet. The patient should avoid contact between fingers and the adhesive part of the patch during application. Each application should be made to a different area of the skin, on the trunk below the waist. The patch should not be applied on or near the breasts, the usual day of changing Evorel Conti patches should be maintained. Children: Not indicated in children. Elderly: Data are insufficient in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: Known, past or suspected breast cancer. Known or suspected oestrogen-dependent malignant tumours or pre-malignant tumours. Undiagnosed genital bleeding. Previous idiopathic or current VTE. Active or recent past ATE disease. Acute liver disease, or a history of liver disease if liver function tests have failed to return to normal. Known thrombophilic conditions. Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal and family medical history should be taken. Conditions which need supervision: If any of the following conditions are present, occurred previously, have been aggravated during pregnancy or previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, thrombo-embolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of endometrial hyperplasia, epilepsy, asthma, otosclerosis and mastopathy. Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication is discovered and in the following situations: jaundice/deterioration in liver function, significant increase in blood pressure, new onset of migraine-type headache, pregnancy. Interactions: The metabolism of oestrogens and progestogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and bosentan. Ritonavir, telaprevir, nelfinavir and herbal preparations containing St. John’s Wort may induce the metabolism of oestrogens and progestogens. Clinically, an increased metabolism of oestrogens and progestogens may lead to decreased effect and changes in the uterine bleeding profile. Oestrogen-containing oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine when co-administered due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose adjustment of lamotrigine may be necessary. Fertility, Pregnancy and lactation: Not indicated, treatment should be withdrawn immediately. Data on a limited number of exposed pregnancies indicate adverse effects of norethisterone on the foetus. At doses higher than normally used in oral contraceptives and HRT formulations, masculinisation of female foetuses was observed. Side effects: Adverse reactions observed in clinical trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the available clinical trial data). Very common: Application site erythema, Application site pruritus, Application site rash, Application site reaction. Common: Hypersensitivity, Depression, Insomnia, Anxiety Nervousness, Paraesthesia, Headache, Palpitations, Hypertension, Varicose veins, Vasodilation, Abdominal pain, Diarrhoea, Nausea, Rash erythematous, Arthralgia, Back pain, Breast pain, Cervical polyp, Endometrial hyperplasia, Genital discharge, Dysmenorrhoea, Menorrhagia, Menstrual disorder, Metrorrhagia, Pain, Oedema, Application site oedema, Fatigue, Weight increased. Uncommon include: Candidiasis, Myalgia, Oedema, Oedema peripheral. Rare: Epilepsy, Thrombosis. Frequency not known include: Breast neoplasms, Endometrial cancer, Cerebrovascular accident, Deep vein thrombosis, Pulmonary embolism, Abdominal distension, Cholelithiasis, Stevens-Johnson syndrome. Package Quantities & Cost: Each carton box has 8 or 24 TDSs in individual foil-lined sachets. Cost – 1x8 £13.00; 1x24 £37.22. Marketing authorisation number: PL 49105/0009 Marketing authorisation holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: THX_GB_PI_001473.

Please consult the Summary of Product Characteristics for other adverse reactions and full prescribing information Abbreviated Prescribing Information: EVOREL® Sequi (estradiol hemihydrate/norethisterone acetate) Presentation: Evorel Sequi is a transdermal therapy comprising a) 4 Evorel 50 Transdermal Delivery Systems (TDSs), each containing: 3.2 mg of estradiol hemihydrate. b) 4 Evorel Conti TDSs, each containing: 3.2 mg of estradiol hemihydrate, 11.2 mg of norethisterone acetate. Indication: HRT for oestrogen deficiency symptoms in peri- and post-menopausal women. Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage & administration: Adults: Evorel Sequi is a continuous sequential HRT preparation. Patches are applied to the skin twice weekly. One Evorel Sequi patch should be worn at all times, without interruptions. For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose for the shortest duration should be used. Guidance on how to start therapy: Any previous therapy with HRT must be stopped prior to starting Evorel Sequi. Post-menopausal women currently not on HRT may start Evorel Sequi at any time. Peri-menopausal women who are still having regular menstrual cycles and are not currently on HRT should start Evorel Sequi within 5 days of the start of bleeding. Peri-menopausal women with irregular menstrual cycles, for whom pregnancy has been excluded, can start Evorel Sequi at any time. Switching from other HRT: Women on a continuous combined regimen wishing to switch from another oestrogen to Evorel Sequi may do so at any time. Women on a cyclic or continuous sequential regimen wishing to switch from a sequential combined HRT preparation to Evorel Sequi may do so at the end of a cycle of the current therapy or after a 7-day hormone free interval. Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women. Method of Administration: A treatment cycle with Evorel Sequi is 28 days. During the first 14 days, one estradiol-only (Evorel 50) patch should be worn at all times, without interruption. During days 15-28, one estradiol + norethisterone (Evorel Conti) patch should be worn at all times, without interruption. A subsequent treatment cycle should follow immediately, without a treatment free interval. Patches should be applied to the trunk, below the waist. Patches should be changed twice a week, i.e. every three to four days. Application of a new patch should be to a site different from the previous application site. The patch should not be applied on or near the breasts. Wearing a patch for more than 4 days by mistake or any period without a patch may increase the likelihood of breakthrough bleeding or spotting. Children: Not indicated. Elderly: Data are insufficient in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: Known, past or suspected breast cancer. Known or suspected oestrogen-dependent malignant tumours or pre-malignant tumours. Undiagnosed genital bleeding. Untreated endometrial hyperplasia, Previous idiopathic or current VTE. Active or recent past ATE disease. Acute liver disease, or a history of liver disease if liver function tests have failed to return to normal. Known thrombophilic conditions. Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal and family medical history should be taken. Conditions which need supervision: If any of the following conditions are present, occurred previously, have been aggravated during pregnancy or previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, thrombo-embolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus; erythematosus, history of endometrial hyperplasia, epilepsy, asthma, otosclerosis, hereditary angioedema and mastopathy. Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication is discovered and in the following situations: jaundice/deterioration in liver function, significant increase in blood pressure, new onset of migraine-type headache, pregnancy. Interactions: The metabolism of oestrogens and progestogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and bosentan. Ritonavir, telaprevir, nelfinavir and herbal preparations containing St. John’s Wort may induce the metabolism of oestrogens and progestogens. Clinically, an increased metabolism of oestrogens and progestogens may lead to decreased effect and changes in the uterine bleeding profile. Oestrogen-containing oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine when co-administered due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose adjustment of lamotrigine may be necessary. Fertility, Pregnancy and lactation: Not indicated, treatment should be withdrawn immediately. Data on a limited number of exposed pregnancies indicate adverse effects of norethisterone on the foetus. At doses higher than normally used in oral contraceptives and HRT formulations, masculinisation of female foetuses was observed. Side effects: Adverse reactions observed in clinical trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the available clinical trial data). Very common: Application site erythema, Application site pruritus, Application site rash, Application site reaction. Common: Depression, Insomnia, Affect lability, Nervousness, Migraine, Headache, Hypertension, Abdominal pain, Gastrointestinal disorder, Diarrhoea, Flatulence, Nausea, Pruritus, Rash erythematous, Arthralgia, Back pain, Myalgia, Breast pain, Dysmenorrhoea, Menorrhagia, Menstrual disorder, Pain, Oedema, Malaise, Weight increased. Uncommon include: Candidiasis, Breast cancer, Fibroadenoma of breast, Hypersensitivity, Paraesthesia, Palpitations, Endometrial hyperplasia, Metrorrhagia, Oedema. Rare include: Epilepsy, Thrombosis, Stevens-Johnson syndrome. Frequency not known include: Endometrial cancer, Cerebrovascular accident, Epilepsy, Deep vein thrombosis, Thrombosis, Pulmonary embolism, Abdominal distension, Cholelithiasis, Oedema peripheral, Application site oedema. Package Quantities & Cost: Each carton box has 8 TDSs in individual foil-lined sachets. One Evorel Sequi box contains 4 Evorel 50 TDS and 4 Evorel Conti TDSs. Cost: £11.09. Marketing authorisation number: PL 49105/0010. Marketing authorisation holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: THX_GB_PI_001474.

Please consult the Summary of Product Characteristics for other adverse reactions and full prescribing information Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play or Apple App store. Adverse events should also be reported to Theramex on medinfo.uk@theramex.com or Tel: 0333 0096795

ON THE GROUND

Right place, right time, right person Increasing access to primary care gynaecology services via a hub model.

orthern Ireland has some of the longest outpatient waiting lists in the UK. It would not be unthinkable that a woman might spend more than 2 years waiting for a routine new patient gynaecology assessment. Against this backdrop, the last decade has seen a decline in the number of GPs able to provide long-acting reversible contraception (LARC) services in practice. Many women were being referred by their GP to family planning clinics for LARC or to gynaecology outpatients for the management of their heavy menstrual bleeding (HMB) or to have an IUS fitted for add-back progesterone. In 2017 GP clinical leads in gynaecology were appointed through GP Federations in Belfast, Northern Ireland, to explore how access to primary care gynaecology could be improved. Initial data suggested that at least 10% of referrals to secondary care were for common gynaecological problems such as

32 | Primary Care Womenâ&#x20AC;&#x2122;s Health Forum | pcwhf.co.uk

LARC requests, uncomplicated HMB and HRT/perimenopausal problems. The birth of the GP Elective Care Service (GPECS) facilitated building primary care capacity through localitybased gynae hubs enabling improved access and primary care management of women with common gynae conditions. In addition, the development of clinical pathways, peer support, education and training provide opportunities for GP colleagues to upskill and increase the support to women within their own practices. This elective care hub model sought to deliver care in the right place at the right time, by the right person. Across Northern Ireland, there are 17 GP Federations which have been established by GPs to support general practice and facilitate the transformation of health and social care in a primary care setting. Each Federation has been established as a Not-For-Profit Community Interest Company and any financial surplus generated through efficiency is re-invested in front-line services.

ON THE GROUND

WORDS BY DR URSULA MASON

OF ALL THE PATIENTS WHO ATTENDED THERE WAS AN 82% PROCEDURE RATE AND ONLY A 6% REFERRAL RATE ONWARDS TO SECONDARY CARE

Each Federation is supported by one of 4 Federation Support Units (FSU) which are designed to provide Federation members with support, advice and expertise in the design and delivery of service provision. It was through the FSUs that the hub model was costed and commissioned to provide an additional referral pathway for GP colleagues to use if they were unable to provide primary care-based gynae services to their own patients in four clinical domains: • Menorrhagia in women under 45 years • Hormone replacement therapy (HRT) • Provision of LARC services within primary care • Replacement of vaginal pessaries for prolapse. Hub practices were identified in each Federation area and GPs with enhanced skills (GPES) were appointed to provide clinic services in addition to peer support and education for colleagues in their locality. Hubs are local GP practices with clinical room capacity and support

from their administrative and nursing teams. In many of the hubs one of the GPESs is a GP partner in that practice and utilises the clinical and support expertise onsite. One of the many benefits of a federationbased service is that each locality hub is commissioned in an identical manner with identical governance, procurement, logistics and HR. The first hub clinics went live in Belfast Federations (1 clinic per week across 5 hubs) in November 2018 with an additional 9 hubs coming online during 2019 and further hubs planned for the remaining Western Federations in 2020. Patients are referred electronically and are appointed to their local hub. Once seen, they are discharged back to their own GP or referred on to secondary care where required. Women attending have reported very favourable service ratings with 100% rating the service good – excellent and 100% likely to recommend to a friend.

Her Life Her Health | Autumn 2020 | 33

ON THE GROUND

PROPOSED PRIMARY CARE GYNAE PATHWAY

Patient has HMB

Patient requests LARC

Attends GP History and examination carried out

Patient has menopausal symptoms

Patient referred to local primary care hub for assessment/advice/LARC

Patient is referred to secondary care

Appropriate management outcome for patient is achieved

WOMEN ATTENDING HAVE REPORTED VERY FAVOURABLE SERVICE RATINGS WITH 100% RATING THE SERVICE GOOD – EXCELLENT AND 100% LIKELY TO RECOMMEND TO A FRIEND

Up to the point of suspension of services due to the Covid 19 pandemic, there had been 2816 referrals into the service and 1585 patients appointed. Initial data on referrals into the service is in excess of original predicted secondary care data. This would suggest a considerable degree of unmet need unearthed by improving not only capacity and local access but also the ability of our GP colleagues to have conversations with women about a breadth of timely primary care options now available. The education and demand management arm to the model sees regular educational events aimed at improving knowledge in managing common primary care conditions as well as supporting GP colleagues to train and certify in LARC techniques, thereby increasing the skill mix within primary care to deal with these common conditions. Collaboration with the Northern Ireland Medical

and Dental Training Agency not only raised the profile and increased opportunities and support for GP specialty trainees to upskill in LARC during their training programme, but facilitated a doubling of Faculty Registered Trainers in NI, through encouraging diplomates who were GP Trainers to apply for registration. Training within the hubs started early in 2019 in Belfast clinics and has been hugely popular. Despite its fledging origins, over the course of 10 months, 6 GPs achieved LoC IUT and 4 GPs achieved LoC SDI through the hub clinics facilitated by 5 GPES acting as secondary trainers with external primary trainer support. Such is the success of this service that there is a waiting list of interested GPs who are keen to train in these techniques, allowing them to provide LARC provision in their own practices but also impacting positively on gynae GPES recruitment.

34 | Primary Care Women’s Health Forum | pcwhf.co.uk

In the months following lockdown the clinical leads and locality GPESs worked hard to make necessary adjustments to the service to enable a safe resumption of clinics across the region by August 2020. Women avail of remote assessment and advice, only attending inperson for procedures. While the service strives to make up for lost ground in terms of waiting lists there are plans afoot to expand both training and to diversify, with the recognition that adding capacity and an improved skill base to primary care sexual health services would greatly benefit women in the region. The GPECS hub model was designed by GPs to universally increase women’s access to timely primary care gynaecology services across the region. In addition, it has not only allowed clinicians to work at the top of their licence, but to support colleagues and encourage the education and training of their peers and the next generation of GPs.

Older women deserve safe, enjoyable sex. Empower them to

Following menopause, women may not use protection during sex leaving them at risk of STIs and HIV. Rock My Sex Life Safely will empower and educate women to

#GetSexy Safely

We’re looking for expert contributions from primary care clinicians for patients and HCPs, including: • ‘How to’ guides • Myth busters • When and how to talk about STIs

• Facts and information on HIV • Patient resources • HCP resources.

Email submissions@pcwhf.co.uk. #RockMySexLifeSafely is the PCWHF’s 2020 campaign and runs in tandem with #RockMyMenopause

ROCKMYMENOPAUSE.CO.UK @RockMyMenopause # RockMyMenopause #GetSexySafely

EXPERTISE FROM THE PCWHF

TIME TO REFLECT

From challenge to opportunity It’s time to grab the opportunities that lockdown has created to transform the future of women’s healthcare.

s primary healthcare professionals, we have weathered the first wave of the pandemic. As we sail into calmer waters, it is time to reflect. The pandemic has “stress tested our fragmented healthcare system” according to RCOG’s President, Dr Edward Morris. You, the reader will have seen the consequences first-hand. As a second wave is forecast, let’s consider how women’s healthcare has been impacted, what can be learnt and how we can use this to focus our work as we move forwards together?

I AM CONCERNED FOR WOMEN BUT OPTIMISTIC ABOUT NEW WAYS OF WORKING TO IMPROVE THE OUTCOMES FOR FEMALE HEALTH

How women have been impacted The arrival of Covid-19 on the back of persistent underfunding has revealed a healthcare system which is both fragmented and deeply unequal for women. We saw the abortion rate soar during lockdown. Statistics published in June showed rates at their highest since the abortion act was introduced1. Essential sexual

36 | Primary Care Women’s Health Forum | pcwhf.co.uk

health provision was suspended by 77% of GP practices, with LARC and emergency IUD provision stopping entirely for many 2. Dr Anne Connolly, Chair of the PCWHF, says: “There is an urgency to restart LARC services as COVID-19 pandemic lockdown restrictions ease.” While many services have now reopened, there still remains a desperate need. Vulnerable women have suffered because of lockdown. Reports of domestic violence increased by up to 49%2 amid fears of underreporting of sexual violence. Additionally, many women have lost their jobs. Women hold most lower paid, insecure jobs, while typically carrying responsibility for care and domestic tasks. We have seen a huge rise in unemployment in the 16 – 24-yearold age group. This is worrying as suicide rates in females under 25 were the highest ever in 2019. Women’s vulnerability in the face of the crisis has been reflected globally, creating what the UN describes as a “shadow pandemic”.

TIME TO REFLECT

LOCKDOWN IS AN OPPORTUNITY FOR US TO SPRING FORWARDS NOT TO SLIP BACKWARDS

WORDS BY DR JANE DAVIS

A GP’s view As a GP, I have seen women burnt out and utterly exhausted by the consequences of the pandemic. Women continued to put their own needs last. For many, the pressures of work, care and home schooling came together in a perfect storm. For others, it was isolation, loneliness, and grief. Younger women lost their independence as they were forced to move home. Older women were reopening their arms to adult children and grandchildren. Despite all of this, I have been saddened to hear women apologising for asking for help for their female health care. A ray of light Amid the fear and uncertainty for women, however, I have seen hope. As the crisis unfolded, barriers came down rapidly, red tape was removed UK-wide and many areas of women’s healthcare benefitted. I was encouraged by improved access to abortion services. Selfreferral has been slow to reach many places in the UK; suddenly a phone call or an email to abortion services was possible. Online access to oral contraception became readily available. Back in December 2019, the RCOG’s ‘Better for women’3 report suggesting provision of POP over the counter, which seemed a long way off. Now incredibly, this is in sight. Remote consulting was remapped at scale almost overnight. This has revolutionised the way we work. I find that many women are benefitting from an increased sense of empowerment when consulting remotely. Professionals collaborated as never before to produce practical guidance. The demand for online learning exploded as clinicians were hungry to stay abreast of the fast-moving medical landscape. The events of the last few months have left us all reeling. I am concerned for women but optimistic about new ways of working to improve the outcomes for female health.

What can be learnt? The key to the lockdown period is to ask ourselves, what can we stop, start and continue. Stop

• A ny further widening of the gender equality gap. As stated by the UN Secretary-General António Guterres: “COVID-19 could reverse the limited progress that has been made on gender equality and women’s rights.”4 • F urther underfunding of the women’s health services. The All Party Parliamentary Group inquiry has shown clearly how cuts to followed by Covid-19 has exacerbated the provision gap in provision of SRH services. Start

• Funding adequately for LARC training and provision in primary care. • Reproductive and Women’s Health Hubs – these are clearly where the future lies. Trail blazers such as James Woolgar in Liverpool (see Her Life Her Health Summer) and Amanda Britton in Basingstoke will show you how you can really make things happen when you team up with other professionals in your PCN. Continue

• Removal of unnecessary barriers to women’s healthcare. • O nline access and remote consultation while addressing models for vulnerable women to access these services. REFERENCES 1. Department of Health and Social Care (2013). Abortion statistics in England and Wales. [online] GOV. UK. Available at: www.gov.uk/government/collections/ abortion-statistics-for-england-and-wales. 2. FSRH.org. (2020). FSRH COVID-19 Members Survey – Faculty of Sexual and Reproductive Healthcare. [online] Available at: www.fsrh.org/policy-and-media/ members-survey [Accessed 19 Sep. 2020]. 3. RCOG (n.d.). Better for women report. [online] Royal College of Obstetricians & Gynaecologists. Available at: www.rcog.org.uk/better-for-women [Accessed 19 Sep. 2020]. 4. FSRH.org. (2020c). Women’s Lives, Women’s Rights: Full Report - Faculty of Sexual and Reproductive Healthcare. [online] Available at: www.fsrh.org/documents/womens-lives-womensrights-full-report/ [Accessed 19 Sep. 2020].

KEY POINTS • It is time for each of us to analyse the fallout from lockdown for the women for whom we provide care. • It is time to feel the very real threat to women’s health provision. • It is time to act together – use this opportunity to join forces, to push for an improvement in service provision. • It is only through providing excellent women’s healthcare that we can strive towards gender equality, and the time is now.

The future In conclusion, the improvement of women’s healthcare is urgent and important. As clinicians passionate about women’s health in primary care, this is your top priority. You are the women’s health advocates. The time is now and we cannot afford to lose ground. I would urge you to open your LARC clinic if you have not done so already, campaign for better funding for LARC, approach your PCN regarding reproductive and women’s health hubs. If you are interested, seek training or become a trainer. If you need guidance training or support, contact us at the PCWHF. Together we will drive this forward. Lockdown is an opportunity for us to spring forwards not to slip backwards. The PCWHF is full of powerhouses who are passionate about this; connect with them, join forces. These are exciting times. The future is very positive for women’s health, but we will need to work hard, we will need to pull together to achieve excellent women’s healthcare and ultimately gender equality.

Her Life Her Health | Autumn 2020 | 37

PIONEERS IN WOMEN’S HEALTH

Standing on the back of giants

38 | Primary Care Women’s Health Forum | pcwhf.co.uk

PIONEERS IN WOMEN’S HEALTH

DR LUCY CHIDDICK and her team have worked tirelessly to gain the trust of vulnerable sex workers by going to them to help the women in accessing essential healthcare and support. WORDS BY DR LUCY CHIDDICK

hursday afternoons are the highlight of my week. Lunchtime finds me running round the practice, after a clinic which has generally overrun, gathering various pieces that I think we might need to supplement the well-stocked outreach van. Speculums, swabs, drug testing kits and most importantly various bags of shampoo, hygiene products, notebooks, pens. This is the afternoon we take the outreach bus to the managed approach area in Leeds. 15 years ago I co-founded a charity in Leeds to work with women engaged in street sex work or at risk of coercion – The Joanna Project works with street sex workers and they meet up to 300 women during the evening outreach a year, with around 100 on their support list. They have a building in the managed approach area from which they run a regular drop-in, though have had to close this and work in a more agile and responsive way during the lockdown period. I stopped chairing and being part of The Joanna Project nearly 7 years ago after moving to Hull and having a second child. Instead I spent time managing a project working with street sex workers closer to home.

Taking the service to the women When I joined Bevan in 2017 as a GP for the homeless in Leeds, I realised that many of the women I had once known, and more besides, were not accessing the healthcare and substance misuse treatment they both wanted and needed, despite us being a very accessible, open and compassionate specialist service for those who are homeless in the city. By speaking to The Joanna Project, Basis Sex Work Project and the women themselves, I realised we needed to bring the services to them. Approximately a third of the women were registered with a youth sexual health project, a third at a mainstream service and one third were not registered with anyone or had a historical registration they were not aware of, often in a different city. For those registered in mainstream services, working through the night and thus being unable to engage with the processes required first thing in the morning to get an appointment were two incompatible requirements. For those women, health and appointments took the back seat. For others, the competing priorities of managing dependence, finding food and ensuring there was a bed for the night took precedence over healthcare.For the rest, the potential

re-traumatisation of engaging back into services and organisational structures where in the past they had experienced pain, unhappiness, maltreatment and for many the loss of their children, was a barrier too huge to navigate through. The answer was clear. We needed to go to the women rather than expect them to jump over the high barbed wire-like barriers to come to us. Dom – at that time the outreach coordinator for Leeds – agreed and together we put the case forward. Bevan gave us the freedom one afternoon a week to take the street health bus out to the managed approach to the drop-in project. The ability of Bevan to work creatively and responsively to identified need is one for which I am forever grateful.

Her Life Her Health | Autumn 2020 | 39

PIONEERS IN WOMEN’S HEALTH

Coming together We needed to be accessible, open, non-threatening, kind and above all willing to put the time and legwork in. The manager used to remind us weekly that we could be there all afternoon and no-one would engage. She was worried that we would give up with the lack of response. No chance. We were lucky. We stood on the back of giants; the compassion of The Joanna Project staff and the firesidelike warmth of the homely space of the drop-in project were a beacon for the most vulnerable women engaging in street sex work, many of whom live lives with multiple complexities, chaotic and full of trauma. We chose a day when food was being served, and sometimes just started there, round the table, talking, laughing; a part of the ‘life and love’ which was in abundance. I remember in the early days one of the ladies asking me about hormones and suddenly the whole table of women exploded into a cacophony of storytelling and asking questions. I distinctly remember within this though the voice of one young girl I hadn’t met before in response to someone telling her to “show Lucy your finger”, (alluding to a sore injection site). She simply said: “I need to trust you first.” I will always remember her clear still voice cutting through the laughter and warmth, its tough embodiment of the harsh edgy pain of life, wounding in its delivery. Her words remain a regular reminder to me that each relationship requires work, time, commitment, and the ability to navigate rejection, along with consistency and compassion. As someone said to me recently – it’s really important that people lead their care as they often sit on the sidelines of their own lives with little involvement in decisions that are made. She needed to be in control of that decision and whether she wanted to make it or not, without me pressing any of my own agendas.

THE ANSWER WAS CLEAR. WE NEEDED TO GO TO THE WOMEN RATHER THAN EXPECT THEM TO JUMP OVER THE HIGH BARBED WIRE-LIKE BARRIERS TO COME TO US

After weeks of saying hello to this particular girl, one day she showed me her injection sites in passing in the corridor. I did the impromptu consultation there and then – in her time and her space. Months later she came onto the bus and now I can’t get her off! She’ll sit and talk for hours. She is engaged in substance misuse treatment now, her sites look great and we are also doing an ADHD assessment. What a difference a few months makes! One of the most poignant moments was when popping into the kitchen area where many would gather after lunch, I saw a lady I had met 8 years previously on the streets of Leeds. We were both pregnant at the time and I spent many months then with her. We caught up, cried, shared stories of our young boys – hers in care. She was my greatest advocate for the women then – our longstanding relationship supported a further depth of relationship and trust with the women which experience as a health professional would take far longer to gain. I now often have little time to sit and chat around the meal table. Over a year on, the bus is overwhelmed

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with need. The staff had to start a list to ensure that everyone knew they would be seen! We even have women coming onto the bus, brought by their friends who attend the drop-in, who the project staff have only seen fleetingly in the streets and struggled to engage with. We support all their needs from registering with a GP, to substance misuse treatment (within certain criteria) to primary healthcare, to sexual health needs and smears. The smear taking took a while to take off as the majority of the women were cautious about having one done and often hadn’t had one done for years or since having a child who had been taken away, thus they had traumatic associations. There was a large element of peer support involved, with the women encouraging each other to ‘go for it’. Some weeks the sexual health nurse and I would do joint clinics (she attended the project with another service) as she would have regular patients who needed smears or primary care and I would have ones who needed more comprehensive assessment, coils or implants.

PIONEERS IN WOMEN’S HEALTH

My colleague Dom became a practitioner and he also sees the women, dressing their ulcers and wounds, helping with access to housing or offering peer support for their substance misuse experiences. He sometimes gets asked to sit in the cab so we can have a ‘women only space’, but more often than not they now want him involved. He has put in the hours, the time, the waiting, the trust and relationship building, and gradually been let in. COVID-19 has meant we have to work differently. The drop-in is currently closed and we can no longer park outside the clinic on a Thursday afternoon. But we have adapted to respond to need in a different way. We contact the women we know who street sex-work and we visit those in need in the temporary accommodation. Basis and The Joanna Project will contact us with names of women they know need some healthcare and we will contact and visit them – parking the bus in car parks and street corners to ensure we reach those who are most marginalised and vulnerable. The demand remains high.

It is a privilege to be let into the women’s lives – their humour, their strength, and their resilience are humbling and also a driving force to advocate for change, for more of these responsive services across the system. Please stand with us and with the women in your area to do the same. Where are we now? Since the beginning of the pandemic we have evolved and grown our women’s outreach. We now have another experienced GP from the practice, Dr Rees,who shares the weekly outreach with me and we are often joined by Sister Gina Rowlands (also CEO of Bevan Healthcare CIC). Another of our GPs, Dr Duodu, will be doing a regular outreach LARC clinic and our lead practice nurse, Maggie Smith, and our practice manager Jess Rouse, will be starting a regular evening outreach to the women. This, in addition to our regular street health outreach and practice base provision, we hope will engage yet even more vulnerable women who might still be sitting on the edge or even falling off that proverbial cliff edge of care.

IT IS A PRIVILEGE TO BE LET INTO THE WOMEN’S LIVES – THEIR HUMOUR, THEIR STRENGTH, AND THEIR RESILIENCE ARE HUMBLING AND ALSO A DRIVING FORCE TO ADVOCATE FOR CHANGE

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Holistic support

CHARITY FOCUS

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OFTEN THE DIAGNOSIS OF POI IS ONLY CONSIDERED AT QUITE A LATE STAGE AS MANY OF THE PRESENTING SYMPTOMS ARE NON-SPECIFIC OR ATTRIBUTED TO OTHER GYNAECOLOGICAL DISORDERS

CHARITY FOCUS

DAISY NETWORK is a charity providing support and information for women with premature ovarian insufficiency (POI).

aisy Network was set up over 20 years ago, initially as a local support group where women could meet and share information and support. It started with a small group of women meeting in someone’s living room and has now grown into a large international online community, but ultimately we still have the same goals. Women with POI frequently suffer from a lack of age-appropriate information and so the Daisy Network website has lots of information about all aspects of POI including a freely available section for health professionals. We have regional groups across the UK and also internationally so women can join support groups local to them. We hold twice monthly ‘livechat’ sessions with our Daisy doctors and an annual Daisy Day conference. This year, as Daisy Day was cancelled due to COVID-19, we ran a series of webinars with a variety of menopause and POI experts which are now available on the website. Our private Facebook members page is very active and is one of the key ways in which our members interact and support each other. Raising awareness POI is uncommon as it only affects 1 in 100 women before the age of 40 and so it is not a condition that GPs will encounter regularly. However, rates of POI are increasing, particularly iatrogenic POI, as more women survive treatment for cancer. Studies have shown that there is often significant diagnostic delay for women with POI. Often the diagnosis of POI is only considered at quite a late stage as many of the presenting symptoms are non-specific or attributed to other gynaecological

disorders such as PCOS or stress, without investigation. Another aspect frequently underappreciated by clinicians is the enormous impact that a diagnosis of POI can have on a woman physically and emotionally. Many of our members report having difficulty accessing the treatment they need, particularly in terms of hormonal replacement and emotional support. As a charity we work to improve education for women and health professionals so that diagnosis and management can be improved. Another issue we are pleased to support is the Prescription Charges Coalition as we strongly believe that women with POI should be eligible for free prescriptions for their hormone replacement. Clinicians should be aware that the diagnosis of POI is frequently traumatic even when sensitively handled. Women need ageappropriate information and treatment, as there are many differences to menopause in the 50s. Ideally women should be referred to a menopause/POI specialist where they can access multi-disciplinary care including POI specialists, fertility specialists, counsellors, psychosexual therapists and dietitians. The NICE guidelines have given standardised diagnostic criteria which should help avoid the diagnostic delays for many women. They also state clearly that the treatment options for estrogen replacement include both combined oral contraceptives or HRT. The guidelines emphasise the need for ongoing hormone replacement until at least the average age of menopause, which is important as many of our members are being advised to stop HRT after 5 years of use.

POI CAN HAVE A DEVASTATING EFFECT ON A WOMAN’S MENTAL HEALTH AND SO ENSURING THEY HAVE APPROPRIATE SUPPORT IS VITAL WORDS BY DR KATE MACLARAN

Holistic care Women with POI frequently have complex physical and emotional needs. Due to the adverse long-term effects of estrogen deficiency on bone, heart and brain health, patient education on diet and lifestyle, along with risk factor assessment, is a crucial part of preventative medicine in women with POI. POI can have a devastating effect on a woman’s mental health and so ensuring they have appropriate support is vital. Access to counsellors with experience in menopause/POI and support groups can be extremely beneficial. Psychosexual health can also be seriously affected in POI and so it is really important to ask women about this aspect of their health and consider the various treatment options which may range from vaginal estrogens and systemic testosterone replacement, to psychosexual or relationship counselling. ► Go to www.daisynetwork.org

Her Life Her Health | Autumn 2020 | 43

PCWHF PEOPLE

IT WAS QUITE APPARENT TO ME THAT I COULD MAKE A DIFFERENCE TO THE WOMEN UNDER MY CARE AND IT PROPELLED ME TO DO MORE INTERVIEW BY AMY SCHOFIELD

PCWHF MEMBER PROFILE

Making a difference We welcome the latest member of the PCWHF’s Executive Committee, DR AAMENA SALAR.

Tell us about what you do.

I’m a GP with specialist interest in Gynaecology, Clinical lead for Modality Gynaecology Service and Medical Director for Modality Community services. I have to be really honest, I completed my GP training and wanted to specialise in cardiology! However, in our area there was a desperate need for doctors to provide contraception services. I decided to complete my FSRH and DRCOG training as a GP registrar and started providing LARC clinics for our practice. I soon became the ‘go to person’ for women’s health. I decided that in order to fulfil that role I needed to be credible so I embarked on the Community Gynaecology diploma from Bradford University. As soon as I finished that I realised I had a bad case of diplomaitis and went on to complete the Diploma in Diagnostic Hysteroscopy.

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Somewhere in that journey I developed a real passion for women’s health. It was quite apparent to me that I could make a difference to the women under my care and it propelled me to do more. I was fortunate to land the opportunity to pilot my own gynaecology service via the Vanguard 5 year Forward Plan project. I was given a blank sheet, business and finance manager and told to build a service for my patients. 4 years on that service is still running and I have had the further fortune to train other GPs and nurses to join the team. What are you most passionate about in women’s health? It’s quite

simple – I can make a difference. What does being a member of the PCWHF’s Executive Committee mean to you? Well I have to say being part

of a group of people who have carved a path for the rest of us to follow is an absolute delight. I have benefitted from the support from the PCWHF over the years and really want to support and give something back. What or who has influenced your career the most? Without a shadow of

a doubt it was the people around me who supported all my training over the years. It really is time for me to give back!

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Become a PCWHF Member For just over £4 a month (£49 paid annually), you can help us champion women's health and receive some great membership benefits. ► Join today at www.pcwhf.co.uk

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PCWHF Annual Conference 2021 Join leading experts to discuss latest developments in women's health. 24 FEBRUARY 2021 | VIRTUAL

Key topics • Abortion care • AUB guidance • Women & HIV • PMS • Contraception • Menopause • Ovarian cancer • PCOS • Out of hospital care

Speakers include James Woolgar, Dr Virginia Beckett, Dr Caroline Gazet, Dr Anne Connolly, Dr Toni Hazell, Dr Victoria Barber > Explore evidence > Translate into practice > Expert guidance & tips > Live sessions & workshops > Network with colleagues virtually CPD available | PCWHF Member discount