Her Life Her Health Spring 2021

SPRING 2021

THE OFFICIAL PUBLICATION OF THE PRIMARY CARE WOMEN’S HEALTH FORUM PCWHF.CO.UK

Rebuilding a workforce in primary care Ask the Experts: Heavy menstrual bleeding

Bone health in the over-65s

Menopause & Ethnicity

PCWHF Menopause eLearning FREE TO PCWHF MEMBERS | COMING SOON We believe that excellent women’s healthcare is essential.

Menopause care lies at the heart of this and we want to give you the best tools to deliver this.

Menopause eLearning delivers comprehensive, clinically based menopause training for primary care.

LEARNING OBJECTIVES

KNOWLEDGE

COMPREHENSION

APPLICATION

ANALYSIS

SYNTHESIS

EVALUATION

Recognise menopausal symptoms

Discuss menopause with confidence

Explain how the menopause changes the body and mind

Identify when blood tests may be helpful

Build up a directory of evidencebased menopause resources

Describe how to advocate for women seeking help for menopausal symptoms

► Become a PCWHF member www.pcwhf.co.uk Membership costs just £49 per year and also gives you exclusive discounts and events.

WELCOME

From the Editor-in-Chief

EDITOR-IN-CHIEF

Dr Anne Connolly SENIOR EDITOR

Amy Schofield

MEDICAL EDITOR

Dr Jane Davis

CREATIVE DIRECTOR

Emma Warfield

HEAD OF MARKETING OPERATIONS

W

Emma Morriss

GRAPHIC DESIGNER

Olivia Cummins COMMERCIAL DIRECTOR

Hazel Lodge

SECRETARIAT

Tracey Oliver

FINANCIAL CONTROLLER

Fiona Beard

PUBLISHER

Karl Hamer DIRECTOR

Melanie Hamer HEAD OFFICE

3 Waterloo Farm Courtyard, Stotfold Road, Arlesey, Bedfordshire, SG15 6XP www.pcwhf.co.uk hello@pcwhf.co.uk 01462 226130 ADVERTISING

For sales and advertising, contact hello@pcwhf.co.uk 01462 226130 MEMBERSHIP

Become a PCWHF member for just over £4 a month (£49 charged annually) www.pcwhf.co.uk SUBSCRIPTIONS

A digital version of Her Life Her Health is available to download from www.pcwhf.co.uk The next issue will be published in July 2021.

AS WE COME OUT OF THIS LATEST PHASE OF THE PANDEMIC, OUR FOCUS AS PRIMARY CARE CLINICIANS IS AS EVER ABOUT LISTENING, PERSONALISED CARE, AND EMPOWERMENT.

Look for this icon for free downloadable resources at www.pcwhf.co.uk/HLHH

elcome to the Spring 2021 issue of Her Life Her Health.

As social interaction begins to increase again, those of us working in healthcare face ongoing challenges. We continue to develop some of the lessons learned about providing care over the past year, along with facing increasing demands and expectations from patients for face-to-face appointments.

Once again, this edition includes articles and reports covering various aspects of holistic women’s healthcare throughout the life course. Within these pages you’ll find tips and tricks to update and optimise care, all the while supporting women and their families with the information they need to make individual choices about their management.

Last year saw the publication of First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review. The findings are so important for us to apply to practice; not only about the specific issues covered in the report, but also about prescribing for any woman of reproductive age and again the importance of providing evidencebased information to support women in their personalised choices.

From our recent Future of Women’s Health survey, we know that education in menopause care at every level of need is the most needed focus. We are delighted to announce that the first part of the PCWHF Menopause eLearning training is coming soon. It is set at the fundamental level so that women can be supported with information and signposting by all members of the multidisciplinary team. Also in this issue of Her Life Her Health, several articles focus on the needs of menopausal women and osteoporosis prevention.

As we come out of this latest phase of the pandemic, our focus as primary care clinicians is as ever about listening, personalised care, and empowerment. Thank you to all of you for all that you do day in day out to support your women. We are always keen to hear your stories and share your expertise and advice, so if you would like to contribute to the journal, please get in touch with us at submissions@pcwhf.co.uk.

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 | Spring 2021 | 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.

DR JANE DAVIS, MEDICAL EDITOR

Jane is a GP based in Cornwall with a special interest in women’s health.

She is a member of the PCWHF’s Board and spokesperson for the Forum’s public-facing menopause campaign, Rock My Menopause.

DR VICTORIA FREIRE

IMOGEN PINNELL

Victoria is a GP working in a Hampshire practice with a specialist interest in women’s health.

Imogen is the Health Information Manager at Jo’s Cervical Cancer Trust.

She works closely with their community to create high quality, evidence-based information for patients living with and beyond a cervical cancer diagnosis.

DR FAYE HAMILL

Faye is a GP partner on the Isle of Arran in Scotland. She has a specialist interest in gynaecology and is an Associate Specialist at Crosshouse Hospital, Kilmarnock.

SARAH JOHN

Sarah is a fifth-year medical student at the University of Cambridge. She has an interest in women’s health, winning a national prize in the Target Ovarian Cancer Essay Competition.

DR RAMIYA AL-ALOUSI

Ramiya qualified from Leicester University in 2009 and currently works as a GP. She is passionate about women's health and takes an interest in metabolic bone-related conditions.

DR AMANDA BRITTON

Amanda is a GP in a merged 43,000 patient practice that is also a primary care network. She is Director of the local federation of practices, The North Hampshire Alliance.

DR CLARE ETHERINGTON

Clare is a GP educator, with interests in women’s health, lifestyle medicine and shared decision-making. She advocates for the voice of patients, particularly those least likely to be heard.

ANNABEL LINES

Annabel is a 4th year medical student at Brighton and Sussex Medical School with an interest in obstetrics and gynaecology.

In 2020 she undertook a BSc in Reproductive and Developmental Sciences at Imperial College London.

PROFESSOR CHRISTIAN PHILLIPS

Christian is a consultant obstetrician and gynaecologist in North Hampshire. He has been the clinical lead for gynaecology at Basingstoke Hospital since 2009. He has a keen interest in research and has a DM thesis in urogynaecology.

DR CLARE SEARLE

Clare has been a GP for 23 years.

She has worked within fertility services since 2002 and completed an MSc in community gynaecology and reproductive health care in 2005. Clare was also involved in the development of the NICE guidelines for fertility and for abortion services.

BE AWARE THAT THERE ARE NO DIRECT TRANSLATIONAL WORDS FOR VAGINA, OVARY AND MENOPAUSE IN SOUTH ASIAN CULTURE

DR INNA VARDI-FLYNN

Inna is a GP partner and a GPwSI in gynaecology clinic in the Watford area.

DR RADHIKA VOHRA

Radhika is a GP with a special interest in women’s health having undertaken specialist training to consult and teach in these areas.

She is a Diplomate and Trainer for the FSRH, a Member of the British Menopause Society and an NHS Appraiser and Educational Speaker.

DR ANGELA WRIGHT

Angela is a GP and Clinical Sexologist based in North Yorkshire, with a special interest in menopause. She is trained in Psychosexual Medicine and is also a Fellow of the European Committee of Sexual Medicine.

MENOPAUSE & ETHNICITY, PAGE 21

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.

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

IN THIS ISSUE

Contents

HOW TO TALK TO WOMEN ABOUT SEX AT MENOPAUSE, PAGE 24

Her life

Her health

EARLY YEARS

RISING STARS

Management of recurrent vulvovaginal candidiasis 10

Early diagnosis of ovarian cancer in primary care 16

Practical and evidence-based tips on the management of RVVC Dr Clare Searle, Annabel Lines & Dr Inna Vardi-Flynn

Prize-winning essay exploring the opportunities and hurdles Sarah John

ON THE GROUND

FERTILE YEARS Premature ovarian insufficiency

13

POI patient information leaflet Dr Ramiya Al-Alousi I want my life back

14

Gaps in care for women with pelvic radiation disease Imogen Pinnell

30

The story of a pilot study for the development of a women’s health hub in Hampshire Dr Victoria Freire, Prof Christian Phillips & Dr Amanda Britton The future of women's healthcare

34

A rallying call to help transform the future of healthcare for women patients Dr Jane Davis

RENAISSANCE YEARS

Island life

Menopause & Ethnicity

Life as a GP on the remote Isle of Arran Dr Faye Hamill

21

Barriers and challenges to diagnosis and management of menopause in South Asian women Dr Radhika Vohra

ESSENTIAL UPDATES

Mentoring model

36

PCWHF PEOPLE

News & Policy

04

How to talk to women about sex at menopause

First Do No Harm: The Cumberlege Review

06

Research & Guidelines

08

The biopsychosocial approach to approaching problems with sexual function Dr Angela Wright

Introducing Her Life Her Health’s Medical Editor and PCWHF Board Member Dr Jane Davis

GOLDEN YEARS

ASK THE EXPERTS

EDUCATION & LEARNING The PCWHF’s Menopause eLearning Become more menopause aware with this interactive course Amy Schofield

09

Postmenopausal osteoporosis A guide to optimising bone health in women over-65 Dr Ramiya Al-Alousi

24

28

For the love of learning

Your questions answered

38

40

Dr Anne Connolly answers your questions on managing heavy menstrual bleeding

Her Life Her Health | Spring 2021 | 3

ESSENTIAL UPDATE

News & Policy

FROM THE NEXT FINANCIAL YEAR (2021/22), MATERNITY SERVICES IN ENGLAND WILL RECEIVE AN EXTRA £95.9M YEAR ON YEAR

UK’S ‘SILENT’ PCOS SUFFERERS A study has revealed that polycystic ovary syndrome (PCOS), one of the most common causes of female infertility, is going undiagnosed for many young adults.

While easily treated in most cases, PCOS was the most common obstacle for couples who are trying to conceive – 58% of couples seeking fertility advice have had a diagnosis of PCOS. According to the NHS, about 1 in every 10 women in the UK is affected by the condition.

The 2021 Fertility Journey study, conducted by Fertility Family, surveyed 395 women with PCOS. The study found that there was potential for misinformation online about the condition. Understanding symptoms is key to identifying the syndrome, though when seeking information on PCOS, 54% choose not to seek it from a healthcare professional. Instead, many turn to online forums, Instagram influencers and Facebook groups.

The study authors are calling for more conversations at the primary care level about PCOS and its relation to female health and infertility. Increased education surrounding PCOS would lead to more being diagnosed, resulting in higher awareness of the risks in later life that the syndrome can lead to including type 2 diabetes, depression, high blood pressure, high cholesterol, heart disease and stroke.

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

Royal Colleges welcome ‘significant’ maternity funding boost

T

wo leading Royal Colleges have welcomed a significant injection of funding for maternity services. The Royal College of Obstetricians and Gynaecologists (RCOG) and The Royal College of Midwives (RCM) state that the new money from NHS England and NHS Improvement is an investment in safety for women, their babies and their families.

From the next financial year (2021/22), maternity services in England will receive an extra £95.9m year on year. A large proportion of the funding will boost midwife and obstetrician numbers, and will also fund essential joint training with midwives, obstetricians, and other maternity staff.

The funding comes in response to the Ockenden First Report which recommended 7 immediate and essential actions needed to make maternity services safer. The announcement contains funding for new senior posts including 7 deputy regional chief midwives, new regional chief obstetricians, and a national Independent Senior Advocate to ensure consistency in maternity services across England.

RCOG’s President Dr Edward Morris said: “We are delighted to see that such a significant amount of funding has been dedicated to maternity services. This funding will go a huge way to creating a much more cohesive system.”

ESSENTIAL UPDATE

THE SPRING ISSUE

DATES FOR YOUR DIARY MENOPAUSE SPECIAL SKILLS

Looking to build your confidence and knowledge around menopause? The Menopause Special Skills course delivers the information you need to advise and treat women before, during and after menopause.

• Course material is NICE NG23 compliant.

• Developed as the theory component of the FSRH Special Skills Module in Menopause.

• With extended training can lead to a FSRH Advanced Certificate in Menopause.

Date: 19–20 May 2021 Venue: Online Cost: £455 LIMITED SPACES AVAILABLE.

► www.skills-in-menopause.e4h.co.uk

Pioneering ovarian cancer drug combination made available

A

n innovative combination of ovarian cancer drugs is set to be made available to more women with ovarian cancer than ever before. The ovarian cancer drugs olaparib (Lynparza®) and bevacizumab (Avastin®) have been made available in combination for newly diagnosed women with ovarian cancer, for the first time.

This combination will be available to around half of women newly diagnosed with advanced high-grade serous ovarian cancer (the most common type). Through new genomic testing, tumours will be tested to see if they are more susceptible to these drugs (HRD testing). Now this is in place, more women than ever before will be able to access personalised ovarian cancer drugs from their very first treatment, giving them a better chance of survival.

Annwen Jones OBE, Chief Executive of Target Ovarian Cancer, said: “This announcement is an extremely positive sign of the progress we’re now making in ovarian cancer treatment. The NICE recommendation and the introduction of HRD testing means that so many more women will receive treatment personalised to them. The future we want to see – where every woman with ovarian cancer has access to innovative treatments – has come a big step closer.”

'MENOPAUSE POST PANDEMIC’ WEBINAR, brought to you by Theramex This expert led webinar will explore the current situation with delivering menopause care during and beyond the Covid-19 pandemic.

The speakers, Dr Anne Connolly & Dr Paula Briggs, will discuss how we effectively manage menopause.

This is a non-promotional event organised and funded by Theramex Date: 19th May 2021 Venue: Online Time: 7–8pm ► www.formenopause.co.uk 003478 04/21

Existing drug could offer new treatment for triple negative breast cancer New research suggests that palbociclib, an already approved breast cancer drug, could help to treat triple negative breast cancer.

Researchers funded by Breast Cancer Now have found a change in some triple negative breast cancers that makes them vulnerable to existing treatments.

The study suggests that palbociclib, which is currently used to treat oestrogen receptor positive (ER+) secondary breast cancer, could also help to treat about a fifth of people with triple negative breast cancer.

The study, led by Dr Rachael Natrajan at the Breast Cancer Now Toby Robins Research Centre, provides a strong case for a clinical

trial and could lead to a much-needed new treatment for women with triple negative breast cancer. Dr Simon Vincent, Director of Research, Support and Influencing at Breast Cancer Now, said: “Each year, around 8000 UK women are diagnosed with triple negative breast cancer and we desperately need new, effective ways to treat them and stop them dying from this devastating disease.”

Dr Natrajan said: “Our study shows what drives the growth of some triple negative breast cancers and suggests the exciting possibility that an already-approved breast cancer drug could be used to help women with triple negative breast cancer.”

Her Life Her Health | Spring 2021 | 5

ESSENTIAL UPDATE

News & Policy

FIRST DO NO HARM The Cumberlege Review and the findings of the First Do No Harm report were met with shock by many in the healthcare community. How is the RCGP working with other stakeholders to ensure that the recommendations are implemented?

I

n 1961 my mother was offered, but did not take, thalidomide. I was very lucky.

Many countries subsequently introduced more robust systems of drug regulation and monitoring. There have however been further cases of severe harm caused by delays in recognising iatrogenic harm.

The Independent Medicines and Medical Devices Safety Review led by Baroness Cumberlege was set up as a response to patient-led campaigns on the use of the hormone pregnancy test Primodos, the anti-epileptic drug sodium valproate for women of childbearing age, and pelvic mesh.

Primodos was a hormone-based pregnancy test used in the 1960s and 1970s, found to cause miscarriage and birth defects. Sodium valproate taken during pregnancy is associated with birth defects such as cleft palates, spina bifida and limb defects. Synthetic

WORDS BY DR CLARE ETHERINGTON

THE REPORT GAVE 9 RECOMMENDATIONS:

1.

The government to give an apology on behalf of the healthcare system.

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

2.

The appointment of a Patient Safety Commissioner.

3.

The creation of an independent Redress Agency.

4.

Separate recompense schemes to be set up for each of the 3 interventions.

ESSENTIAL UPDATE

THE SPRING ISSUE

THE PATIENTS PARTICIPATING IN THE REVIEW DESCRIBED THEIR FRUSTRATION AND MISERY AT NOT BEING BELIEVED, AND SYMPTOMS BEING DISMISSED AS ‘WOMEN’S ISSUES'

mesh used in the repair of pelvic organ prolapse has been associated with infection, pain, bleeding and other long term side effects.

The First Do No Harm report (July 2020) makes uncomfortable reading.

Despite what should have been the learning from thalidomide and other examples of delays in recognising side effects, the patients participating in the review described their frustration and misery at not being believed, and symptoms being dismissed as ‘women’s issues’.

In November 2020 I represented the Royal College of General Practitioners (RCGP) with Baroness Cumberlege on an All Party Parliamentary Group (APPG) on Women’s Health Virtual Conference, listening to women’s reactions to the Review.

Baroness Cumberlege eloquently described the emotions evoked in her and her team by the patients

5.

Networks of specialist centres to be set up to support those affected by implanted mesh and those

who relived their experiences. The conference attendees were passionate and articulate, submitting more questions than we could answer, and supported the recommendations, particularly that of appointing a Patient Safety Commissioner. They saw this appointment as a route to independent, unbiased championship of women’s health issues. The overwhelming message was the importance of clinicians listening to and respecting patients.

There was considerable discussion about the marginalisation of women’s health problems at all levels. Many felt that doctors at all levels tend to feel that symptoms to do with menstruation, pregnancy and the menopause are ‘normal’ and therefore they get ‘dismissed’ in consultations.

This feeling came across very powerfully, even in the virtual format dictated by the pandemic.

The RCGP has worked with all of the APPG women’s health groups.

The College has collaborated with NHS England in the creation of a Personalised Care Institute and has produced a Person-centred Care Toolkit, giving information on shared decision making, social prescribing, health coaching and other consultation tools to empower patients to make informed decisions about their own health. I belong to the College Overdiagnosis Group which is a virtual group of lay and clinical members who discuss clinical evidence and how it can be used to

adversely affected by medications taken during pregnancy.

6.

Revision of the Medicines and Healthcare products Regulatory Agency (MHRA).

7.

help people understand decisions they take about their health.

All Royal Colleges are working towards systems that ensure that clinicians declare their interests when working in all roles within the scope of their practice. I, along with many of my colleagues, have signed up to www.whopaysthisdoctor.org.

In her thanks to the hundreds of people that the team met, Baroness Cumberlege wrote ‘Your bravery, dignity and tenacity in the face of the terrible harm you have suffered makes you truly extraordinary people.’ She promised at the end of the conference that she would go on working to ensure that the recommendations of the review would not disappear but would be enacted. She will drive the recommendations for a Patient Safety Commissioner, for improved and equitable regional access to care for women’s health problems, for improved clinician awareness and for the creation of an information hub for women.

My take home message was to actively listen to patients. Many new diseases have come into being during my medical career. These stories by women who had serious iatrogenic problems made me reflect on my listening skills. We have always used a mantra in my practice ‘If someone comes in 3 times for the same problem, share it with someone else’. The conference reinforced that as a useful strategy.

Creation of a central patient-identifiable patient database.

8.

Transparency of payments made to clinicians.

BARONESS CUMBERLEGE ELOQUENTLY DESCRIBED THE EMOTIONS EVOKED IN HER AND HER TEAM BY THE PATIENTS WHO RELIVED THEIR EXPERIENCES

REFERENCES https://immdsreview.org. uk/Report.html www.rcgp.org.uk/personcentred-care.aspx www.england.nhs.uk/ personalisedcare/ www.rcgp.org.uk/clinicaland-research/about/ special-interest-groups/ overdiagnosis-group.aspx www.appgwomens health.org

9.

The government to set up a task force to implement the Review’s recommendations.

Her Life Her Health | Spring 2021 | 7

ESSENTIAL UPDATE

Research & Guidelines RCGP Women’s Health toolkit: Women’s Health & COVID-19 Since the start of the COVID-19 pandemic primary care clinicians have changed their way of working in general practice by continuing to deliver high quality care through initial remote consultation and triage, aiming to reduce infection spread by unnecessary face-toface contact. This section of the Women’s Health toolkit contains resources to help provide care during the COVID-19 pandemic, including when this can be offered remotely, along with tips on applying recommendations to practice. ► Go to www.rcgp.org.uk/clinical-and-research

CKS contraception update NICE has recently updated the following clinical knowledge summary (CKS) topics: 1 Contraception – Emergency 2 Contraception – IUS/IUD. The topic structures have been updated and the recommendations clarified in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) guidelines. ► Read more at cks.nice.org.uk/topics

FSRH progestogen-only implant guidance This guidance has been updated. The recommendation for length of use of implant remains as 3 years because of lack of evidence of efficacy after that time.

There is a recognition that clinicians can continue to change later in the 4th year of use without requiring extra contraception, especially with reduced access to face-to-face services during COVID-19. The guidance provides evidence-based recommendations and good practice. ► Go to fsrh.org/standards-and-guidance

FERTILITY TREATMENT LESS SUCCESSFUL FOR ETHNIC MINORITY PATIENTS

A

report by the Human Fertility and Embryology Authority (HFEA) has found that people from ethnic minority backgrounds undergoing fertility treatment are less likely to have a baby, with black patients having the lowest chances of successful treatment.

Data showed that while overall birth rates from fertility treatment have increased and are highest in patients under 35, black patients aged 30-34 have an average birth rate of 23%, compared to 30% for mixed and white people. It also found that black patients are starting IVF treatment almost 2 years later (36.4 years old) compared to the average person at 34.6 years old.

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

THIS SECTION OF THE WOMEN’S HEALTH TOOLKIT CONTAINS RESOURCES TO HELP PROVIDE CARE DURING THE COVID-19 PANDEMIC

Dr Christine Ekechi, Co-Chair of the Royal College of Obstetricians and Gynaecologists’ Race Equality Taskforce, said: “This HFEA report is vital in understanding the barriers faced by women from ethnic minority backgrounds when trying to start a family and we welcome its publication. What is now required is a combined effort to provide solutions to include better awareness, safeguarding of reproductive health and improving the availability of targeted options for fertility treatments.”

ESSENTIAL UPDATE

Education & Learning

MENOPAUSE EDUCATION FROM THE PCWHF Our Menopause eLearning course will help you to make a difference every day to the lives of women going through menopause.

M

illions of women struggle with debilitating menopausal symptoms every day, but many often find it hard to find the right diagnosis, treatment and care. GPs and nurses working in primary care have so much to learn and keep up to date with that menopause education may sometimes not be a priority.

The PCWHF Menopause eLearning course is a relaxed, entertaining and educational approach to menopause education. It has been created to enable you to deliver excellent menopause care personal to each patient.

This interactive eLearning course has been designed by practising primary care GPs and menopause specialists, led

by Dr Jane Davis. The creators of the course have a wealth of experience in caring for women going through menopause and understand the pressures of working in primary care.

“I believe passionately that the key to gender equality is the delivery of excellent women’s healthcare,” says Jane. “The results of the PCWHF’s recent ‘Shaping the future of women’s health’ survey overwhelmingly showed that healthcare professionals are seeking menopause education. We saw that there was nothing available that the whole primary care team could access. In response to this need we created the eLearning course that everyone in the primary care team can access and come away from doing a better job for your patients.”

Convenient online learning Phase One of the PCWHF Menopause eLearning course is delivered as easy to consume, case-based learning with animated videos and questions throughout that identify key learnings.

Following individual women as they share their experiences of different aspects of the menopause, you will become confident in your identification and management of perimenopause and menopause symptoms.

The course has been created for everyone in the primary care team, because everyone has a vital role to play in supporting women at this time of life. It’s an accessible and relaxed look at perimenopause and menopause.

We look at how patients present with perimenopausal and menopausal symptoms, and importantly, how these symptoms impact on their lives.

Using real cases to demonstrate this gives you a ‘true to life feel’ for what you will see in clinical practice.

We provide resources for you to signpost your patients towards, helping them to feel informed and empowered to seek appropriate help.

Learning objectives: • Recognise the women who are struggling with menopause-related symptoms.

• Understand how the menopause changes the body and mind.

• Identify the stages of perimenopause, menopause and postmenopause.

• Advocate for the health of the women you work, live, and socialise with.

• Feel more confident in discussing menopause with confidence.

The course then goes into more detail about managing and prescribing for women experiencing perimenopausal symptoms. It is designed to build the knowledge and confidence of all those responsible for the health needs of women experiencing menopause.

THE SPRING ISSUE

EVERYONE HAS A VITAL ROLE TO PLAY IN SUPPORTING WOMEN AT THIS TIME OF LIFE WORDS BY AMY SCHOFIELD

Learning objectives: • Understand when investigations such as blood tests are needed for diagnosis.

• K now more about options to manage menopause symptoms, including HRT and alternatives such as lifestyle medicine.

• K now where to signpost patients to find further information on their perimenopause and menopause.

• To help a woman plan follow up.

The PCWHF Menopause eLearning course is FREE for PCWHF Members.

If you’re not a Member, you can sign up for just £49 per year and get access to the eLearning when available and a range of additional Membership benefits.

Menopause for Prescribers will follow later this year and will be offered at a discount for PCWHF Members.

“It has been an absolute pleasure to bring this course together,” says Jane.

“The field of menopause education is exciting and so worthwhile. We want to make a difference to our women every day and this course makes a difference at grass roots level.” ► Become a PCWHF Member today.

Go to www.pcwhf.co.uk/membership

Her Life Her Health | Spring 2021 | 9

EARLY YEARS

Management of recurrent vulvovaginal candidiasis Practical and evidence-based tips on the management of RVVC

RECURRENT VULVOVAGINAL CANDIDIASIS IS DEFINED AS 4 OR MORE EPISODES IN A SINGLE YEAR AFFECTING FEMALES AGE 12 AND ABOVE

WORDS BY DR CLARE SEARLE, ANNABEL LINES & DR INNA VARDI-FLYNN

W

hat are the key points to cover in a consultation with a woman presenting with recurrent vulvovaginal candidiasis (RVVC)?

Epidemiology and definition of RVVC Most women with vulvovaginal candidiasis self-diagnose and self-treat the condition. It has an effective cure in over 80% of cases. RVVC is defined as 4 or more episodes in a single year affecting females age 12 and above1.

The prevalence of recurrent vulvovaginal candidiasis is estimated at 9% of women aged 25-34, with 138 million women affected globally annually 2 .

Assessment We recommend a broad framework to follow when assessing these patients in primary care: 1 Aim to confirm the diagnosis though history and examination, ruling out other infections or skin problems 2 Identify any underlying causes or modifiable factors 3 Understand the impact the symptoms are having on your patient.

Aetiology of RVVC This is currently poorly understood. Molecular techniques indicate a pattern of relapse due to persistent candida species in the vagina rather than frequent vaginal reinfection5,6. It is thought that there are changes in the host defence mechanisms which result in uncontrolled vaginal candida proliferation11. Genetic susceptibility factors are also believed to be involved in vaginal mucosal defence mechanisms7.

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

HISTORY CHECKLIST AND RISK FACTORS • Diabetes mellitus • Immunosuppression • Oestrogen exposure is now a recognised factor 1,8,9 hence recurrent vulvovaginal candidiasis is more common in reproductive years and in pregnancy • Oestrogen-containing medications • A ntibiotic use and immunosuppressing drugs (eg steroids) • Specific history of vaginal douching and skin products used • Skin conditions/allergies • Use of local irritants (eg soaps, shower gels, and ‘feminine hygiene’ products) and tight-fitting, synthetic clothing can predispose to (or exacerbate) candidiasis5,10 • Sexual health history to assess risk of other STIs • Vulvovaginal candidiasis can be triggered by sex, especially if there is vaginal dryness during intercourse • Women receiving oral sex may be at higher risk of vulvovaginal candidiasis.

EARLY YEARS

Impact Affected women are reported to show loss of confidence, lower self-esteem, sexual dysfunction and inability to carry on with their normal physical activities2.

EXAMINATION CHECKLIST • E xamine for other conditions that can mimic candidiasis.

These include infective causes such as bacterial vaginosis (BV) and chlamydia or non-infective causes such as lichen sclerosis, physiological discharge and vulvar dermatoses (eg eczema or psoriasis).

• Consider sending a low vaginal swab for microscopy, culture, and sensitivity (M, C&S).

It is believed that up to 10% of infections are mixed1.

Therefore, the patient could have a combination of candida and BV or trichomonas.

• Consider the self-swabbing technique. This means providing the patient with 3 swabs to use herself when she thinks she has candida. This can be very helpful if the diagnosis is unclear and your swabs are negative for candida.

• Consider an STI screen including an HIV test if there is an appropriate history. Ensure you do a FBC and possibly HbA1C. • It is recommended to consider non-albicans species1.

Specify on the vaginal swab form that you need testing for non-albicans species also.

Management It may be appropriate and pragmatic to change contraception choice as many women will be fertile and recurrence is associated with hyper-oestrogenic states. There is evidence to suggest that switching contraceptives may help relieve symptoms10.

Guidelines recommend a 2-step treatment protocol, an induction regime followed by maintenance treatment. This approach leaves 90% women symptom-free at 6 months and 40% free at 12 months1.

Induction regime The British Association for Sexual Health and HIV (BASHH) suggests that the initial episode should be treated with a course of 3 doses of oral fluconazole 150 mg, or alternatively, an intravaginal antifungal for 10–14 days according to the patients’ response1.

Maintenance regime In the UK there are several licensed preparations for a 6-monthly maintenance regime.

Namely, intravaginal clotrimazole 500 mg once a week, oral fluconazole 150 mg once a week, or oral itraconazole 50–100 mg daily.

Her Life Her Health | Spring 2021 | 11

EARLY YEARS

What to do if this does not work?

1.

2.

3.

There is a link between recurring candidiasis and allergy12.

Therefore, cetirizine 10mg daily for 6 months may increase the remission rate12.

The majority of non-albicans are c glabrata which are still susceptible to azoles.

However, recent evidence suggests that c glabrata is better treated with topical nystatin13.

The use of topical nystatin is supported by the Australian guidelines on RVVC 14.

They recommend a regime from 2 weeks to 6 months of once weekly application of vaginal, topical nystatin cream.

In practice, if there is inflammation of the skin and other options have failed, we discuss topical agents such as Nystaform HC. Discuss care of vaginal skin as well as discussing risk factors that predispose the patient to the condition.

IT HAS BEEN REPORTED THAT AFFECTED WOMEN SHOW A LOSS OF CONFIDENCE, LOWER SELF-ESTEEM, SEXUAL DYSFUNCTION AND INABILITY TO CARRY ON WITH THEIR NORMAL PHYSICAL ACTIVITIES

Finally, if your patient is not improving or if there is uncertainty in the diagnosis, refer them to GUM or gynaecology clinics.

Conditions such as vulvodynia or dermatitis can then be excluded and other treatment options can be considered such as itraconazole, boric acid or amphotericin.

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

4.

5.

6.

Consider discussing the use of probiotics. It is important to stress that there is no concrete evidence that they are useful in recurrent vulvovaginal thrush, but there are currently no concerns about any unwanted effects either. Recent evidence shows that the use of probiotics as an adjuvant therapy could increase the rate of short-term clinical and mycological cure20. Non-pharmacological alternatives such as tea tree oil are not currently recommended in the guidelines due to the potential for adverse effects.

Although the media has frequently advocated dietary changes (eg a yeast-free diet), studies have not documented any efficacy to this approach14. In practice, we often see patients with RVVC seeking dietary exclusion advice. In this situation, we often discuss lifestyle and diabetes reducing strategies. nterestingly, BASHH and the Centre for Disease Control and Prevention (CDC) believe that uncomplicated vulvovaginal candidiasis does not require the treating of asymptomatic male partners of affected women. This is because no clinical trial data has found that the treatment of male sexual partners prevents recurrences of vulvovaginal candidiasis in women.

REFERENCES 1. Candida - female genital - NICE CKS [Internet]. Cks.nice.org.uk. 2019 [cited 5 January 2019].

Available from: https://cks.nice.org.uk/candida-female-genital#!scenario:2 2. Denning D, Kneale M, Sobel J, Rautemaa-Richardson R. Global burden of recurrent vulvovaginal candidiasis: a systematic review. The Lancet Infectious Diseases. 2018;18(11):e339-e347.

5. Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines [Internet]. Cdc.gov. 2019 [cited 6 January 2019]. Available from: https://www.cdc.gov/std/tg2015/candidiasis.htm 6. Cooke G, Watson C, Smith J, Pirotta M, van Driel M. Treatment for recurrent vulvovaginal candidiasis (thrush). Cochrane Database of Systematic Reviews. 2011 7. Tian C, Hromatka B, Kiefer A, Eriksson N, Noble S, Tung J et al. Genome-wide association and HLA region fine-mapping studies identify susceptibility loci for multiple common infections.

Nature Communications. 2017;8(1).

8. Chronic vaginal candidiasis. Management in the postmenopausal patient.

Climacteric. 2000;3(4):297-297.

9. Tarry W, Fisher M, Shen S, Mawhinney M. Candida Albicans: The Estrogen Target for Vaginal Colonization. Journal of Surgical Research. 2005;129(2):278-282.

10. [Internet]. Bashh.org. 2019 [cited 6 January 2019]. Available from: https://www.bashh.org/documents/1798.pdf 11. Sobel J. Pathogenesis of recurrent vulvovaginal candidiasis. Current Infectious Disease Reports. 2002;4(6):514-519.

12. Neves N, Carvalho L, Lopes A, Cruz ?, Carvalho E. Successful Treatment of Refractory Recurrent Vaginal Candidiasis with Cetirizine Plus Fluconazole. Journal of Lower Genital Tract Disease. 2005;9(3):167-170.

13. Fan S, Liu X, Wu C, Xu L, Li J. Vaginal Nystatin Versus Oral Fluconazole for the Treatment for Recurrent Vulvovaginal Candidiasis. Mycopathologia. 2014;179(1-2):95-101.

14. racgp [Internet]. Racgp.org.au. 2019 [cited 27 January 2019]. Available from: https://www.racgp.org.au/download/documents/AFP/2011/March/201103watson.pdf

EARLY YEARS

TREATMENT OPTIONS

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

STOPPING SMOKING, REDUCING ALCOHOL AND EXERCISING REGULARLY ARE ESSENTIAL WORDS BY DR RAMIYA AL-ALOUSI

Premature ovarian insufficiency PIL This downloadable patient information leaflet can be shared with your patients to advise them on diagnosis, treatment and management of premature ovarian insufficiency.

Premature menopause or premature ovarian insufficiency (POI) is when your periods stop before the age of 40 years. It means that the ovaries are not working well and if affects less than 1% of women. This early drop in hormones is associated with many troublesome symptoms and health conditions if left untreated.

The good news is that there are lots of options available to help treat this condition. Your doctor or nurse may refer you to a specialist with expertise in this field. The aim is to replace the hormone levels until at least the natural age of menopause, which in the UK is roughly around 51 years.

One option is to take hormone replacement therapy (HRT).

In most women, the benefits of HRT far outweigh the risks, especially in POI. Often higher doses are needed in younger women to help with symptoms.

Combined hormonal contraception is an alternative which is particularly good if you are also sexually active, as there is a very small chance that the ovaries can kick start at any point. The intrauterine system or ‘coil’ is also great at this, and can be combined with oestrogen to replace the hormones that you need.

Stopping smoking, reducing alcohol and exercising regularly are also essential, as is optimising your bone health. Looking after your mental health is really important too, you may be feeling upset or alone with this diagnosis but there’s a lot of support available to help.

USEFUL FACTS DIAGNOSIS • Symptoms and hormonal blood test 6 weeks apart SYMPTOMS • Mood changes • Fatigue • Hot flushes • Night sweats • Irregular periods • Reduced libido

CAUSES • Surgical removal of ovaries • After Chemo/Radiotherapy • Genetics • Autoimmune diseases • Infection RISKS If left untreated, there’s an increased risk of long-term health conditions such as heart disease and thinning of the bones.

For women who would like to have a family, a referral to the fertility clinic can be arranged. There are various options including the possibility of using donor eggs.

► For more information on POI, visit The Daisy Network,

a UK based charity to support women who have premature ovarian insufficiency. www.daisynetwork.org.uk

This resource has been produced on behalf of the PCWHF. Please note this resource is for guidance only and you should use your clinical judgement on a case-by-case basis. Review due Feb 2022.

Her Life Her Health | Spring 2021 | 13

FERTILE YEARS

WORDS BY IMOGEN PINNELL

I want my life back

GAPS IN UNDERSTANDING AND LACK OF FUNDING AROUND PELVIC RADIATION DISEASE MEAN MANY PATIENTS ARE LIVING WITH LIFE-ALTERING CONDITIONS AND NOT GETTING THE SUPPORT OR TREATMENT THEY DESPERATELY NEED

Research from JO’S CERVICAL CANCER TRUST has found that cervical cancer patients treated with radiotherapy are not receiving appropriate care for the long-term side effects of their treatment.

A

bout 49,000 women in the UK are living with and beyond a cervical cancer diagnosis, with over half of those diagnosed living for 10 years or more – but surviving is very different to living well.

Around 40% of patients receive radiotherapy during treatment for cervical cancer. It’s an effective treatment, but can lead to long term impacts, including Pelvic Radiation Disease (PRD) – a collection of symptoms affecting pelvic organs following toxicity exposure. Gaps in understanding and lack of funding around PRD mean many patients are living with life-altering conditions and not getting the support or treatment they desperately need.

We spoke with 18 patients living with PRD, interviewed health professionals working within late effects and radiotherapy, and issued Freedom of Information requests to NHS Trusts and Health Boards across the UK. Our report, I want my life back, highlights lack of consistent guidance, diagnosis, and treatment for those affected.

What is Pelvic Radiation Disease?

During radiotherapy treatment, body parts surrounding the targeted area are sometimes unavoidably affected and damaged. PRD describes symptoms continuing for at least 3 months following radiotherapy and can include incontinence, pain, infertility, lymphoedema, bone fractures, and nerve damage. These can be debilitating, permanent, and leave sufferers unable to continue dayto-day activities. These symptoms are often related to underlying conditions including radiation osteitis, pelvic insufficiency fractures and exocrine pancreatic insufficiency.

Poor resourcing to aid PRD management, in addition to limited awareness amongst both primary and secondary care, mean symptoms are often looked at in isolation. With underlying causes unidentified, ineffective treatment can be given and patients report ricocheting around the health system seeking answers. ► More information and support: Action

Radiotherapy www.actionradiotherapy.org, Jo’s Cervical Cancer Trust www.jostrust.org.uk, Pelvic Radiation Disease Association www.prda.org.uk, Macmillan Cancer Care www.macmillan.org.uk

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

Case study: Jess’ Story “I began to experience issues with my bowels and was given loperamide but was offered no alternative treatment.

I have had diarrhoea every day since Christmas Eve 2016 but despite this have managed to gain 10 stone. My GP has been of little help, suggesting I get a gastric band or just stop eating.

Problems with my bladder began a year after treatment. One day I was fine, the next I wet myself. It began to happen more regularly and then I started to have pains. I was initially given antibiotics for thrush but they eventually referred me to a bladder specialist. I was told I had an over-reactive bladder due to scarring caused by my cancer treatment.

FERTILE YEARS

What can healthcare professionals do?

1.

2.

3.

4.

5.

I tried 5 different kinds of medication, none of which helped, and began a nerve stimulation treatment, percutaneous tibial nerve stimuation (PTNS). It didn’t completely solve my issues but was improving things significantly. Then the pandemic put me back to square one with my treatment.

I find leaving the house really difficult and I don’t eat for two hours before I leave because I’m terrified that I’ll need the toilet. I’ve pulled away from friends and family. My relationship with my husband is strained because I’m so tired all the time and the continence issues make it really hard for me to feel attractive.”

6.

7.

8.

Raise the topic of PRD. Explain the possibility of PRD before and after radiotherapy, and discuss signs to look out for. Ensure your patient knows to tell you or someone else in their medical team if they notice any symptoms.

Check your patient has a Treatment Summary. It should have been completed and passed to you by their secondary care team. If your patient doesn’t have one, you or they can enquire with the hospital.

Ask questions. Patients may feel uncomfortable talking about personal symptoms or believe it’s something they should ‘put up with’. If a patient has had radiotherapy at any point in the past, check in with them and ask how they are doing. They may not make the connection between treatment and the symptoms, so it can help to be prompted.

Introduce tools and checklists to aid identification of symptoms.

Utilise ALERT-B and The Practical Management of the Gastrointestinal Symptoms of Pelvic Radiation Disease, but be aware of other PRD symptoms falling outside of the gastrointestinal umbrella.

Offer ways to manage PRD symptoms and address underlying causes.

While PRD can be complex, there are some steps that can help: • Medication or surgery can help manage bowel and bladder problems.

• Medication can help with bone problems and pain, while physiotherapy can support with mobility issues.

• Creams can ease vaginal symptoms and help improve sexual wellbeing.

• Talking therapy may help someone experiencing psychological issues.

Identify services, pathways and clinicians available to you and your patients. Dedicated late-effects clinics, integrated services supporting patients post-radiotherapy, and clinicians with specialist knowledge of PRD symptoms can significantly improve quality of life.

Signpost to further information and support. You can refer patients to our information about PRD and other organisations that offer support, including the Pelvic Radiation Disease Association.

Identify opportunities for training among your workforce.

Share resources or our report I Want My Life Back.

Her Life Her Health | Spring 2021 | 15

RISING STARS

Early diagnosis of ovarian cancer in primary care: OPPORTUNITIES & HURDLES The Target Ovarian Cancer Essay Prize runner-up explores the challenges of early diagnosis of ovarian cancer in primary care.

I

t is a simple fact that early diagnosis of ovarian cancer leads to a far better chance of survival. Whilst over 90% of women live 5 years after a diagnosis of stage I ovarian cancer, just 5% of women are alive after 5 years with stage IV cancer.

Therefore, there is a clear incentive to strive for the earlier diagnosis of this disease, particularly in primary care where many women first present with symptoms. Staging aside, a simple framework to think about the

progression of ovarian cancer is that it moves through an asymptomatic phase to an eventual symptomatic one, which is often what prompts investigation and diagnosis (Figure 1). In order to practically achieve an earlier diagnosis within primary care, it can be argued that there are 3 key areas for improvement: shortening the time for diagnosis after presentation, shortening the time it takes for women to attend the GP with symptoms, and the detection of cancers prior to the development of symptoms.

Figure 1: PROGRESSION OF CANCER WITH TIME

Ovarian cancer begins to develop

HEALTHY

Symptoms First presentation begin to GP

ASYMPTOMATIC

Diagnosis of ovarian cancer

SYMPTOMATIC

Average may be 4.3 years *

Estimated UK average: 8.6 weeks+

Estimated UK average: 22.2 weeks+

Current lack of viable screening programme

Delay in presentation

Delay in diagnosis

Timeline illustrating an example of events which may lead to the presentation of ovarian cancer, and where delays occur. Note that time of onset of symptoms does not necessarily correlate with staging of the cancer. *Serous tumours may spend on average 4.3 years as histopathologically detectable but clinically silent (Brown and Palmer, 2009) +Data reported by ‘The Every Woman Study’ (World Ovarian Cancer Coalition, 2018)

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

Reducing time for diagnosis: rethinking the diagnostic pathway There are several factors which make ovarian cancer particularly challenging to diagnose and which are likely to contribute to diagnostic delay. Firstly, common symptoms of ovarian cancer, such as tiredness, bloating and change in bowel habit, are relatively non-specific and in reality, the majority of women presenting with these symptoms will not have ovarian cancer. Secondly, Hamilton (2012) writes that GPs may only encounter ovarian cancer once every 5 years, which makes it difficult to gain personal experience in its diagnosis. For these reasons, it is of utmost importance that clinicians have reliable investigations available to pick out those who do have ovarian cancer, but currently used investigations are not necessarily the most reliable.

In primary care, NICE guidelines recommend initial testing of the serum level of CA-125 (a tumour marker) followed by a transvaginal ultrasound if CA-125 is found to be 35 IU/ml or greater. However, it is widely known that the sensitivity and specificity of CA-125 is somewhat poor (80% and 75% respectively [Medeiros et al., 2009]).

NICE does acknowledge that the diagnostic pathway is far from perfect; in fact, referral strictly on the basis of both a positive CA-125 and ultrasound means that 34% of women who do have

RISING STARS

Figure 2: ESTIMATED AVERAGE TIME FROM EXPERIENCING SYMPTOMS TO DIAGNOSIS,

BY COUNTRY IN WEEKS (N=1093)  Time to visit doctor 35 30

22.8 21.8

Average time for all symptomatic women who consulted a doctor 31 weeks 16.3

25

23.6

22.2

15.4

20

11.0

15.8

15 10

 Time doctor to diagnosis

15.0

15.2 35

12.8

5

11.2

12.9

10.7 7.9

8.6

Spain

UK

5.5

0 Australia

Canada

ovarian cancer will not be referred in accordance with this pathway (North Bristol NHS Trust, no date).

Therefore, it is up to GPs to adequately use safety netting and encourage patients to return if their symptoms persist, which is not an ideal system.

Despite these general challenges with the diagnosis of ovarian cancer that would apply in any country, it is interesting that the Every Woman Study reported the UK to have one of the highest intervals between presentation with symptoms and diagnosis of ovarian cancer (Figure 2; World Ovarian Cancer Coalition, 2018).

Given that the same investigations are used across many different countries, perhaps there lies an issue in the guidelines themselves that could account for this discrepancy.

Intriguingly, the guidelines for investigation of suspected ovarian cancer differ across the UK. Whilst in England, except in the case of urgent referral, there is sequential testing with CA-125 blood test and ultrasound, the protocol in Scotland is to order these two investigations simultaneously. Of note, in Germany, where the average diagnostic time

Germany

Hungary

Italy

was found to be 15.8 weeks compared to the UK’s 22.2 weeks (Figure 2), a transvaginal ultrasound is the single first line investigation in suspected ovarian cancer. The justification for the sequential testing guidelines appears to be a trade-off between diagnosing true ovarian cancers and avoiding over-investigation in huge numbers of women who would turn out not to have cancer. However, it seems logical that the simultaneous ordering of these two investigations would help provide a broader clinical picture to guide decision making rather than the CA-125 result in isolation, which currently then determines subsequent management.

It may be a worthwhile investment to increase the number of trained ultrasonographers to facilitate carrying out more transvaginal ultrasounds within GP practices.

Outside of primary care, research must look to developing more sensitive and specific biomarkers to enable earlier diagnosis; there is also the possibility of using a predictive algorithm to provide computer assisted diagnosis (Hamilton, 2012), but this is still far from fruition.

Japan

WORDS BY SARAH JOHN

USA

Increased symptom awareness: Is raising public awareness a useful strategy for earlier diagnosis in primary care?

Koldjeski et al (2005) describe the time in which symptoms begin to present in a woman with ovarian cancer as the ‘self-care phase’. They highlight that a particular issue with ovarian cancer is that the symptoms that can be experienced, such as bloating, frequent urination and abdominal discomfort, are often uncomfortable but not debilitating. This may represent a barrier to women seeking help from a doctor. Many women become accustomed to experiencing similar symptoms throughout their lives in relation to their menstrual cycle, often learning to manage these independently. It would be interesting to study whether the attitude of ‘putting up’ with such symptoms and dismissal has any contribution to diagnostic delay in ovarian cancer.

Koldjeski et al (2005) also emphasise that if there is an extended ‘self-care phase’, there is a stronger possibility of a diagnostic delay after presentation.

The reasons for this are unclear, but perhaps some follow up into

Her Life Her Health | Spring 2021 | 17

RISING STARS

THERE ARE SEVERAL FACTORS WHICH MAKE OVARIAN CANCER PARTICULARLY CHALLENGING TO DIAGNOSE AND WHICH ARE LIKELY TO CONTRIBUTE TO DIAGNOSTIC DELAY

GP implicit bias and perception of the seriousness of symptoms based on time taken to present is needed.

Thus, education about the symptoms of ovarian cancer, especially in postmenopausal women, has a key role to play in striving for earlier diagnosis within primary care. Public awareness campaigns related to ovarian cancer can theoretically lead to earlier diagnosis by the following means: 1 Instilling the concept of being aware of one’s bodily functions and when these become perturbed; encouraging symptom recognition in those who may not otherwise notice.

2 Validating that these symptoms are important and should not be dismissed and establishing a clear recommendation of when to see a doctor.

3 Encouraging women to highlight the specific concern of ovarian cancer to the GP – this may potentially accelerate diagnosis or ruling out.

It is also essential that primary care doctors are aware of ongoing public campaigns so they are able to reinforce these principles and messages. However, do these symptom awareness campaigns actually lead to earlier diagnosis?

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

‘Be Clear on Cancer’ ran a local pilot campaign from January to March 2013 to increase awareness of ovarian cancer symptoms in women over 50, highlighting the symptom of feeling bloated most days for 3 weeks or more. Evaluation of this campaign encouragingly highlighted increases in public knowledge and awareness of symptoms, the number of GP visits for unexplained bloating and the number of diagnostic tests such as CA-125. However, the evaluation did not demonstrate increased diagnosis or earlier diagnosis of ovarian cancers (Public Health England, 2015; Cancer Research UK, 2014). A sceptical eye may infer that this campaign simply increased ‘unnecessary’ tests ordered by GPs, however, there are several reasons why this may not have translated into a quantifiable increase in diagnoses. Firstly, this was a short campaign involving relatively small numbers. The much larger lung cancer awareness campaign run by ‘Be Clear on Cancer’ was in fact able to demonstrate a statistically significant (9%) increase in the number of cases diagnosed during the campaign (Cancer Research UK, 2014), suggesting that this strategy holds value for improving diagnosis if the scale is large enough. Despite the lack of tangible figures demonstrating earlier diagnosis, a more implicit success of the pilot ovarian cancer campaign was its effect on the doctorpatient relationship and willingness of women to open up about their symptoms; women must be able to trust that they will be investigated accordingly in order to present to their GP. In the long term, if such campaigns are more widespread, perhaps there will be a trend towards earlier diagnosis not just via the direct effects of these campaigns, but also due to a shift in attitude towards close selfmonitoring and willingness to speak to a healthcare professional, which would be much more difficult to quantify.

REFERENCES 1. Brown, P. and Palmer, C., 2009.

The Preclinical Natural History of Serous Ovarian Cancer: Defining the Target for Early Detection.

PLoS Medicine, 6(7), p.e1000114.

2. Cancer Research UK, 2014.

Be Clear On Cancer Evaluation Update. [online] Cancer Research UK. Available at: <https://www. cancerresearchuk.org/sites/default/ files/evaluation_results_2014.pdf> [Accessed 3 June 2020]. 3. Hamilton, W., 2012. Computer assisted diagnosis of ovarian cancer in primary care.

BMJ, 344(jan04 1), pp.d7628-d7628.

4. Koldjeski, D., Kirkpatrick, M., Swanson, M., Everett, L. and Brown, S., 2005. An Ovarian Cancer DiagnosisSeeking Process: Unraveling the Diagnostic Delay Problem.

Oncology Nursing Forum, 32(5), pp.1036-1042. 5. Medeiros, L., Rosa, D., da Rosa, M. and Bozzetti, M., 2009. Accuracy of CA 125 in the diagnosis of ovarian tumors: A quantitative systematic review.

European Journal of Obstetrics & Gynecology and Reproductive Biology, 142(2), pp.99-105.

6. Nathan, P., Johnson, O., Clamp, S. and Wyatt, J., 2016. Time to rethink the capture and use of family history in primary care. British Journal of General Practice, 66(653), pp.627628. 7. NHS England, 2015. Clinical Commissioning Policy: Genetic Testing For BRCA1 And BRCA2 Mutations. [online] Available at: <https://www.england.nhs.uk/ commissioning/wp-content/ uploads/sites/12/2015/10/e01pbbrca-ovarian-cancer-oct15.pdf> [Accessed 3 June 2020].

8. North Bristol NHS Trust, no date.

Guidelines For CA-125 Requesting.

Available at: <https://www.nbt.nhs.uk/ sites/default/files/Guidelines% 20for%20CA-125%20Requesting. pdf> [Accessed 7 June 2020].

9. Public Health England, 2015.

Evaluation Of The Be Clear On Cancer Ovarian Cancer Awareness Campaign. [online] Available at: <https://assets.publishing.service. gov.uk/government/uploads/ system/uploads/attachment_data/ file/412941/CRUK_Report_Local_ Ovarian_130315_CT_GW_final.pdf> [Accessed 3 June 2020].

10. World Ovarian Cancer Coalition, 2018. The Every Woman Study Summary Report. [online] Available at: <http:// worldovariancancercoalition.org/ wp-content/uploads/2019/11/ WOCC-Every-Woman-StudySummary-Report-Nov-08.pdf> [Accessed 3 June 2020].

RISING STARS

SCREENING: A LONG-TERM GOAL FOR EARLY DIAGNOSIS, BUT IS IT A VIABLE APPROACH?

S

creening is the process of identifying individuals at a higher risk of or who currently have a particular condition but are not yet symptomatic. In essence, the point of screening is to facilitate early diagnosis in order to save lives. For ovarian cancer, a screening programme does not yet exist, despite numerous randomised controlled trials (RCTs) investigating their use. Two of the largest RCTs – UKCTOCS and PLCO – were not able to demonstrate a statistically significant reduction in mortality from ovarian cancer as a result of screening with CA-125 and transvaginal ultrasound. A key explanation for this may be that the screening tools tested are simply not sensitive enough to pick up early stage ovarian cancer in many cases, particularly since serous ovarian tumours are estimated to spend most of their occult period at a diameter of less than 1cm (Brown and Palmer, 2009). Therefore, the future success of a national screening programme is dependent on investment into the development of better screening tools; new research is geared towards uncovering a panel of biomarkers which may serve this purpose. Whilst this is certainly a worthwhile long-term investment with the potential to lead to the biggest change in shifting to earlier diagnosis, this is a strategy that is far from implementation. Thus, what measures can be implemented in primary care to screen for vulnerable patients without a national screening programme?

Perhaps, a shift in culture is needed within primary care towards increasing awareness of genetic testing amongst asymptomatic women who report a family history of breast or ovarian cancer. 15-20% of ovarian cancers are thought to be due to a genetic cause, with 10-15% of ovarian cancers having a mutation in BRCA1 or BRCA2. However, the ‘Every Woman Study’ also revealed that among women with two or more relatives with ovarian cancer in their family, 80% were not tested for higher risk gene variants prior to their own diagnosis of ovarian cancer (World Ovarian Cancer Coalition, 2018). In England specifically, NICE estimates that just 34% of eligible individuals were accessing testing of BRCA1 and BRCA2 in 2015 (NHS England, 2015). If asymptomatic carriers of mutations are aware of their greater risk, they can be more vigilant of symptoms if they are to develop, and clinicians can have a lower threshold for deciding to order investigations in this higher risk group. It is possible that this may contribute to earlier diagnosis in many women.

Of course, genetic testing is a highly sensitive issue, and there are many ethical reasons why someone may wish to decline testing. Nonetheless, it is important that women are made aware of their eligibility for testing, which begins with the collection of a comprehensive family history in general practice. Unfortunately, competing priorities and pressures do not allow for collection of a sufficiently detailed family history in asymptomatic patients in current primary care. Nathan et al (2016) advocate for the introduction of a system to better collect detailed family history data from patients, perhaps using an online form which patients complete in their own time. This may allow the identification of higher risk women without significantly increasing the burden on GP consultations, which are already in short supply and time pressured. This is a long term goal, but is an important one with the potential to truly lead to earlier diagnosis in the significant population of genetically susceptible individuals.

Concluding remarks When thinking about the question at hand, the key hurdles preventing the earlier diagnosis of ovarian cancer are slow diagnosis which may be facilitated by lack of sufficiently reliable tests and laboured diagnostic pathway; the lack of public awareness of the symptoms of ovarian cancer leading to a delay in presentation; and the lack of tools which enable us to screen for ovarian cancer amongst asymptomatic women, whether they have a genetic susceptibility or not.

Whilst a national screening programme remains a long-term goal, there are several much more quickly achievable strategies that can be implemented in the meantime that could shorten diagnosis for many women. The key targets must be reform of the diagnostic pathway, education of the general public and healthcare professionals and increased genetic testing to monitor higher risk individuals.

The Faster Diagnosis Standard within the NHS Long Term Plan set out the aim that all patients suspected of having cancer should have this ruled out or diagnosed within 28 days. This target will certainly not be met if there is no change in our practices for diagnosing ovarian cancer.

Her Life Her Health | Spring 2021 | 19

SUPPLY OF SAMPLES | For prescribers interested in gaining greater familiarity with Blissel® please contact medinfo@flynnpharma.com

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/2021/1386 Date of preparation: March 2021

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

Menopause & Ethnicity What are the barriers and challenges to diagnosing and managing menopause in South Asian women, and what are the possible consequences?

BE AWARE THAT THERE ARE NO DIRECT TRANSLATIONAL WORDS FOR VAGINA, OVARY & MENOPAUSE IN SOUTH ASIAN CULTURE

R WORDS BY DR RADHIKA VOHRA

esearch into cultural variations in menopause, treatment and long-term consequences is scarce, so I write this with insight from clinical experience. My aim is that it assists gaps in health provision.

Since completing my doctor and GP training, like many others, I have seen a lot of female patients. It’s hardly surprising, as research shows, that women see a GP 32% more than men between the ages of 16-60 years1. There are many reasons, including perimenopause and

menopause, yet only 12% of women receive help in the form of hormone replacement therapy (HRT).

The BJGP published a paper recently, showing that women from lower socioeconomic groups were 29% less likely to be prescribed HRT than those from more affluent areas2 . In addition, the 2011 Census showed that of the 14% BAME population of England and Wales, 7.5% was of Asian ethnic groups3 . There exists a correlation between the Asian ethnic populations and lower socioeconomic status.

Join me. Reflect and ask yourself – is there a pattern to how South Asian

women presented in their late 40s to early 50s? For me, they presented with non-related symptoms such as anxiety, palpitations, menstrual changes, insomnia, urinary changes and body aches. Despite investigations, a diagnosis was not found for many and they accumulated into the group: ‘medically unexplained symptoms’. The term ‘heart sink’ patient was often used as was the presenting complaint of ‘pain, pain, pain…’ It feels terrible looking back, however, perhaps like me, your training included little on menopause and even less on the impact of oestrogen deficiency.

Asian women believe menopause is a life event which marks the end of childbearing and which gives them freedom from the inconvenience of menstruation. It is ‘liberating’ rather than a time of gradual psychological and physical decline. The menopause does not pass silently, and most South Asian women will have short-term and long-term consequences of oestrogen deficiency.

In total the menopause has almost 50 recorded symptoms. The short-term and most common are hot flushes, night sweats and tiredness. What has been noticed is that different ethnic backgrounds display symptoms to a different extent and this can make recognising menopause more challenging for the women themselves and for the caring professionals.

Not only this, oestrogen balance is dependent on diet, lifestyle and medical history and for many women the disruption of perimenopause can be disastrous; limiting personal life, work and social interactions.

Woman from South Asia have a more plant-based diet and tend to suffer from fewer hot flushes, night sweats and skin changes from lack of oestrogen. However, they have more body aches, palpitations and urinary symptoms from the change in oestrogen, progesterone and testosterone. This often leads to menopause and HRT being considered much later as a cause and sometimes over-investigation.

Her Life Her Health | Spring 2021 | 21

RENAISSANCE YEARS

TIPS TO HELP

IN CONSULTATIONS WITH SOUTH ASIAN WOMEN

• Due to pandemic changes – consider a video or face-to-face consultation if appropriate rather than telephone.

• Allow extra time or rebook, use diagrams/models.

• Be aware there are no direct translational words for vagina, ovary and menopause in South Asian culture.

• Be DIRECT, ask about vaginal dryness, pain and urinary change as they may not raise this.

Potential barriers for South Asian women • Embarrassment and cultural taboo for discussing vaginal, menstrual and menopausal issues.

• Reluctance to see a male doctor, for examination or follow-up.

• Language and literacy barriers.

• IT challenges, social media influencers, community acceptance.

• F inancial constraints – dual prescription charge for HRT. • Less motivation for exercise and diet change.

• Show an HRT demo to reduce the fear of the unknown.

• Use a symptom diary such as the Greenes Questionnaire/ Rock My Menopause’s symptom tracker.

What are the possible long-term consequences?

• A higher risk of: ˚ diabetes ˚ osteopenia and osteoporosis ˚ cardiovascular disease ˚ dementia • Muscular weakness • Frequent presentation • M isdiagnosis, for example UTI, CFS • Polypharmacy and medication side-effects • Reluctance to take HRT treatment.

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

Case study • Mrs ST, 49yo, from North India, teenage children, works as a kitchen assistant, limited English.

• Has seen 6 different GPs complaining of palpitations and body aches.

• Notes show she’s seen a rheumatologist, pain team, orthopaedic surgeon & cardiologist.

• Has had over 14 different investigations which found that she had no causal disease for symptoms.

• 6 repeat medications, including co-codamol, amytriptyline and naproxen. Side-effects of dry skin, blurred vision and gastrointestinal disturbance.

• Translation consult & direct questioning showed – LMP 10 months ago, inability to cope with activities of life due to body aches, low mood and thinking of stopping work; nocturia and sleep disturbance.

• Started transdermal sequential HRT with counselling and support.

• At 3-month review = cholesterol improved, analgesics stopped and continuing to work.

Serum Oestradiol 236. Body aches much better.

• At 6-month review = changed to continuous combined HRT, annual review planned.

• Use available translated counselling material available in Hindi and Punjabi on: Videos

► menopausedoctor.co.uk

REFERENCES 1. Wang Y, Hunt K, Nazareth I, et al. BMJ Open 2013;3:e003320. doi:10.1136/ bmjopen-2013-003320 2. Sarah Hillman, Saran Shantikumar, Ali Ridha, Dan Todkill and Jeremy Dale British Journal of General Practice 2020; 70 (700): e772-e777.

3. Population of England and Wales – GOV.UK Ethnicity facts and figures (ethnicity-facts-figures. service.gov.uk)

• Work with nurses/ colleagues conducting smears to pick up genitourinary syndrome of menopause as this indicates oestrogen deficiency and can be a good starting point.

The early explanation of menopause symptoms, reassurance and treatment with HRT is important for South Asian women. There is a genetic tendency towards diabetes, bone and heart disease which is exemplified during and after menopause. In my experience, the provision of literature and counselling material in the mother tongue can empower women to understand the massive impact menopause will have on their life so they can increase not only their lifespan but also their quality of life.

WIDE AWAKE AT

NIGHT?

Isolation and loneliness can affect our quality of sleep1

•

Provides clinically meaningful improvements in quality of sleep and morning alertness2

•

Monotherapy for the short-term treatment of primary insomnia characterised by poor quality sleep in patients aged 55 or over2

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.

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.

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 March 2021

UK/CIR/2021/1324

RENAISSANCE YEARS

M How to talk to women about sex at menopause Approaching problems with sexual function within a biopsychosocial framework places the individual at the centre of solutions.

enopause describes a biological event in a woman’s reproductive life: but it is much more than that. It has social, cultural and relational significance as well. The Diagnostic and Statistical Manual of Disorders (DSM) 5 (DSM-5) and the World Health Organization’s International Classification of Diseases 11 (ICD-11) attempt to classify female sexual dysfunction, but with a firm focus on their biological causes. As a GP and clinical sexologist, however, I know that most of us working in women’s health are only too aware that the problems experienced by a menopausal woman will have unique impacts that will differ significantly according to her particular life circumstances.

Problems of libido loss, vulvovaginal pain, and changes in arousal and climax are common at menopause, and often there is a lot we can do to help tackle these. Ensuring we approach such problems within a biopsychosocial framework ensures we let women know they are being heard and seen as an individual, and that we place them at the centre of any approach to offer a solution.

There are common themes in each of these areas that may affect women at menopause:

WORDS BY DR ANGELA WRIGHT

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

OUR ROLE AS WOMEN’S HEALTH PRACTITIONERS IS TO BOTH START, AND OPEN UP THE CONVERSATION AROUND SEX

RENAISSANCE YEARS

BIOLOGICAL Physical changes throughout the brain and body, due to both ageing and falling hormone levels, can have a myriad of potential effects on women’s sexual function. Oestrogen and testosterone are important in both the central and the peripheral systems that govern our libido, arousal and climax. Reduced blood flow to the breasts and our pelvic organs after menopause contributes to changes in how we experience touch, and also in the ability of the clitoris to engorge in response to tactile stimulus. The ability of our sensory nerves to respond to touch is also reduced as we age – meaning that we may require more intense touch to elicit the same responses we enjoyed at an earlier age.

Loss of oestrogen in the genitourinary tract can also lead to genitourinary syndrome of menopause (GSM). This significantly thins the vaginal epithelium, and can cause changes in lubrication in response to sexual stimulus, and in the ability of the vagina to increase in size in readiness for penetration. It changes the vaginal pH and reduces our defences against infection. Dermatological conditions, such as lichen sclerosus, become more common again in older, oestrogen deprived women. The dryness and itch associated with GSM can contribute to superficial sexual pain, and embarrassment about the appearance of the vulva. This is also true regarding the increased prevalence of pelvic organ prolapse. Bladder issues such as LUTS or interstitial cystitis may also become worse after menopause, and impact enormously on sex, making women anxious about pain or loss of control of continence during sex. We may have to ask direct questions to elicit concerns about these things, as women might feel a great deal of embarrassment about raising them.

In addition to the more direct effects on sexual function of post-menopausal hormone deprivation, there are also wider effects from the loss of the relative oestrogenic protection against other conditions such as cardiovascular disease. The increased prevalence of comorbid conditions, and the side effects of the medicines we prescribe to treat them, also have a significant effect on sexual function.

PSYCHOLOGICAL It is important to recognise how individual the psychological impact of menopause is. Many previously healthy women will go through menopause without experiencing any significant psychological distress as a result of it. In fact, many might enjoy freedom from contraception worries, or the time constraints of caring for a young family. Others will have had their family later and be managing the demands of a young child as they try to simultaneously grapple with their menopause. For women who have struggled with infertility, it may mark the final, painful closing of that door.

Certainly, we know that for women with premature ovarian insufficiency and surgical menopause, the psychological impacts of their last period can be far greater. What is important to recognise is that no one woman will have the same concerns as another. We need to show that we are sensitive to the issue full stop, and ask the woman sitting before us about how she is feeling, and about what else might be happening in her life.

We increasingly understand, however, that some women are more susceptible

than others to the impact of fluctuating hormones on their psychological wellbeing. We also know that sleep disturbances, such as insomnia, are prevalent around menopause and that these also impact on energy levels and mood. What is important is that we explore with each woman in front of us whether their mood is an issue for them at this time – and then consider if it might be impacting the sexual problem they are experiencing.

Being able to enjoy sex, and experience arousal and climax often means being able to switch our minds off from other worries to focus more fully on our sensory experience. Even when everyday stresses don’t manifest as clinical depression or anxiety, the other demands of life at menopause can create a very challenging background to place sexual problems into context with. Where this does form a clinical diagnosis of its own, there are the additional complications of loss of libido as part of these conditions, and the prevalent sexual side effects of the SSRIs and other drugs that we use to treat them.

SOCIAL Without necessarily realising it, we all carry our own ‘sexual scripts’ with us. These are the received messages – from parents, teachers, books, TV – and our early lived experiences – that underpin our beliefs about sex and sexuality. They help to form our sense of how our own sexuality fits into these societal, religious and cultural norms. For example, do we think monogamy is normal, achievable, desirable? What about our ideas around what constitutes ‘normal’ gender expression, or how we feel about our sexual orientation and those of others? What are normal ‘turn-ons’ and what do we consider ‘kink’? Our beliefs about all of these things will impact how satisfied we are with our own sexual behaviours. They will impact, as other scripts do in all arenas of health, on whether we believe we have a problem that needs solving.

Women’s individual beliefs about the significance of menopause are bound, therefore, to impact on their sexual function. There are many societal and cultural messages around ageing and sexuality that can feel negative to women as they go through menopause. It is important to consider how they feel about the importance of their sexuality as they get older. Whether they feel more, or less attractive as they age? Do they still find their current partner attractive, and feel desire for them?

Do they worry about still being desirable to their partner? The women we see are increasingly in second or third long term partnerships too – or dating again after divorce. We also need to recognise the prevalence of non-heteronormative relationships too. All these factors will impact what women perceive to be acceptable, or problematic, in their sex lives.

Her Life Her Health | Spring 2021 | 25

RENAISSANCE YEARS

What can we do to help?

When it comes to exploring the causes and potential solutions to sexual problems, taking time to put them into context is everything.

Always ask - is this problem new, or long standing? Does the same thing happen in solo sex, or only when you’re with a partner? Has it happened with every partner? And so on.

It is also worth being aware that research shows that a woman’s sexual satisfaction scores at menopause are more closely linked to the health of her partner than they are to her own health. This should remind us that any woman coming to us for help with her sex life will also potentially be bringing with her the problems of her partner, too. We need always to place the problem in context.

A helpful model to use with your patient is one based on Basson’s Dual Control model of sexual arousal. This essentially reminds us that there is a balance between factors that dampen or inhibit our sexual response, and the factors that can enhance and accelerate it. Working with your patient to identify these sexual ‘brakes’ and ‘accelerators’, using the biopsychosocial model, can help to frame both the problem and the solution in a way that’s pragmatic and clear.

Common areas to consider when doing this are as follows:

NON-EXHAUSTIVE LIST OF MEDICATIONS THAT IMPACT SEXUAL RESPONSE:

• Anti-anxiety including benzodiazepines

• Antidepressants • Anti-epileptics

• Antihistamines

• Anti-hypertensives • Anti-psychotics

MAKING TIME & SPACE

INCREASING AROUSAL

• Emphasise the need to ensure privacy and energy for sex.

• Managing stress and anxiety where they are impacting on libido or arousal, using psychological therapies, breathing exercises, and also mindfulness techniques.

• Focus on normalising any body image issues that may exist as bodies age and change.

• E xplain and psychoeducate: knowing what is 'normal' in terms of our anatomy and sexual function at this life stage can relieve a lot of shame and anxiety.

• E xplaining that good pelvic blood flow is vital to ongoing sexual satisfaction helps us to encourage women to understand that getting aroused on a regular basis is good for their ongoing sexual function.

• E xplain to women that sensory changes as we age can make tissues less sensitive, normalising the need for more intense touch.

• Toys such as clitoral suckers (modelled on the Eros device) and vibrators can intensify sensation.

• Discuss ways to increase eroticism with their partner in order to help them to keep feeling aroused and interested as they age.

Referrals for psychosexual counselling, where possible, can really help couples and individuals with this.

• PDE5-inhibitors such as Viagra are sometimes used off licence in women with arousal/climax problems with some success. Tibolone, and testosterone gel, can be useful adjuncts to help with libido and response at this stage. The British Menopause society has a helpful consensus statement on the use of testosterone in menopause, and there is good evidence that its use can improve sexual satisfaction scores.

RELATIONSHIP ISSUES • Loss of desire in a long term relationship is not uncommon: couples therapy – with Relate or a COSRT approved therapist – can be hugely enlightening and helpful.

THE ROLE OF HRT, TESTOSTERONE & OTHER MEDICATIONS • Discuss the role of systemic and local HRT with your patients, and remain conscious that some of the non-hormonal alternatives to HRT may actually hinder sexual response – in some circumstances, alternative approaches such as CBT for menopause may be more useful for these women.

• Local oestrogen is often safe for women who cannot have systemic HRT. • Look for obvious culprits in any other medications that might also be affecting their sexual function.

• Optimising general health and mobility is likely to optimise sexual function too: in particular addressing bladder issues and pelvic organ prolapse. Gynae physios are experts in helping with pelvic floor tone issues too – referral here can be very useful.

LUBRICANTS & MOISTURISERS • The use of vaginal moisturisers and lubricants, where needed, is important.

• Many psychosexual practitioners suggest women try ‘double glide’ when needed – the combined use of an oil and a water-based lubricant – in order to maintain the lubrication successfully for longer during sex.

• Chemotherapy drugs • Nsaids

• Opiates

• Contraceptives

• Anti-Parkinsonian drugs

Despite what we may think, the onset of menopause does not mean it is all doom and gloom ahead sexually speaking. Our role as women’s health practitioners is to both start, and open up the conversation around sex. We need to let the patient decide how important their sexuality is to them – and to be curious about the problem to show them we take it seriously, too. We are able to do far more than many of us realise using our existing skills without needing to spend hours training, or providing psychosexual input. With a few considered interventions, we can make a lot of difference in women’s lives.

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

For Women, For Health For Women, For Health

1 1

HRT for estrogen deficiency symptoms HRT for estrogen deficiency symptoms in post-menopausal women more than inmonths post-menopausal women2more than 6 post-menopause.

6 months post-menopause.2

AVAILABLE. AFFORDABLE. EVOREL. AVAILABLE. AFFORDABLE. EVOREL.

Estradiol/norethisterone acetate Estradiol/norethisterone acetate

Abbreviated Prescribing Information: EVOREL® Conti (estradiol hemihydrate/norethisterone acetate) Abbreviated Prescribing Information: Presentation: Evorel Conti 3.2 mg of estradiol hemihydrate, 11.2 mg of EVOREL® Conti (estradiol hemihydrate/norethisterone acetate) norethisterone acetate transdermal patch. Indication: HRT for oestrogen Presentation: Evorel Conti 3.2 mg of estradiol hemihydrate, 11.2 mg of deficiency symptoms in post-menopausal women more than 6 months postnorethisterone acetate transdermal patch. Indication: HRT for oestrogen menopause (or 18 months since last period). Prevention of osteoporosis in deficiency symptoms in post-menopausal women more than 6 months postpostmenopausal women at high risk of future fractures who are intolerant of, menopause (or 18 months since last period). Prevention of osteoporosis in or contraindicated for, other medicinal products approved for the prevention of postmenopausal women at high risk of future fractures who are intolerant of, osteoporosis. Dosage & administration: Adults: Evorel Conti is a continuous or contraindicated for, other medicinal products approved for the prevention of combined HRT preparation. Patches are applied to the skin twice weekly. osteoporosis. Dosage & administration: Adults: Evorel Conti is a continuous One Evorel Conti patch should be worn at all times, without interruptions. For combined HRT preparation. Patches are applied to the skin twice weekly. initiation and continuation of treatment of menopausal symptoms, the lowest One Evorel Conti patch should be worn at all times, without interruptions. For effective dose for the shortest duration should be used. Guidance on how to initiation and continuation of treatment of menopausal symptoms, the lowest start therapy: Post-menopausal women currently not on HRT may start Evorel effective dose for the shortest duration should be used. Guidance on how to Conti at any time. Switching from other HRT: Women on a continuous combined start therapy: Post-menopausal women currently not on HRT may start Evorel regimen wishing to switch from another oestrogen to Evorel Conti may do so Conti at any time. Switching from other HRT: Women on a continuous combined at any time. Women on a cyclic or continuous sequential regimen wishing to regimen wishing to switch from another oestrogen to Evorel Conti may do so switch from a sequential combined HRT preparation to Evorel Conti may do so at at any time. Women on a cyclic or continuous sequential regimen wishing to the end of a cycle of the current therapy or after a 7-day hormone free interval. switch from a sequential combined HRT preparation to Evorel Conti may do so at Unless there is a previous diagnosis of endometriosis, it is not recommended to the end of a cycle of the current therapy or after a 7-day hormone free interval. add a progestogen in hysterectomised women. Method of Administration: The Unless there is a previous diagnosis of endometriosis, it is not recommended to sachet containing one Evorel Conti patch should be opened and one part of the add a progestogen in hysterectomised women. Method of Administration: The protective foil removed at the S-shaped incision. The patch should be applied sachet containing one Evorel Conti patch should be opened and one part of the to clean, dry, healthy, intact skin as soon as it is removed from the sachet. The protective foil removed at the S-shaped incision. The patch should be applied patient should avoid contact between fingers and the adhesive part of the patch to clean, dry, healthy, intact skin as soon as it is removed from the sachet. The during application. Each application should be made to a different area of the patient should avoid contact between fingers and the adhesive part of the patch skin, on the trunk below the waist. The patch should not be applied on or near the during application. Each application should be made to a different area of the breasts, the usual day of changing Evorel Conti patches should be maintained. skin, on the trunk below the waist. The patch should not be applied on or near the Children: Not indicated in children. Elderly: Data are insufficient in the elderly breasts, the usual day of changing Evorel Conti patches should be maintained. (>65 years old). Route of administration: Transdermal use. Contraindications: Children: Not indicated in children. Elderly: Data are insufficient in the elderly Known, past or suspected breast cancer. Known or suspected oestrogen(>65 years old). Route of administration: Transdermal use. Contraindications: dependent malignant tumours or pre-malignant tumours. Undiagnosed genital Known, past or suspected breast cancer. Known or suspected oestrogenbleeding. Previous idiopathic or current VTE. Active or recent past ATE disease. dependent malignant tumours or pre-malignant tumours. Undiagnosed genital bleeding. Previous idiopathic or current VTE. Active or recent past ATE disease.

1. Theramex Data on File Mar 2021. Based on the number of prescriptions written for transdermal HRT Summarywritten of Product Characteristics. the UK and at time publication.

Evorel®ofConti 1. in Theramex Dataconfirmed on File Mar 2021.ofBased on the2.number prescriptions for transdermal HRT Hormone Replacement Therapy in the UK and confirmed at time of publication. 2. Evorel® Conti SummaryHRT: of Product Characteristics.

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 Acute liver disease, or a history of liver disease if liver function tests have failed to active substances or to any of the excipients. Porphyria. Special warnings and return to normal. Known thrombophilic conditions. Known hypersensitivity to the precautions for use: Before initiating or re-instituting HRT, a complete personal active substances or to any of the excipients. Porphyria. Special warnings and and family medical history should be taken. Conditions which need supervision: precautions for use: Before initiating or re-instituting HRT, a complete personal If any of the following conditions are present, occurred previously, have been and family medical history should be taken. Conditions which need supervision: aggravated during pregnancy or previous hormone treatment, supervise patient If any of the following conditions are present, occurred previously, have been closely. Conditions may recur or be aggravated during treatment, in particular: aggravated during pregnancy or previous hormone treatment, supervise patient Leiomyoma or endometriosis, a history of, or risk factors for, thrombo-embolic closely. Conditions may recur or be aggravated during treatment, in particular: disorders or oestrogen dependent tumours, hypertension, liver disorders, Leiomyoma or endometriosis, a history of, or risk factors for, thrombo-embolic diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic disorders or oestrogen dependent tumours, hypertension, liver disorders, lupus erythematosus, history of endometrial hyperplasia, epilepsy, asthma, diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic otosclerosis and mastopathy. Conditions which require monitoring while on lupus erythematosus, history of endometrial hyperplasia, epilepsy, asthma, oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal otosclerosis and mastopathy. Conditions which require monitoring while on dysfunction should be carefully observed. Disturbances or mild impairment of oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. dysfunction should be carefully observed. Disturbances or mild impairment of Rare cases of large increases of plasma triglycerides leading to pancreatitis liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. have been reported with oestrogen therapy in this condition. Therapy should Rare cases of large increases of plasma triglycerides leading to pancreatitis be discontinued if a contraindication is discovered and in the following have been reported with oestrogen therapy in this condition. Therapy should situations: jaundice/deterioration in liver function, significant increase in blood be discontinued if a contraindication is discovered and in the following pressure, new onset of migraine-type headache, pregnancy. Interactions: The situations: jaundice/deterioration in liver function, significant increase in blood metabolism of oestrogens and progestogens may be increased by concomitant pressure, new onset of migraine-type headache, pregnancy. Interactions: The use of substances known to induce drug-metabolising enzymes, specifically metabolism of oestrogens and progestogens may be increased by concomitant cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and use of substances known to induce drug-metabolising enzymes, specifically bosentan. Ritonavir, telaprevir, nelfinavir and herbal preparations containing cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and St. John’s Wort may induce the metabolism of oestrogens and progestogens. bosentan. Ritonavir, telaprevir, nelfinavir and herbal preparations containing Clinically, an increased metabolism of oestrogens and progestogens may lead St. John’s Wort may induce the metabolism of oestrogens and progestogens. to decreased effect and changes in the uterine bleeding profile. OestrogenClinically, an increased metabolism of oestrogens and progestogens may lead containing oral contraceptives have been shown to significantly decrease to decreased effect and changes in the uterine bleeding profile. Oestrogenplasma concentrations of lamotrigine when co administered due to induction containing oral contraceptives have been shown to significantly decrease of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose plasma concentrations of lamotrigine when co administered due to induction adjustment of lamotrigine may be necessary. Fertility, Pregnancy and lactation: of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose Not indicated, treatment should be withdrawn immediately. Data on a limited adjustment of lamotrigine may be necessary. Fertility, Pregnancy and lactation: Not indicated, treatment should be withdrawn immediately. Data on a limited

HRT: Hormone Therapy number of exposed pregnancies indicate adverse effects Replacement of norethisterone on the foetus. At doses higher than normally used in oral contraceptives and HRT number of exposed pregnancies indicate adverse effects of norethisterone on formulations, masculinisation of female foetuses was observed. Side effects: the foetus. At doses higher than normally used in oral contraceptives and HRT Adverse reactions observed in clinical trials: Very common (≥1/10); common formulations, masculinisation of female foetuses was observed. Side effects: (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to Adverse reactions observed in clinical trials: Very common (≥1/10); common <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to available clinical trial data). Very common: Application site erythema, Application <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the site pruritus, Application site rash, Application site reaction. Common: available clinical trial data). Very common: Application site erythema, Application Hypersensitivity, Depression, Insomnia, Anxiety Nervousness, Paraesthesia, site pruritus, Application site rash, Application site reaction. Common: Headache, Palpitations, Hypertension, Varicose veins, Vasodilation, Abdominal Hypersensitivity, Depression, Insomnia, Anxiety Nervousness, Paraesthesia, pain, Diarrhoea, Nausea, Rash erythematous, Arthralgia, Back pain, Breast pain, Headache, Palpitations, Hypertension, Varicose veins, Vasodilation, Abdominal Cervical polyp, Endometrial hyperplasia, Genital discharge, Dysmenorrhoea, pain, Diarrhoea, Nausea, Rash erythematous, Arthralgia, Back pain, Breast pain, Menorrhagia, Menstrual disorder, Metrorrhagia, Pain, Oedema, Application site Cervical polyp, Endometrial hyperplasia, Genital discharge, Dysmenorrhoea, oedema, Fatigue, Weight increased. Uncommon include: Candidiasis, Myalgia, Menorrhagia, Menstrual disorder, Metrorrhagia, Pain, Oedema, Application site Oedema, Oedema peripheral. Rare: Epilepsy, Thrombosis. Frequency not known oedema, Fatigue, Weight increased. Uncommon include: Candidiasis, Myalgia, include: Breast neoplasms, Endometrial cancer, Cerebrovascular accident, Deep Oedema, Oedema peripheral. Rare: Epilepsy, Thrombosis. Frequency not known vein thrombosis, Pulmonary embolism, Abdominal distension, Cholelithiasis, include: Breast neoplasms, Endometrial cancer, Cerebrovascular accident, Deep Stevens-Johnson syndrome. Package Quantities & Cost: Each carton box has vein thrombosis, Pulmonary embolism, Abdominal distension, Cholelithiasis, 8 or 24 TDSs in individual foil lined sachets. Cost: 1 x 8 £13.00; 1 x 24 £37.22.

Stevens-Johnson syndrome. Package Quantities & Cost: Each carton box has Marketing authorisation number: PL 49105/0009. Marketing authorisation 8 or 24 TDSs in individual foil lined sachets. Cost: 1 x 8 £13.00; 1 x 24 £37.22. holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London Marketing authorisation number: PL 49105/0009. Marketing authorisation SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London THX_GB_PI_001473.

SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: Please consult the Summary of Product Characteristics for other adverse THX_GB_PI_001473. reactions and full prescribing information 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 Adverse events should be reported. Reporting forms and information can in the Google Play or Apple App store. Adverse events should also be be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard reported to Theramex on medinfo.uk@theramex.com or Tel: 0333 0096795 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 Evor_GB_PRNTAD_003174 Date of preparation: March 2021 Evor_GB_PRNTAD_003174 Date of preparation: March 2021

16570 Evorel Conti 292x215.indd 1

24/03/2021 14:40

16570 Evorel Conti 292x215.indd 1

24/03/2021 14:40

GOLDEN YEARS

TOP TIPS

Postmenopausal osteoporosis

1.

A GUIDE TO OPTIMISING BONE HEALTH IN WOMEN OVER-65.

W

ith figures showing as many as 1 in 2 women over the age of 50 years are sustaining a potentially preventable fragility fracture1, it becomes paramount that more focus is given to optimising bone health. The resulting aftermath of such fractures is that of disability, pain, loss of confidence and increased mortality, with a staggering estimated annual cost to the NHS of £4.4 billion 2.

The risk of osteoporotic fractures increases steeply in women after the age of 65 years with around a third of patients who sustain hip fractures dying within the following 12 months3 .

NICE recommends that all women over the age of 65 undergo a fracture risk assessment 4 . There are numerous factors that increase this risk further including untreated early menopause, parental hip fracture, alcohol of 3 or more units daily and chronic health conditions. Various medications accentuate the problem such as long-term SSRIs/PPIs, antiepileptic drugs, and steroids.

Treatment options First line: • Bisphosphonates have antiresorptive effects with varying strengths, the most potent oral therapy being alendronate, and parentally being zoledronate5. Poor compliance with oral medications is a key reason for treatment failure.

Strategies to improve this include detailed counselling on how to take, expected side effects and duration of treatment. The Royal Osteoporosis Society (ROS) suggests

follow-up within 4 months and then annually 1 where adherence is checked and reinforced similar to the management of other silent conditions like hypertension.

Second line: • Denosumab, a monoclonal antibody that inhibits osteoclasts, is administered as a 60mg 6-monthly subcutaneous injection. The MHRA emphasised the risk of multiple rebound and potentially lifechanging vertebral fractures after stopping or delaying denosumab treatment6. Timely injections, which can now be self-injected, are crucial as is switching to bisphosphonates when discontinuing treatment.

• Teriparatide, a recombinant form of parathyroid hormone with bone forming effects, is given as a daily 20µg subcutaneous injection over 2 years. In those with severe spinal osteoporosis, SIGN highlights superior outcomes if this is used first line before transition onto bisphosphonates. Consider this in women with T score <-1.5 and two or more moderate vertebral fractures on x-ray, or a spinal BMD of <-4.05.

Other options: • The British Menopause Society advocates that HRT could be a first-line treatment for osteoporosis in healthy women under 60 years if benefit outweighs risks, but does not recommend this solely for osteoporosis management in women over this age7.

• HRT/Tibolone can be used if there are coexisting menopausal

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

symptoms and after appropriate risk/benefit counselling. Bone conserving effect at all sites can be achieved from even low doses of 0.5mg estradiol daily 8 which may be more suitable if being considered in the older postmenopausal woman. Benefits wear off soon after treatment cessation although longterm effects have been shown if HRT is given at the time of menopause7.

Strontium ranelate and raloxifene have a limited role reserved for women who cannot use other osteoporosis medications, and are associated with increased VTE and cardiovascular risk5.

The impact of COVID-19 According to the ROS, there has been a significant drop in the administration of injectable drugs during 20209, with denosumab delays in particular carrying stark effects on further fracture potential. With restrictions resulting in reduced physical activity and sunlight exposure, the rapid deconditioning that ensues has amplified the risk of falls and therefore fractures. This is further heightened by decreased uptake of online fracture risk assessments and follow-up of all fragility fractures causing an overall under-diagnosis of osteoporosis.

The effects of COVID-19 are therefore prominent and will be evident for many years to come. ROS offers a wealth of resources and a helpline for professionals or patients run by specialist nurses which can provide much needed support during these ongoing challenges.

Review the need for medications like SSRIs/ PPIs – consider stopping if appropriate

2.

Always think of vertebral fractures in back pain presentations – these are underdiagnosed and almost always signify osteoporosis

3.

To protect against the rapid bone loss with steroid initiation, consider starting bone protection in patients with high fracture risk at the onset of steroid therapy of ≥7.5mg/day or equivalent for ≥3months

4.

Check if there is a Fracture Liaison Service in your area – this provides multidisciplinary and costeffective care for secondary fracture prevention.5

GOLDEN YEARS

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

SUMMARY A summary of guidance from the National Institute for Health and Care Excellence (NICE)4 , National Osteoporosis Guidelines Group (NOGG)2 and latest 2020 Scottish Intercollegiate Guidelines Network (SIGN)5.

Primary Prevention

Secondary Prevention

QFracture/FRAX 10-year fracture risk assessment All women >65 or younger with risk factors

Offer DXA*

<10% QFracture Low-risk FRAX Reassure and review within 5 years

>10% QFracture High-risk OR Intermediate FRAX Offer DXA*

Offer lifestyle advice and assess falls risk

If using FRAX reassess using femoral neck BMD to guide management Normal T > -1.0

Osteopenia T -1.0 to -2.5

Osteoporosis T < -2.5

Address modifiable risk factors If high-risk repeat DXA in 2 years

As for normal unless: >65 consider zoledronate 18 monthly for 6 years then review5

Exclude secondary causes FBC, U+E, LFT, CRP/ESR, bone profile, TFT, vitamin D7 Other tests if appropriate

Offer pharmacological treatment and review after 3-5 years

LIFESTYLE ADVICE

1. Stop smoking and reduce alcohol 2. Regular weight bearing and strength training exercise 3. Balanced diet 4. Calcium intake of a least 700mg/day 5. Consider vitamin D 400-800IU daily

Continue for up to 10 years if: • age >75 • previous hip/ vertebral fracture • i f fracture during treatment • on oral glucocorticoids Treatment beyond 10 years only under specialist advice

All other women, arrange DXA: If T < -2.5 continue treatment and reassess in 3-5 years If T >-2.5 use FRAX for guidance/stop treatment and reassess after 2 years

*Consider proceeding to treatment without DXA if high-risk on FRAX or previous fragility fracture2 especially hip/vertebral fractures

WORDS BY DR RAMIYA AL-ALOUSI

REFERENCES 1. ROS 2017. Quality standards for osteoporosis and prevention of fragility fractures. https://theros. org.uk/media/0dillsrh/ ros-op-standardsnovember-2017.pdf 2. NOGG 2017.

Clinical guideline for the prevention and treatment of osteoporosis. https:// www.sheffield.ac.uk/ NOGG/NOGG%20 Guideline%202017.pdf 3. NICE 2017. Hip fracture: management. https://www.nice.org. uk/guidance/cg124 4. NICE CKS 2020.

Osteoporosis – prevention of fragility fractures. https:// cks.nice.org.uk/ topics/osteoporosisprevention-of-fragilityfractures/ 5. SIGN 145. 2020.

Management of osteoporosis and the prevention of fragility fractures. https://www. sign.ac.uk/media/1741/ sign142.pdf 6. MHRA 2020. https://www.gov.uk/ drug-safety-update/ denosumab-60mgprolia-increased-riskof-multiple-vertebralfractures-afterstopping-or-delayingongoing-treatment 7. Hillard et al. 2017.

Management of the menopause. 6th Edn. British Menopause Society.

8. https://pubmed.ncbi. nlm.nih.gov/18063490/ 9. ROS 2020. Delivering core NHS and care services during the pandemic and beyond. https://tinyurl.com/ yds6uvw8

Her Life Her Health | Spring 2021 | 29

ON THE GROUND

Mentoring model How a mentoring pilot study for the development of a women’s health hub in Hampshire developed and provided opportunities for GPs with an extended role.

W WORDS BY DR VICTORIA FREIRE PROFESSOR CHRISTIAN PHILLIPS (NOT PICTURED) & DR AMANDA BRITTON

omen’s health is a significant part of most GPs’ working days, yet can be quite complex and often requires specialist input. In 2017/18 there were over 3.6 million primary care referrals to gynaecology. The NHS Long Term plan sets out the ambition to ‘provide alternative models of care to avoid up to a third of outpatient appointments’ and sets out interventions to ensure patients see the ‘right person in the right place, first time’ (NHS England and NHS Improvement, 2019).

In this pilot study, a women’s health hub (WHH) was set up in Hampshire with an upskilling GP working together with a specialist from secondary care for a 2-year mentoring scheme.

Prior to the COVID pandemic, our clinical commissioning group (CCG), and other secondary care trusts were developing opportunities to deliver more integrated, person-centred care by developing a specialist clinic or new WHH. For example, Bayer looked at developing the WHH model as services such as coil fitting had been

significantly compromised through funding cuts, (Inclusive Health for Bayer Ltd 2018). At the same time, many general practices were merging and forming a Primary Care Network (PCN). The idea is that the PCN population base is large enough so that other organisations can link to deliver integrated care and yet is small enough to focus on team working with a focus on patientcentred care (Britton, A 2019).

This article outlines our model piloted within North Hampshire, to develop and provide opportunities for GPs with an extended role.

We demonstrated that this mentoring model has been effective in reducing referrals to secondary care, providing increased access locally for patients and improved multidisciplinary working and enhanced specialist knowledge within primary care. Here we refer to a GP with an extended role as an ‘upskilling GP’.

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

29 PATIENTS WERE MANAGED CONSERVATIVELY AND ‘DISCHARGED’ ON THE SAME DAY, THEREBY REDUCING SECONDARY CARE REFERRALS BY AT LEAST 36%

ON THE GROUND

MANY PATIENTS BENEFITTED FROM LEARNING SELFMANAGEMENT STRATEGIES AND EDUCATION WHICH EMPOWERED THEM TO MAKE INFORMED CHOICES

METHOD

RESULTS

DISCUSSION

Under this pilot study, a WHH model was piloted for 7 months at a PCN with 45,000 patients. Prior to this the upskilling GP spent 12 months being mentored in a gynaecology clinic in a secondary care setting.

Following this mentorship period, a professor in gynaecology conducted a clinic at the PCN, alongside a GP upskilling in women’s health, on a monthly basis. One women’s health GP or a specialist nurse would also attend in an observational capacity.

GPs at the PCN were able to book appropriate patients directly into one of these clinics following discussion with the upskilling GP. A number of patients were also discussed in a multi-disciplinary team (MDT) style meeting where any complex patients were discussed with the professor and a plan was formulated.

Over the 7-month period 80 patients were reviewed in the WHH. Of these: • 29 patients were managed conservatively and ‘discharged’ on the same day, thereby reducing secondary care referrals by at least 36%.

• 35 patients were referred on for further treatment such as surgery, physio, urodynamics or to other clinics such as the menstrual disorder clinic. While this did not reduce the physical number of appointments the patient had to attend, the first stage was managed outside the hospital, providing a local community service to the patient.

• The remaining 16 patients were booked for follow up at a future date in the WHH.

The results of this study show that there was a significant reduction in secondary care referrals as a result of the implementation of a WHH. This created better patient care with a ‘one stop clinic’ where they saw either an upskilling GP or the professor, thus avoiding a referral to the hospital or enabling direct referrals to a physio, a uro-gynae specialist nurse, or listed for theatre. The MDT-style approach also avoided referrals to secondary care and contributed to enhancing specialist knowledge within primary care. By having the GPs being able to book directly into the clinic appropriately this enabled the referrals to be streamlined. Having a women’s health GP or nurse sitting in with the professor enhanced their skills and knowledge, in addition to improving communication and future working between primary and secondary care.

In the 7 months prior to the start of the WHH clinic, there was a mean referral rate of 50 referrals per month to secondary care from the PCN. In the 7 months following implementation of the WHH this was reduced to a mean of 30 patients per month therefore resulting in a 40% reduction of secondary care referrals to gynaecology.

Her Life Her Health | Spring 2021 | 31

ON THE GROUND

THE FUTURE The team proposes that if this initiative was implemented nationwide it would ease pressure on an already stretched secondary care network and make more appropriate use of funds.

The MDT approach and development of clinical knowledge of GPs in the PCN enabled more patients to be managed directly by their GP without referral to the WHH or to secondary care.

We also elicited patient feedback about the initiative from patients and GPs. The feedback was very positive, including comments in relation to reductions in waiting time and reduced travel. Many patients benefitted from learning selfmanagement strategies and education which empowered them to make informed choices such as whether to opt for particular treatments. In addition, feedback has shown that the confidence of GPs in the PCN has also been increased, enabling them to

manage more difficult gynaecological cases which is consistent with the NHS Long Term Plan.

As PCNs evolve, there is certainly scope for this model of service provision and as the service develops the option of appropriate patients being booked directly into these services could reduce an additional primary care consultation appointment. With appropriate education and ongoing support, GPs with a specialist interest in gynaecology can manage the more common gynaecological problems, freeing up the consultants to deal with very complex patients and those requiring surgery. Specialist clinics such as pessary fitting services (including gel horn), menorrhagia and a specialist menopause service could also be established which could be managed by specialist GPs. In addition, this model could easily be extended (and is being

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

piloted) in other areas of medicine outside gynaecology. Patients being assessed in this way ensures that they are reviewed by the most appropriate medical professional to limit unnecessary examinations and consultations and enhance their overall patient experience.

As a result of this initiative there was a 36% reduction in referrals to secondary care and patient care was streamlined to more local provision. In addition, it enhanced the working relationship between primary and secondary care and supported further ‘upskilling’ within the primary care arena. We continue to develop this initiative with the aim to widen the impact of this service model. If this was continued and extrapolated across the country this could play an important part in reducing referrals to secondary care with a positive impact on patient care.

REFERENCES 1. Britton, A (2019) ‘Opportunities for Women’s Health within Primary Care Networks’. Her life Her Health, Primary Care Women’s Health Forum, pp 34-35 2. Inclusive Health for Bayer Ltd (2018) Developing the ‘Women’s Health Hub’ Model . Available at: http://www. pmlive.com/awards/ communique/ previous_winners/ communique_ awards_2018_results/ healthcare_ communications_ awards/excellence_ in_communications_ via_meetings/ developing_the_ womens_health_hub_ model (Accessed 25 January 2021) 3. NHS England and NHS Improvement (2019) Transforming elective care services gynaecology, Available at: https:// www.england.nhs. uk/wp-content/ uploads/2019/06/ gynaecology-electivecare-handbook.pdf (Accessed 26 January 2021) 4. Royal College of Obstetricians & Gynaecologists (2017) Obstetrics and Gynaecology Workforce Report.

Available at: https:// www.rcog.org. uk/globalassets/ documents/careersand-training/ workplace-andworkforce-issues/ rcog-og-workforcereport-2017.pdf (Accessed 26 January 2021)

For Women, For Health For Women, For Health

1 1

HRT for estrogen deficiency symptoms HRT for estrogen deficiency symptoms in peri and post-menopausal women.2 in peri and post-menopausal women.2

AVAILABLE. AFFORDABLE. EVOREL. AVAILABLE. AFFORDABLE. EVOREL.

1. Theramex Data on File Mar 2021. Based on the number of prescriptions written for transdermal HRT ® Patch Summary ofwritten Product in UK andData confirmed time of publication.

2. Evorel 1. the Theramex on FileatMar 2021.

Based on the number of prescriptions forCharacteristics. transdermal HRT HRT: Hormone Replacement Therapy in the UK and confirmed at time of publication. 2. Evorel® Patch Summary of Product Characteristics.

HRT: Hormone Replacement Therapy 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: Abbreviated Prescribing Information: EVOREL® 25,50,75,100 (estradiol/patch) 4.8mg estradiol patch; Evorel 100: 6.4mg estradiol patch. Indication: HRT for oestrogen deficiency Presentation: Evorel 25: 1.6mg estradiol patch; Evorel 50: 3.2mg estradiol patch; Evorel 75: symptoms in peri- and post-menopausal women. Evorel 50, 75 and 100 only: Prevention of 4.8mg estradiol patch; Evorel 100: 6.4mg estradiol patch. Indication: HRT for oestrogen deficiency osteoporosis in post-menopausal women at high risk of future fractures who are intolerant of, or symptoms in peri- and post-menopausal women. Evorel 50, 75 and 100 only: Prevention of contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage osteoporosis in post-menopausal women at high risk of future fractures who are intolerant of, or & administration: Adults: Evorel is an oestrogen-only HRT patch applied to the skin twice weekly. contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose & administration: Adults: Evorel is an oestrogen-only HRT patch applied to the skin twice weekly. for the shortest duration should be used. For women with an intact uterus progestogen should For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose normally be added to Evorel for the prevention of adverse endometrial effects, e.g. hyperplasia for the shortest duration should be used. For women with an intact uterus progestogen should and cancer. The regimen may be either cyclic or continuous sequential. Only progestogens normally be added to Evorel for the prevention of adverse endometrial effects, e.g. hyperplasia approved for addition to oestrogen treatment may be prescribed (e.g. oral norethisterone, and cancer. The regimen may be either cyclic or continuous sequential. Only progestogens 1mg/day or medroxyprogesterone acetate, 2.5mg/day) and should be added for at least 12approved for addition to oestrogen treatment may be prescribed (e.g. oral norethisterone, 14 days every month/28-day cycle. Unless there is a previous diagnosis of endometriosis, it is 1mg/day or medroxyprogesterone acetate, 2.5mg/day) and should be added for at least 12not recommended to add a progestogen in hysterectomised women. Treatment of oestrogen 14 days every month/28-day cycle. Unless there is a previous diagnosis of endometriosis, it is deficiency symptoms: Therapy should be started with one Evorel 50 patch (delivering 50 µg of not recommended to add a progestogen in hysterectomised women. Treatment of oestrogen estradiol/24 hours) and the dose adjusted after the first month if necessary, depending on efficacy deficiency symptoms: Therapy should be started with one Evorel 50 patch (delivering 50 µg of and signs of over-oestrogenisation. For maintenance therapy the lowest effective dose should be estradiol/24 hours) and the dose adjusted after the first month if necessary, depending on efficacy used; a maximum dose of 100 µg of estradiol/24 hours should not be exceeded. Evorel 50, 75, and signs of over-oestrogenisation. For maintenance therapy the lowest effective dose should be 100: Prevention of post-menopausal osteoporosis: Therapy should be started with Evorel 50. used; a maximum dose of 100 µg of estradiol/24 hours should not be exceeded. Evorel 50, 75, The dose may be adjusted depending on efficacy and signs of over-oestrogenisation. The efficacy 100: Prevention of post-menopausal osteoporosis: Therapy should be started with Evorel 50. of Evorel 25 for the prevention of post- menopausal osteoporosis has not been demonstrated. For The dose may be adjusted depending on efficacy and signs of over-oestrogenisation. The efficacy maintenance therapy, the lowest effective dose should be used. A dose of 100 µg of estradiol/24 of Evorel 25 for the prevention of post- menopausal osteoporosis has not been demonstrated. For hours should not be exceeded. Guidance on how to start therapy: Post-menopausal women maintenance therapy, the lowest effective dose should be used. A dose of 100 µg of estradiol/24 currently not on HRT may start Evorel at any time. Peri-menopausal women who are still having hours should not be exceeded. Guidance on how to start therapy: Post-menopausal women regular menstrual cycles and are not currently on HRT should start Evorel within 5 days of the start currently not on HRT may start Evorel at any time. Peri-menopausal women who are still having of bleeding. Peri-menopausal women with irregular menstrual cycles, for whom pregnancy has regular menstrual cycles and are not currently on HRT should start Evorel within 5 days of the start been excluded, can start Evorel at any time. Switching from other HRT: The switch from another of bleeding. Peri-menopausal women with irregular menstrual cycles, for whom pregnancy has oestrogen-only therapy in post-menopausal women to Evorel may occur at any time. Women on been excluded, can start Evorel at any time. Switching from other HRT: The switch from another a continuous combined regimen wishing to switch from another oestrogen to Evorel may do so at oestrogen-only therapy in post-menopausal women to Evorel may occur at any time. Women on any time. Women on a cyclic or continuous sequential regimen wishing to switch from a sequential a continuous combined regimen wishing to switch from another oestrogen to Evorel may do so at combined HRT preparation to Evorel may do so at the end of a cycle of the current therapy or after 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, a 7 day hormone free interval. Method of Administration: Evorel should be applied to the skin as intact skin and each application should be made to a slightly different area of skin on the trunk soon as it is removed from the wrapper. Recommended application sites are on clean, dry, healthy, below waistline. Should not be applied on or near the breasts. Only one patch should be applied intact skin and each application should be made to a slightly different area of skin on the trunk at a time. There is an increased likelihood of break-through bleeding and spotting when a patch is below waistline. Should not be applied on or near the breasts. Only one patch should be applied not replaced at the normal time. Children: Not indicated in children. Elderly: Data are insufficient at a time. There is an increased likelihood of break-through bleeding and spotting when a patch is in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: not replaced at the normal time. Children: Not indicated in children. Elderly: Data are insufficient Known, current or past or suspected breast cancer. Known or suspected oestrogen-dependent in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: malignant tumours or pre-malignant tumours. Undiagnosed genital bleeding. Previous idiopathic Known, current or past or suspected breast cancer. Known or suspected oestrogen-dependent or current VTE. Active or recent past ATE disease. Acute liver disease, or a history of liver malignant tumours or pre-malignant tumours. Undiagnosed genital bleeding. Previous idiopathic disease if liver function tests have failed to return to normal. Known thrombophilic conditions. or current VTE. Active or recent past ATE disease. Acute liver disease, or a history of liver Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special disease if liver function tests have failed to return to normal. Known thrombophilic conditions. warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special and family medical history should be taken. Conditions which need supervision: If any of the warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal following conditions are present, occurred previously, have been aggravated during pregnancy or and family medical history should be taken. Conditions which need supervision: If any of the previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated following conditions are present, occurred previously, have been aggravated during pregnancy or during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated thromboembolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of thromboembolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes endometrial hyperplasia, epilepsy, asthma, otosclerosis, hereditary angioedema and mastopathy. mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause endometrial hyperplasia, epilepsy, asthma, otosclerosis, hereditary angioedema and mastopathy. fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported is discovered and in the following situations: jaundice/deterioration in liver function, significant with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication increase in blood pressure, new onset of migraine-type headache, pregnancy. For Evorel 75 is discovered and in the following situations: jaundice/deterioration in liver function, significant and 100 the endometrial safety of added progestogens has not been studied. Interactions: increase in blood pressure, new onset of migraine-type headache, pregnancy. For Evorel 75 The metabolism of oestrogens (and progestogens) may be increased by concomitant use of and 100 the endometrial safety of added progestogens has not been studied. Interactions: substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, The metabolism of oestrogens (and progestogens) may be increased by concomitant use of such as anticonvulsants, anti-infectives and bosentan. Ritonavir, nelfinavir and herbal preparations substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, containing St. John’s Wort may induce the metabolism of oestrogens and progestogens. Clinically, 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,

Estradiol/patch Estradiol/patch 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 an increased metabolism of oestrogens and progestogens may lead to decreased effect and shown to significantly decrease plasma concentrations of lamotrigine when co-administered changes in the uterine bleeding profile. Oestrogen- containing oral contraceptives have been due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, shown to significantly decrease plasma concentrations of lamotrigine when co-administered dose adjustment of lamotrigine may be necessary. Pregnancy and lactation: Not indicated, due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, treatment should be withdrawn immediately. Side effects: Adverse reactions observed in clinical dose adjustment of lamotrigine may be necessary. Pregnancy and lactation: Not indicated, trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); treatment should be withdrawn immediately. Side effects: Adverse reactions observed in clinical rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); the available clinical trial data). Very common: Application site pruritus, Application site rash. rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from Common: Depressed mood, Migraine, Dizziness, Headache, Abdominal pain, Diarrhoea, Nausea, the available clinical trial data). Very common: Application site pruritus, Application site rash.

Pruritus, Rash, Arthralgia, Breast pain, Metrorrhagia, Pain, Application site erythema, Application Common: Depressed mood, Migraine, Dizziness, Headache, Abdominal pain, Diarrhoea, Nausea, site oedema, Application site reaction, Weight increased. Uncommon include: Genital candidiasis, Pruritus, Rash, Arthralgia, Breast pain, Metrorrhagia, Pain, Application site erythema, Application Hypersensitivity, Palpitations, Myalgia, Dysmenorrhoea, Oedema, Oedema peripheral. Rare: site oedema, Application site reaction, Weight increased. Uncommon include: Genital candidiasis, Breast cancer, Epilepsy, Thrombosis, Abdominal distension, Cholelithiasis. Frequency not known: Hypersensitivity, Palpitations, Myalgia, Dysmenorrhoea, Oedema, Oedema peripheral. Rare: Endometrial cancer, Cerebrovascular accident, Myocardial infarction, Deep vein thrombosis, Breast cancer, Epilepsy, Thrombosis, Abdominal distension, Cholelithiasis. Frequency not known: Pulmonary embolism, Angioedema. Package Quantities & Cost: Each Evorel patch size is Endometrial cancer, Cerebrovascular accident, Myocardial infarction, Deep vein thrombosis, presented in a sealed protective pouch. The pouches are packed in a cardboard carton. Cost: Pulmonary embolism, Angioedema. Package Quantities & Cost: Each Evorel patch size is 25 (1x8) £3.42; 50 (1x8) £3.88; 50 (1x24) £11.66; 75 (1x8) £4.12; 100 (1x8) £4.28. Marketing presented in a sealed protective pouch. The pouches are packed in a cardboard carton. Cost: authorisation number: Evorel 25 PL 49105/0005; Evorel 50 PL 49105/0006; Evorel 75 PL 25 (1x8) £3.42; 50 (1x8) £3.88; 50 (1x24) £11.66; 75 (1x8) £4.12; 100 (1x8) £4.28. Marketing 49105/0007; Evorel 100 PL 49105/0008. Marketing authorisation holder: Theramex HQ UK LTD, authorisation number: Evorel 25 PL 49105/0005; Evorel 50 PL 49105/0006; Evorel 75 PL Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date 49105/0007; Evorel 100 PL 49105/0008. Marketing authorisation holder: Theramex HQ UK LTD, of Preparation: January 2020: THX_GB_PI_001472.

Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date Please consult the Summary of Product Characteristics for other adverse reactions and of Preparation: January 2020: THX_GB_PI_001472. full prescribing information 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 Adverse events should be reported. Reporting forms and information can be found or Apple App store. Adverse events should also be reported to Theramex on at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play medinfo.uk@theramex.com or Tel: 0333 0096795 or Apple App store. Adverse events should also be reported to Theramex on medinfo.uk@theramex.com or Tel: 0333 0096795 Evor_GB_PRNTAD_003173 Date of preparation: March 2021 Evor_GB_PRNTAD_003173 Date of preparation: March 2021

16570 Evorel 50 292x215.indd 1

24/03/2021 14:40

16570 Evorel 50 292x215.indd 1

24/03/2021 14:40

ON THE GROUND

WHAT YOU CAN DO, RIGHT NOW Wave your flag • Take a step back and look at your qualifications.

• If like many of us, you have qualified with the RCOG and FSRH to deliver extra in women’s health, wave your flag, let people know.

The future of women’s healthcare: REBUILDING A WORKFORCE IN PRIMARY CARE

Who are you and what you can do to help transform the future of women’s healthcare?

A

t the PCWHF we are a group of over 11,0000 health care professionals with a passion for delivering excellent women’s health in primary care.

As we emerge from the third national lockdown, we know that women’s healthcare has hit crisis point.

A new approach to female healthcare is urgently needed.

There is hope, as we see pioneering models of care roll out across the UK. With the promise of women’s health hubs, the future looks bright.

However, finding new models of care is all about finding out who is out there and what they can do to help.

This article looks at the PCWHF membership as a rich ground for growing a women’s health workforce.

We will look at how to show what we are capable of and what we can do to help.

First, let us look again at the problem and a possible solution.

THE PROBLEM The urgency As we saw in HLHH’s Autumn issue, ‘From challenge to opportunity 1’ , women have borne the brunt of much of the Covid-19 healthcare disaster. They are left physically, emotionally, and financially weakened. As key women’s health advocates, you, our readers, see this impact in your daily clinical work.

Professor Lesley Regan, past President of RCOG, said: “When we get it right for girls and women, everyone benefits2.”

Imagine a future…

Where your female patients are enabled to access care in the right place, at the right time with the right person.

Dr Ursula Mason describes a proposed primary care gynae pathway that could deliver this UK-wide . This model has been rolled out successfully in Northern Ireland, Liverpool and Basingstoke, to name but a few.

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

• Tell your CCG what you are about. How about letting your PCN know what you can do?

• At the very least, ensure your extra qualifications accompany your email signature. Make sure your female patients know who you are and what you can do to help them. This could be via your website or practice newsletter.

• A word of warning from The GMC – never be deliberately misleading with regards to qualifications.

So, make it clear where your expertise lies and where your limitations are.

If you are not on the GMC specialist register you should not lead patients to think that that you are.

• Now that the titles GPSI and GPwEr are not used so much, can you think of a better title that encompasses what we do? ► If so, please share it with us at the PCWHF, we’d love to hear from you so do get in touch at submissions@pcwhf.co.uk.

ON THE GROUND

THE SOLUTION Who would deliver this service? How about a collection of highly qualified experienced practitioners with a passion for women’s health?

WORDS BY DR JANE DAVIS

GIVE US STANDARDISED CLINICAL CREDENTIALS AND SOME OPPORTUNITIES AND WE’LL BE THERE BEFORE YOU CAN SAY ‘INTRAUTERINE SYSTEM’

PRIMARY CARE HAS OPERATED ON THE SAME MODEL FOR OVER 50 YEARS

How about us?

The PCWHF is chock full of those of us who have followed our hearts with a fascination in women’s health. We have collected numerous memberships and qualifications along the way.

We are a trained workforce ready to go. The problem is GPSI services are no longer recognised and the proposed GPwEr has not materialised. Nobody knows who we are and what we can do to help.

Give us standardised clinical credentials and some opportunities and we’ll be there before you can say “intrauterine system”…

We can deliver office-based gynaecology. We don’t need high tech kit, operating theatres or a team of minions. Many of us are used to working independently in basic, low tech environments.

Furthermore, primary care clinicians are experts in the consultation. We specialise in people and see the patient within the context of their community.

By contrast, in Europe a woman consults a gynaecologist about HRT but if they have hypertension, they must first see a cardiologist.

Gynaecologists from across the Channel are bowled over to find that we fit IUDs in our offices and without the aid of ultrasound.

We can do an awful lot and we don’t need high tech for it.

REFERENCES 1. Davis J. Her Life her health Autumn 2020 p38-39.

Available from https://pcwhf.co.uk/resources/herlife-her-health-autumn-2020 2. “Better for Women Report.” Royal College of Obstetricians & Gynaecologists, 2019 www.rcog. org.uk/better-for-women.

3. Mason U. Her Life her health Autumn 2020 p34-35 Available from https://pcwhf.co.uk/resources/herlife-her-health-autumn-2020

We are here to help This is exactly what we love to do. No one gets through medical or nurse training unless they utterly believe in what they do. It is important to remain a generalist to be able to turn your hand to any issue and know your limitations.

However, primary care has operated on the same model for over 50 years. Many of us have seen the job change beyond recognition within the course of our careers. The current model is unsustainable. Catalysed by the Covid-19 crisis, hospital waiting lists have mushroomed, practices have collapsed, and clinicians have burnt out. This means that GPs and nurses are holding increasing clinical complexity in primary care.

Questions posed by attendees at the PCWHF webinars are increasingly tricky, reflecting the intricacies of clinical management. It is clear from the PCWHF members’ Facebook page how hard clinicians are working for the women they care for and how valuable peer support can be.

Many of these clinicians are operating in a hinterland between primary and secondary care with little support and no recognition of their special skills.

Pursuing a passion can be a great protector against burnout, but don’t we also deserve the opportunity to follow our drive to want to learn more to become good at something that we adore? Clinicians are hungry for a new interest to sustain them through the hardships of working in primary care. Despite the busiest clinical period for years, attendees consistently turn out in their hundreds for evening webinars. The appetite for training in women’s health, particularly in menopause, is insatiable.

Why then are we not recognised for this? If we were recognised, then we could be identified and employed where we are needed in the women’s healthcare workforce.

Protect your service We all know the potential pitfalls of working with unimaginative and financially broken CCGs. However, it doesn’t always have to be this way. We see many PCWHF members who work tirelessly on CCGs to secure services. This year at the PCWHF conference I heard of new services being set up all the time, often by highly motivate dynamic clinicians. New fertility services, outreach work, pessary clinics, community-based hysteroscopy, ultrasounds all run by people putting heart and soul into running it. Some who have designed their own business models and often with little financial backing and very little peer support.

PCWHF is full of these powerhouses.

If you love fitting LARC, fight for it to be protected. If you need support, please let us know, we can signpost you to help.

If you have skills which are not being used, again, please let us know. We are a group of like-minded clinicians and together we are stronger.

Keep up your skills and upskill With women’s health hubs on the horizon, your dream job in primary care women’s health may be just around the corner. So keep up your skills – or if you’ve always fancied training, now is a good time.

Above all know that you are doing an amazing job.

There is a very real need out there and we can see how hard you are all working to meet that need to the best of your abilities.

Know that you are not alone. At the PCWHF, we are like-minded individuals and there are over 11,000 of us. Connect via the PCWHF Facebook group (Facebook.com/PCWHF) or contact your regional director.

We love nothing more than to hear of your ideas, aspirations, and projects. Please share them with us.

Keep your passion for women’s healthcare alive, and together we’ll build a bright future for women and those who care for them, including us.

Her Life Her Health | Spring 2021 | 35

ON THE GROUND

Island life Developing sustainable delivery of women’s healthcare as a GP on the remote Isle of Arran.

THE MODEL OF CARE IS BUILT UPON AN ISLAND COMMUNITY CLINIC, WITH REGULAR SESSIONAL WORK WITHIN THE GYNAECOLOGY DEPARTMENT AT THE LOCAL ACUTE HOSPITAL WORDS BY DR FAYE HAMILL

T

he Isle of Arran lies an hour by ferry off the southwest coast of Scotland. It is often referred to as ‘Scotland in miniature’ – a beautiful island, with lowlands in the south and mountains in the north. I have been a GP on Arran since 2004, and it is a truly generalist role. GPs here work across 5 primary care sites and in the community hospital: providing A&E, inpatient and out of hours care. As part of my role, I provide a specialist GP-led gynaecology service on the island.

This service was developed in partnership with NHS Ayrshire and Arran as a sustainable way to deliver care in a remote location.

Specialist outreach clinics have proven increasingly difficult to maintain and without these an elderly person or working mother would have a full day of travel to attend a clinic appointment. In winter months, ferries are frequently cancelled due to adverse weather and getting stuck on the ‘wrong’ side can be an expensive and distressing experience. The model of care is built upon an island community clinic, with regular sessional work within the gynaecology department at the local acute hospital. This facilitates continuing professional development and clinical governance.

Training and development of the service was only possible with consultant mentorship and support from the mainland-based

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

gynaecology service. I remain incredibly grateful to Dr David Rae and colleagues at Crosshouse Hospital for this. I obtained a Post Graduate Diploma in Gynaecology at Bradford University in 2015, building experience and skills in gynaecology outpatients. This has allowed me to both expand the pre-existing primary care services, (LARC, sexual health and ring pessary replacement) to offer management of a range of gynaecological conditions.

Procedures such as endometrial biopsy, cervical anaesthesia, dilation and polyp removal avoid onward referral. Having the right equipment is vital - I cannot emphasise enough what a difference stirrups make to being able to adequately view a cervix!

One of the main reasons I find my specialist role so rewarding is that even relatively simple interventions can make a huge difference to that person’s wellbeing. So often I see women putting up with troublesome symptoms, that greatly affect their quality of life. I think enabling women to be seen closer to home reduces many of the hurdles, and time delays, that might be a barrier to seeking help. For example, the ability to assess genitourinary prolapse has allowed me to fit vaginal pessaries including more complex pessaries for uterine prolapse. In particular I find the newer silicone pessaries have allowed many women to happily manage their prolapse without the need for surgery.

ON THE GROUND

ENABLING WOMEN TO BE SEEN CLOSER TO HOME REDUCES MANY OF THE HURDLES, AND TIME DELAYS, THAT MIGHT BE A BARRIER TO SEEKING HELP

The links with my secondary care colleagues are essential in streamlining the patient journey. I am fortunate to be able to directly list for surgery, without the requirement for a further outpatient appointment thereby omitting a step and further wait for treatment. I can also conduct postoperative reviews, negating the need for women to return to the mainland hospital. A great deal of the success of the service is relationshipbased. This starts with my GP and nursing colleagues and the awareness of what can be offered locally. My clinic would not function without my superb healthcare assistant, who organises all the supplies and is wonderful at keeping ladies calm and distracted during procedures. Island life and a close-knit community means word of mouth spreads fast and women will often request a consultation having heard of success stories from friends or family.

At the moment it looks as though the effects of the COVID-19 pandemic will be with us for a long time. Cancelled outpatient clinics and theatre sessions have led to exceptionally long waiting times. This makes it even more important to provide direct access

to assessment and treatment close to home and demands new ways of working. The residents of the island were initially very fearful to even attend the GP surgery, far less travel on the ferry to the mainland. Our geographical isolation however, seems to have somewhat protected us. I was able to resume my community gynaecology clinic much earlier than the mainland outpatient clinics. By conducting an initial telephone consultation prior to the appointment, the formation of a management plan and any preprocedure counselling was completed before they attended. This has the advantages of minimising contact time in the surgery and the ‘DNA’ rate was

almost zero. It might be one of the many changes that continues ‘post-COVID’ although I do have to warn ladies that I will only have just said hello then I am asking them to undress!

I continue to thoroughly enjoy my gynaecology work and feel I provide an essential service for the women of Arran. Travelling to the mainland clinic is challenging but adds a different dimension to my working week and allows me to improve my knowledge and skills. I realise I am privileged to live and work in such a beautiful part of the country and being able to walk up the hills with my husband and daughters has saved my sanity!

▲ Faye says she feels

"privileged to live and work in such a beautiful part of the country"

Her Life Her Health | Spring 2021 | 37

PCWHF PEOPLE

How does it feel to be Medical Editor of Her Life Her Health? It’s such a

INTERVIEW BY AMY SCHOFIELD

PCWHF MEMBER PROFILE

For the love of learning Introducing Her Life Her Health’s Medical Editor and PCWHF Board Member, DR JANE DAVIS.

Tell us about what you do. I’m a GP

by trade. I have worked as a doctor in Cornwall for 21 years but my real passion lies in women’s health and medical education. I work as a Specialty Doctor for Brook, as a Menopause Specialist for St. Erme Medical, but I am also an undergraduate tutor at the University of Plymouth and a contraception and menopause trainer.

What are you most passionate about in women’s health? I know that

EXCELLENT WOMEN’S HEALTHCARE IS THE KEY TO GENDER EQUALITY

excellent women’s healthcare is the key to gender equality and I absolutely love to see women supporting women. I see it amongst clinicians and amongst the public and it is particularly apparent in the way the peer support groups work on the healthcare professional and Rock my Menopause websites.

I fell in love with medical education after the FSRH MedEd course in 2016 and have never looked back.

What does being a member of the PCWHF’s Board mean to you?

It gives me a sense of belonging and purpose. It has been a wonderful journey since I’ve joined. I absolutely love working with this fantastic dynamic team on the cutting edge of virtual education over the Covid-19 crisis. I always feel well supported.

I get a thrill when I see hundreds of practitioners turn out night after night for medical education. I know that there is a workforce making excellent women’s healthcare happen out there in the community and it is wonderful to see everyone coming together. I also am very grateful for my role at Rock My Menopause; I adore working with the creative team in connecting with the public making animations and eLearning. I love the can-do attitude of E4H who support us. Who would ever have dreamed being a GP could be this much fun?

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

thrill to be helping others get their ideas and examples of good practice out there. I am delighted to work with the inspiring Dr Anne Connolly and the editorial team. I am never happier than when I have an idea; it’s a thrill to see your ideas in print and I love supporting other people to experience this as well. It combines my two favourite passions which are creativity and a love of learning. This is a professional magazine, it is not meant to feel like homework and I would highly recommend you enjoy it over a glass of your favourite drink while relaxing. I want you to have a sense of community whilst osmosing some essential medical information as well, and I hope that your copy of Her Life Her Health looks like mine, which is absolutely covered in scribbles and action points where I feel inspired to look up more, connect with people and make ideas happen.

What or who has influenced your career the most? In terms of what, it’s

the rise of the feminist movement. I read Caitlin Moran’s How to be a Woman in 2003 and realised I was a feminist.

I had been having a difficult time as a GP partner. I was exhausted, I had hit a wall and realised that I needed to put my energies into what I really love, which is women’s healthcare and advocating for women. In terms of who has influenced my career; Dr Sarah Gray is a phenomenal speaker and teacher with an encyclopaedic and innate knowledge of the body. I have been fortunate enough to be trained and mentored by Sarah for the last 20 years. Through Sarah I have been given opportunities which have taken me all over the world. I have been encouraged and inspired at every turn. She has taught me pretty much everything I know about women’s health and when I’m listening to the great and the good talking internationally I find myself saying to myself, “Well that’s what Sarah said years ago” – who can ask for more than that in a teacher? I have been very fortunate and hope that I in turn can be an inspiration and a good teacher to other practitioners so they can benefit as I have done.

Over 50% of visitors to Rock My Menopause are recommended by their GP

LOOKING FOR RELIABLE, CLINICALLY BASED MENOPAUSE INFORMATION FOR YOUR PATIENTS? ENCOURAGE THE WOMEN IN YOUR CLINIC TO #ROCKMYMENOPAUSE

Backed by the PCHWF, Rock My Menopause includes: • Menopause information • Resources & Factsheets • Podcasts

• Symptom tracker • Private Facebook group for support.

We empower women to be more menopause-aware.

ROCKMYMENOPAUSE.CO.UK @RockMyMenopause # RockMyMenopause

POWERED BY E4H /RockMyMenopause

EXPERTISE FROM PCWHF

ASK THE EXPERTS

WORDS BY DR ANNE CONNOLLY

YOUR QUESTIONS ANSWERED

Q HEAVY MENSTRUAL BLEEDING

In this new series, we pose commonly asked questions to our expert clinicians. This time, DR ANNE CONNOLLY answers your questions on managing heavy menstrual bleeding.

Q

If a woman has active heavy bleeding, can medroxyprogesterone acetate (MPA) be used to cease bleeding as well as prevent it going forward? If so, what dose would you initiate and then use?

MPA can be used as a treatment for cessation of bleeding, cycle regulation or menstrual delay in the absence of structural endometrial pathology.

A prolonged delayed heavy bleed in a perimenopausal woman is often due to anovulation. Managing with the off-license dose of MPA 10mgs twice daily for 10 days stabilises the endometrium and stops her bleeding.

If this treatment is not successful then referral for hysteroscopy, especially if there has been previous cycle irregularity, is important to investigate for endometrial pathology.

Previously norethisterone (NET) was the progestogen treatment of choice but as there is concern about the thrombotic potential of NET many prescribers are using MPA instead as this is deemed to be safer, especially in those who have co-existing risk factors for thrombotic problems (i.e. BMI > 35 smoking over the age of 35 and so on1). Refer to the PCWHF recommendations on MPA use2

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

Please explain the issue of oestrogen-only HRT with HMB. Unopposed oestrogen is a risk factor for endometrial hyperplasia and hence the increased concern in women who are obese, those who have persistent anovulatory cycles with polycystic ovary syndrome or perimenopause or use oestrogen-only HRT. Women with erratic bleeding or HMB with any of the above risk factors or who are found to have inadvertently been prescribed oestrogen-only HRT require endometrial assessment and biopsy 3 .

Q

How long can tranexamic acid be used for HMB? The recommended dose and treatment length for tranexamic acid is up to 4g/day for 4 days for management of HMB but this can be used for longer if required. Tranexamic acid has a number of uses to control bleeding including for nose bleeds or to prevent bleeding from hereditary angioedema as well as for HMB. Starting treatment as soon as menstrual loss starts at a dose of 1-1.5g tds will reduce the blood loss more effectively than waiting until the days of heavier bleeding, following which the dose can be reduced after a few days. Using a NSAID at the same time provides additional benefit. If the treatment is not effective then consider investigations as ‘failed medical management’ is one of the indications for endometrial assessment 4,5. ► Join us at the PCWHF Facebook group to ask your questions at facebook.com/PCWHF. For further reading on HMB, go to our Top Tips on Management of HMB6.

REFERENCES 1. https://www.nice.org.uk/guidance/ng88 2. https://tinyurl.com/u3nfzc4n 3. https://www.rcog.org.uk/en/guidelines-researchservices/guidelines/gtg67/ 4. https://www.nhs.uk/medicines/tranexamic-acid/ 5. https://bnf.nice.org.uk/drug/tranexamic-acid.html 6. https://tinyurl.com/177r4ani

F RO M W I T H I N

IMVAGGIS (ESTRIOL) 0.03MG PESSARY FOR VAGINAL ATROPHY IN POSTMENOPAUSAL WOMEN1 An ultra-low-dose, smooth estriol pessary that is easily inserted without the need for an applicator, designed with the patient in mind1,2 Imvaggis significantly improves the symptoms of vaginal atrophy, restores the vaginal flora by improving the physiology of the vaginal epithelium vs placebo at 12 weeks (P<0.001)1, 3

For more information, visit www.imvaggis.co.uk Please see below for full licensed indication

Reference: 1. Imvaggis (estriol) 0.03mg pessary Summary of Product Characteristics. Available from https://www.medicines.org.uk/emc/product/10435/smpc#gref Last accessed March 2021 2. Data on File IMV/2020/017 3. Griesser H. et al. Maturitas; 2012; 71(4): 360 -368 Prescribing Information Imvaggis (Estriol) 0.03 mg pessary For full prescribing information, including side effects, precautions and contraindications, please consult the Summary of Product Characteristics (SPC).

Presentation: Pessaries containing 0.03 mg of estriol. Indication: Local treatment of vaginal symptoms of estrogen deficiency in postmenopausal women. Dosage and Administration: During the first 3 weeks of treatment, 1 pessary is administered daily.

Thereafter, a maintenance dose of 1 pessary twice a week is recommended. The pessary should be introduced deeply into the vagina, preferably in the evening before going to bed.

For initiation and continuation of treatment, the lowest effective dose for the shortest duration should be used. Contraindications: Hypersensitivity to estriol or any of the excipients; known, past or suspected breast cancer; known or suspected estrogendependent malignant tumours (e.g. endometrial cancer); undiagnosed genital bleeding; untreated endometrial hyperplasia; previous or current venous thromboembolism (deep vein thrombosis, pulmonary embolism), known thrombophilic disorders, active or recent arterial thromboembolic disease (e.g. angina, myocardial infarction); acute liver disease or history of liver disease whilst liver function tests are abnormal; porphyria. Warnings and Precautions: Local estrogen therapy should only be initiated for symptoms that adversely affect quality of life. The risks and benefits should be reviewed annually, and therapy should only be continued as long as the benefit outweighs the risk. Estriol must not be combined with estrogen preparations for systemic treatment. Patients should be closely supervised if any of the following conditions are present, have occurred previously and/or have been aggravated during pregnancy or previous hormone treatment since they may recur or be aggravated during treatment with Estriol: leiomyoma (uterine fibroids) or endometriosis; risk factors for thromboembolic disorders; risk factors for estrogendependent 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 and otosclerosis.

Estriol should be discontinued if a contraindication is discovered or the following occur: jaundice or deterioration in liver function; significant increase in blood pressure; new onset

of migraine-type headache; pregnancy. An increased risk of endometrial hyperplasia or uterine cancer has not been attributed to treatment with estriol by vaginal use.

Endometrial safety of long-term (>1 year) or repeated use of local vaginally administered estrogen is uncertain. Therefore, if repeated, treatment should be reviewed at least annually. If break through bleeding and spotting occurs during therapy or continues after treatment has been discontinued the reason should be investigated. Unopposed estrogen stimulation may lead to premalignant transformation in the residual foci of endometriosis The following risks have been associated with systemic HRT and apply to a lesser extent to estrogen products for vaginal application where systemic exposure is very low, however they should be considered in case of long term or repeated use: Breast cancer, ovarian cancer, venous thromboembolism, coronary artery disease, ischaemic stroke, and certain other conditions including fluid retention. Therefore, patients with cardiac or renal dysfunction should be carefully observed. Interactions: Due to minimal systemic absorption following vaginal administration of low-dose estriol pessaries, systemic drug interactions are unlikely. However, interactions with other locally applied vaginal treatments should be considered. If estriol pessaries are used simultaneously with condoms made of latex, it can decrease the tensile strength and thus impair the safety of condoms. Pregnancy and breastfeeding: Estriol pessaries are not indicated in pregnancy or during breastfeeding. If pregnancy occurs during treatment with Estriol pessaries, the treatment should be withdrawn immediately. Undesirable effects: At the beginning of treatment, when the vaginal epithelial layers are still atrophic, local irritation may occur as a sensation of heat, pain and/or itching. They are often transient and of mild intensity. The following commonly (>1/100; <1/10) occur: vulvovaginal burning, pruritus, pain and dysuria.

The following are uncommon (≥1/1,000; <1/100): vaginal discharge, anorectal discomfort.

Overdose: Toxicity for estriol is very low. Overdose of Estriol pessaries by vaginal application is unlikely. Symptoms that may occur in the case of a high dose accidentally ingested are nausea, vomiting and vaginal bleeding in females. NHS Price: 24 pessaries, £13.38. Legal category: POM. Marketing Authorisation number: PL 42714/0001.

Marketing Authorisation Holder: Besins Healthcare (UK) Ltd, Lion Court, 25 Proctor Street, Holborn, London, WC1V 6NY, UK. Date of preparation of Prescribing Information: April 2020. BHUK/2020/033

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Besins Healthcare (UK) Ltd, Drug Safety on 0203 862 0920 or Email: pharmacovigilance@besins-healthcare.com IMV/2021/014 March 2021 March 2021

2021 MEMBER BENEFITS

FREE NEW PCWHF Member Webinar COMING SOON

PCWHF Menopause Foundation Course Guaranteed copy of Her Life, Her Health

EXCLUSIVE DISCOUNTS Her Life, Her Health Live Online COMING SOON

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/membership

PCWHF Menopause for Prescribers

PLUS Membership Pack

Member Certificate PRACTICE MEMBERSHIPS AVAILABLE