Her Life Her Health 2021

WINTER 2021

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

Endometriosis diagnosis & management

The new DFSRH

Libido and the menopause

Tackling racial disparities in maternal care

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WELCOME

From the Editor-in-Chief

EDITOR-IN-CHIEF

Dr Anne Connolly SENIOR EDITOR

Amy Schofield

MEDICAL EDITOR

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W

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THERE IS SO MUCH EXPERTISE AND PASSION FROM ALL THOSE WHO CONTRIBUTE TO THE JOURNAL, AND WE KNOW THAT THIS IS EQUALLED BY ALL OF YOU WHO READ IT

elcome to this edition of Her Life Her Health, the first of 2021, and here’s hoping that at some point this year we can return to some normality – or whatever the new normal looks like. In this edition we once again have articles covering a range of conditions and concerns that we see in primary care, and advice and recommendations on their diagnosis and management.

We cover a range of subjects across the life course, including early menopause, endometriosis, heavy menstrual bleeding, microscopic colitis, libido and menopause, racial inequality in maternal care, and insights into patient experiences. We also introduce our latest inspiring Pioneer in Women’s Health, and our newest Executive Committee member. Thanks to everyone who has taken the time to write for the journal – you will appreciate there is so much expertise and passion from all those who contribute to the journal, and we know that this is equalled by all of you who read it.

I do not want to single out any specific articles (because they are all fantastic) but I would like to congratulate Jessica Dowle, a medical student from Hull York University who was this year’s winner of the Target Ovarian Cancer Essay competition. Please read this article on page 29 and prepare to be challenged about the dilemma she clearly outlines that many women and their families have when deciding whether to find out about their personal risk and choices.

I would also like to thank Imogen Shaw, a GPSI gynae and menopause specialist who has recently updated the PCWHF HRT prescribing guide. Please download and share this widely as the feedback to the first edition of this was that this was an amazing resource which allowed people a better understanding of the risks and benefits of HRT and confidence to prescribe.

So please enjoy this edition as we continue to thrive to share best practice and to improve the care women receive.

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 April 2021.

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

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

Her Life Her Health | Winter 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 HEATHER CURRIE

KELLY MCNULTY

Heather is Associate Specialist Gynaecologist, Dumfries and Galloway Royal Infirmary, Trustee and past Chair of the British Menopause Society, and Founder and Managing Director of Menopause Matters Limited.

Kelly is a PhD student investigating the effects of the menstrual cycle and hormonal contraceptives on performance, adaptation and recovery.

DR AAMENA SALAR

JESSICA DOWLE

Jessica is a final year student at the Hull York Medical School. She is passionate about women’s health and hopes to specialise in obstetrics & gynaecology in the future.

Aamena is a GP with specialist interest in gynaecology, Clinical Lead for Modality Gynaecology Service and Medical Director for Modality Community services in Birmingham.

FAYE FARTHING

DR CLARE SPENCER

Clotilde is co-founder of the #fivexmore campaign. She is a mum and founder of @_Prosperitys a mental wellbeing social enterprise which supports Black and South Asian mums.

Faye is Communications & Campaigns Manager at Endometriosis UK. She is passionate about making a difference through lobbying and getting endometriosis at the forefront of the media and political agenda.

CLARE BAUMHAUER

DR ANDREW JENKINS

Clare is the founder of the Vulval Cancer UK Awareness support group which raises awareness of lichen sclerosus and VC amongst both women and healthcare professionals.

Andrew is a registered pharmacist and PhD research doctor, graduating from Cardiff University. He now works as a Medical and Scientific Liaison Manager at Tillotts Pharma UK.

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

HAYLEY COCKMAN

DR ANNE LASHFORD

Hayley is a patient advocate for premature menopause after going through it at 14. She now wishes to help women going through the experience to get the support they need.

Anne is the Vice President for General Training at the Faculty of Sexual and Reproductive Healthcare and is a GP and Community Sexual Health doctor in Wiltshire.

TINUKE AWE

Tinuke is co-founder of the #fivexmore campaign and a mum. She also founded @mumsandtea which hosts events for black mothers online.

CLOTILDE REBECCA ABE

THE CAUSES OF LOW SEX DRIVE MAY BE MULTIPLE AND INTERLINKED FOR MANY WOMEN

DR CLARE SPENCER, LIBIDO & THE MENOPAUSE, PAGE 26

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

THE MENSTRUAL CYCLE, ORAL CONTRACEPTIVES & EXERCISE PERFORMANCE, PAGE 14

Her life

Her health

EARLY YEARS

PIONEERS IN WOMEN’S HEALTH

Finding hope

12

One woman’s story of going through menopause at 14-years-old Hayley Cockman

FERTILE YEARS 14

What challenges do women face in maximising their sporting performance?

Kelly McNulty Born into inequality

News & Policy

04

The women campaigning to tackle racial inequalities in maternal care Amy Schofield

Research & Guidelines

07

Remote management of HMB

EDUCATION & LEARNING The new FSRH Diploma 10 Opportunities for learners as the Diploma undergoes major changes Dr Anne Lashford

16

18

22

Tackling the complexities of managing endometriosis Dr Aamena Salar

36

29

CHARITY FOCUS 38

26

How to support your patients experiencing a drop in sex drive Dr Clare Spencer

PCWHF PROFILE

GOLDEN YEARS

A time to thrive Introducing the PCWHF’s latest Executive Committee member, Dr Louise Price

Microscopic colitis - A jobbing GP's perspective RIGHT CARE, RIGHT TIME, PAGE 38

To test or not to test Prize-winning essay exploring the impact of BRCA mutation awareness Jessica Dowle

Right care, right time In the wake of the APPG Inquiry, Endometriosis UK is calling for change Faye Farthing

RENAISSANCE YEARS Libido & the menopause

Opportune time, page The Founder of Vulval Cancer UK Awareness on the importance of recognising vulval skin conditions Clare Baumhauer

RISING STARS

Managing heavy menstrual bleeding during COVID-19 and beyond Dr Anne Connolly Endometriosis diagnosis & management

34

PATIENT VOICE

The menstrual cycle, oral contraceptives & exercise performance

ESSENTIAL UPDATES

Education, education, education Dr Heather Currie shares her vision for the future of menopause care Dr Heather Currie

32

40

Facilitating the diagnosis and management of MC in primary care Dr Andrew Jenkins

Her Life Her Health | Winter 2021 | 3

ESSENTIAL UPDATE

News & Policy

Scotland first country to make period products free for all

FIRST DO NO HARM

The All-Party Parliamentary Group (APPG) on Women’s Health held 3 separate webinars across the month of November 2020 to discuss prominent topics surrounding women’s health. The first of these was ‘The Cumberlege Review: First Do No Harm & What it Means for Women’s Health’.

Hosted by Jackie Doyle-Price MP, the webinar featured a panel discussion with Baroness Cumberlege and her team; Dr Clare Etherington, and Shazia Ginai, who shared her patient perspective. The panel discussed the recommendations which came out of The Independent Medicines & Medical Devices Safety Review, and their implications for our healthcare system and for women’s care in particular. The report, which was due to be published in March 2020 but was delayed due to the pandemic, makes 9 recommendations on the healthcare system’s ability to respond to concerns raised about the safety of 3 clinical interventions: primodos, sodium valproate, and pelvic mesh implants.

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

The team reviewed a vast amount of evidence, including documents seized from the manufacturers of primodos; written evidence from a variety of stakeholders including patient safety groups, clinicians, independent healthcare providers, manufacturer and suppliers, and oral evidence from campaign groups, healthcare bodies, academics, medical societies and Royal Colleges.

What emerged, according to Jackie Doyle-Price, were “heart wrenching” and “intimate stories told with dignity and courage” by women, many of whom suffered damaged relationships, family breakdowns, career collapses and financial ruin because of the detrimental effect of the treatments on their health and wellbeing.

While the report acknowledged that, ‘Most people do excellent work most of the time in the health service’, the stories of the women whose experiences had been ignored, in the words of patient Shazia Ginai, “Highlighted a systemic failure in the healthcare system.” ► Read the report and recommendations in full at https://www.gov.uk/government/publications/.

ESSENTIAL UPDATE

THE WINTER ISSUE

M

SPs unanimously approved the Period Products (Free Provision) (Scotland) Bill in late November 2020, making Scotland the first country in the world to make period products free to all.

The legislation follows previous action by the Scottish Government to tackle period poverty, including introducing a £5.2 million fund to provide free period products for pupils, students and learners at schools, colleges and universities across Scotland in 2018, followed in 2019 by the introduction of grants to enable 500 sports clubs to offer free products to participants and visitors.

Local authorities now have a legal duty to ensure that items such as tampons and sanitary pads are available free to ‘anyone who needs them’.

The bill was introduced by Labour MSP Monica Lennon, who has been campaigning to end period poverty since 2016. “Periods don’t stop for pandemics and the work to improve access to essential tampons, pads and reusables has never been more important,” she said.

LOCAL AUTHORITIES NOW HAVE A LEGAL DUTY TO ENSURE THAT ITEMS SUCH AS TAMPONS AND SANITARY PADS ARE AVAILABLE FREE TO ‘ANYONE WHO NEEDS THEM’.

PCWHF WEBINAR RECORDINGS The PCWHF’s educational programme runs regular webinars on a range of women’s health subjects. If you’re unable to attend on the night, you can catch up with all of them online in your own time. Webinars currently available include: • Contraception, Bleeding Problems and Menopause Masterclass One: Your questions answered.

• Contraception, Bleeding Problems and Menopause Masterclass Two: Your questions answered.

• P re & Post Pregnancy Care in Primary Care • Using Supportive Vaginal Pessaries in Primary Care. ► All webinars are free to listen to on-demand at PCWHF.co.uk/resources.

APPG report shows no improvement in endometriosis diagnosis in 10 years

A

n Inquiry by the APPG on Endometriosis has highlighted the devastating impact that endometriosis can have on all aspects of a person’s life. MPs have called for urgent Government action as this cross-party report, Endometriosis in the UK: Time for change, showed no improvement in endometriosis diagnosis in a decade.

Over 10,000 people with endometriosis were surveyed as part of the Inquiry, which interviewed healthcare practitioners and those with the condition about their experiences.

Findings include: • Average diagnosis times for endometriosis have not improved in over a decade – it still takes 8 years on average to get a diagnosis.

Prior to getting a diagnosis and with symptoms: • 58% visited their GP more than 10 times • 43% visited doctors in hospital over 5 times • 5 3% visited A&E. Once diagnosed: • only 19% know if they are seen in an endometriosis specialist centre • 9 0% would have liked access to psychological support, but were not offered this.

In order to support those with endometriosis, the APPG called on all Governments in the UK to commit to a series of support measures for those with endometriosis. Read about how Endometriosis UK is supporting patients and healthcare professionals on page 38, and find out more about endometriosis diagnosis and management on page 22.

Her Life Her Health | Winter 2021 | 5

ESSENTIAL UPDATE

News & Policy

DATES FOR YOUR DIARY

Booking is open for 2021’s educational events.

To find out more go to www.pcwhf.co.uk/events

A TOTAL OF £1.5M HAS BEEN AWARDED TO 10 PROJECTS TO UNDERSTAND THE IMPACT OF COVID-19 ON SERVICE CHANGE AND HEALTH INEQUALITIES

PCWHF ANNUAL CONFERENCE

The Primary Care Women’s Health Forum Annual Conference will be going virtual in 2021.

Bringing together key expert speakers in women’s health, the conference aims to improve your practice in women’s health.

Key topics include: • Abortion care • AUB guidance • Women and HIV • PMS • Contraception • Menopause • Ovarian cancer • PCOS • Out of hospital care There will be an opportunity to network with colleagues virtually and CPD points available.

Booking is now open.

Date: 24 February 2021 Venue: Online ► www.pcwhf.co.uk/ pcwhf-events/pcwhfconference-2021

Funding for RCOG project on impact of COVID-19 on maternity care & existing inequalities

T

he RCOG has been awarded a grant by The Health Foundation for a project in partnership with Queen Mary University of London, the Caribbean and African Health Network and the University of Bristol.

The project will look at whether changes to maternity care during the COVID-19 pandemic have affected existing inequalities.

A total of £1.5m has been awarded to 10 projects to understand the impact of COVID-19 on service change and health inequalities. The RCOG project will last for 1 year and begins at the start of 2021.

During the pandemic, there have been changes to the way in which maternity care is delivered. Care provision has had to be modified and maternity units have faced staffing shortages.

The research project will use data that is routinely collected during the course of maternity care to identify changes to outcomes for women and babies during the pandemic, and whether these were related to particular changes in maternity services offered.

The study will then identify any maternity units where changes in practice during the pandemic narrowed existing gaps in outcomes between women from different ethnic groups, or units where the impact on existing inequalities was as small as possible.

The final research will be used to provide recommendations on how the quality and safety of maternity care can be improved, and how it can ensure that all women, irrespective of their background or place of residence, have access to safe maternity care.

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THIS GUIDE MAY BE HELPFUL WHEN INITIATING THERAPY OR TO ASSIST IN CHOOSING ALTERNATIVE PREPARATIONS

ESSENTIAL UPDATE

THE WINTER ISSUE

New HRT prescribing guide

Menopause – Guidance on management and prescribing HRT for GPs: Based on NICE guidance 2015 and recent updates

1 Section 1 ‘A summary of the 2015 NICE guidance and other relevant studies’ includes:

S

ome of the most commonly asked questions on the PCWHF Facebook group concern HRT prescribing.

Dr Imogen Shaw, GPSI Gynaecology, has produced this guide which may be helpful when initiating therapy or to assist in choosing alternative preparations for the treatment of symptoms of the menopause.

Included in this guidance: 1 A summary of the 2015 NICE guidance and other relevant studies

2 Oestrogens and progestogens used in HRT

3 A flow chart to use as a guide in choosing the appropriate treatment

Remember that all women are

different, and this is a guide only; treatment must be individualised.

There is a considerable variation in the individual’s response to different types and routes of oestrogen for symptom control.

4 Possible medications to use – these are the drugs frequently used by the author; alternatives are available.

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

• Diagnosis • When blood tests are necessary • Vasomotor symptoms • Genitourinary syndrome of menopause • R isk: Venous thromboembolism • R isk: Cardiovascular disease • R isk: Type 2 diabetes • R isk: Breast cancer – Including an overview of the meta-analysis of all available epidemiologic evidence on the association between HRT use and breast cancer risk which was published in The Lancet in August 2019, and joint statement from BMS, IMS, and RCOG in response • R isk: Ovarian cancer • Benefit: Osteoporosis • Benefit: Muscle mass and strength • P remature ovarian insufficiency • When to review.

2 Section 2 ‘Oestrogens and progestogens used in HRT’ includes information on:

• The metabolic effects of different routes of oestrogen administration • Table: Types of progestogens, what they’re good for, what to watch out for, and prescribing information • Table: Progestogens currently licenced for use in the UK as part of combined HRT. 3 Section 3 'Flowchart for HRT prescribing':

• Vaginal sx. only • Uterus intact • Post hysterectomy.

4 Section 4 'Possible medications to use'.

• Including oral, second line, and transdermal. ► Download this essential resource at www.pcwhf.co.uk/resources.

Her Life Her Health | Winter 2021 | 7

ESSENTIAL UPDATE

Research & Guidelines

SHAPING THE FUTURE OF WOMEN’S HEALTH The results of the PCWHF’s latest survey are in, and they show an interest in both basic and enhanced training, as well as where training is needed the most.

T WORDS BY DR ANNE CONNOLLY

THERE ARE VAST NUMBERS OF WAYS TO ACHIEVE SKILLS AND COMPETENCIES

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he ambition of our Shaping the Future of Women’s Health survey, undertaken in 2020, was to understand the work that Primary Care Women’s Health Forum members were providing in their primary care settings, and to advise on future learning needs. We wanted to understand what training had been undertaken, what training we should develop and how we can best support our members in the future. We also asked questions about services that members were delivering for their neighbouring practices, how these are funded, and future ambitions for service delivery.

From the answers of our 200+ respondents, and also from the discussions that are ongoing on the PCWHF’s Facebook page, it is clear that not only is there an

immense amount of expertise among our members, there is also great interest in developing knowledge and expertise further. The survey responses confirmed that there are vast numbers of ways to achieve skills and competencies, some of which are gained by following formal accredited training packages and some obtained from observing other practitioners and learning in a less formal way.

There is also no standardised accreditation requirement for the majority of care delivered, whether as core or as enhanced work.

The route of training to providing intrauterine devices (for contraception or for gynaecological treatments) is more standardised; whereas menopause training and management of other gynaecology concerns is much more varied. Some clinicians are doing costly, time-intensive

ESSENTIAL UPDATE

THE WINTER ISSUE

training and others are finding that historical skills and regular updating via attending webinars or meetings is sufficient for their needs and commissioned agreements.

The survey results confirm an interest in basic and enhanced training for most aspects of women’s healthcare and an appreciation of the resources that have already been developed. These can be found on the website at www.pcwhf.co.uk/ resources for ongoing use.

At the PCWHF we are determined to provide education and support for members and to improve and enhance the care provided for women in outof-hospital settings as recommended by the NHS plan. The survey results confirm our understanding of the current situation and how to prioritise the work plans, including: • Basic menopause training with a plan to develop resources to support prescribing decisions.

• R ing pessary training.

• Developing training resources for those wanting to deliver enhanced services including modules on AUB, menopause, fertility etc.

• O ngoing training for those new to practice.

• Commissioning resources and business cases to develop out-of-hospital care.

There are also ambitions to increase membership engagement as we continue to expand our portfolio and reach. Thank you to all of you who took the time to complete the survey, you have all made an invaluable contribution to the future learning needs of all those working in primary care who are passionate about women’s health. ► If you are interested in being more involved

The results What do our members who responded to the survey do?

74%

currently fit LARC Of that 74%,

90%

Respondents

14%

Practice Nurses

THE SURVEY RESULTS CONFIRM OUR UNDERSTANDING OF THE CURRENT SITUATION AND HOW TO PRIORITISE THE WORK PLANS

20%

Nurse Practitioners

59% GP Partners

fit IUS/IUD &

95%

fit subdermal implants

92%

see women for contraceptive appointments

77%

do not deliver enhanced menopause care

80%

see women for routine menopause appointments

What training would you like the PCWHF to develop?

“ Dealing with complex contraception issues/ requests; menopause, especially decision making in prescribing the most appropriate preparations” “Current guidelines, regular updates” “Webinars/refreshers in all areas” “Ideas on joint working to put to managers” “Continued guidelines in COVID-19”

“ Menopause webinars – keep them coming – very helpful and I don’t need to travel – all the benefits without the hassle” “ Encouraging other member of PCNs to be happy for joint working in women’s health, as we are doing it in other specialties” “ A ny training tailored for practice nurses/nurse practitioners”

with the work of the PCWHF, including sharing your expertise, interesting cases, audits or other practice quality improvements by writing for Her Life Her Health, please contact us on submissions@pcwhf.co.uk.

Her Life Her Health | Winter 2021 | 9

ESSENTIAL UPDATE

Education & Learning

The new FSRH Diploma After 3 years of revisions, DR ANNE LASHFORD talks through FSRH’s redesigned Diploma.

E WORDS BY DR ANNE LASHFORD

WE HAVE WORKED TOGETHER WITH A RANGE OF CLINICIANS, TRAINERS AND OUR MEMBERS TO ENSURE THAT OUR REDESIGNED DIPLOMA IS EDUCATIONALLY ROBUST AND RELEVANT FOR YOUR WORKPLACE

ver since the Faculty of Sexual and Reproductive Healthcare (FSRH) was formed in 1993, our Diploma has been the nationally recognised qualification for healthcare professionals wishing to gain the knowledge and skills needed to provide high quality, effective contraceptive care.

In 2017, we undertook a periodic review of our Diploma and decided to make major changes which have taken nearly 3 years to come to fruition. We have produced updated SRH learning resources, revised the curriculum and are introducing a new learning management system – our FSRH Training Hub, which will go live shortly.

Historically the Diploma was just for doctors but, as FSRH is a multi-professional college, in 2013 we opened it up to nurses and have since extended our entry requirements to other groups of healthcare professionals working in SRH such as physicians’ associates, pharmacists and paramedics.

However, the majority of Diploma candidates are still GPs.

We have worked together with a range of clinicians, trainers and our members to ensure that our redesigned Diploma is educationally robust and relevant for your workplace. It is a nationally recognised qualification that you can take with you, wherever you may work.

The Diploma curriculum and learning outcomes have been updated to cover the topics listed below.

Diploma curriculum topics • Basic anatomy and physiology • Health history and risk assessment • Contraceptive choices: UKMEC, contraceptive methods, barrier contraceptives, sterilisation and fertility awareness • Emergency contraception including quick start • Managing side-effects and complications of contraception use • Pregnancy: planning, unintended and abortion as well as early pregnancy • STIs: transmission, testing, management and partner notification • Needs of specific groups • Adult and child/young person safeguarding • Psychosexual medicine • Cervical screening.

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Updated SRH content, relevant to your practice We have enhanced the pregnancy content to cover pre-conception care and early pregnancy complications.

The section on needs of specific groups looks at the contraceptive needs of young people, women over 40, those with a raised BMI and contraception following pregnancy. It also includes aspects of service delivery to specific groups who may have different needs such as those whose first language is not spoken English, people with learning disabilities, and the LGBTQ community.

We have an important section on safeguarding – both child/young person and adult. We hope that these changes will make our Diploma content even more relevant to those working in general practice, not just in relation to SRH care. We ran a Diploma pilot last year and have had positive feedback from GPs on our revised content.

We have updated a range of resources to support our Diploma which includes our NICE accredited FSRH standards and guidance. The main one of these is e-Sexual and Reproductive Healthcare (e-SRH) on the e-Learning for Health platform (e-LfH). This was a huge piece of work done in collaboration with Health Education England (HEE). Topics are now fully aligned with our Diploma curriculum and learning outcomes and have a more modern look and better functionality. It is free to access for all UK NHS healthcare professionals.

Our new FSRH Training Hub will act as an online logbook for candidates working through the Diploma pathway and will give access to a range of learning resources, from webinars and bite-sized videos to useful guidance and articles. Candidates will have up to 2 years to complete our Diploma.

In the longer run, the Hub will also provide access to ongoing CPD, with a CPD diary for our members and training materials for our trainers.

ESSENTIAL UPDATE

THE WINTER ISSUE

What will my journey through the FSRH Diploma look like?

1.

Check you meet the FSRH Diploma (DFSRH) entry requirements.

2.

Find a Faculty Registered Training (FRT) Programme using the online map.

3.

Once you have your FRT secured, you can apply for the DFSRH. Diploma assessment framework The assessment framework for the Diploma consists of four elements:

1 Independent Learning Portfolio (ILP) • Self-guided e-learning, topic investigations, case discussions, patient feedback.

2 Online Theory Assessment (OTA) • Multiple choice x 50 questions, 1 hour to complete.

3 Summative Clinical Assessments (SCA) x5 • Workplace based – can be done remotely.

4 Assessment Half-Day (AHD) • Written paper, clinical stations.

These can be done in any order, although we suggest that the Assessment HalfDay is done towards the end of the journey. This will consist of a written paper and 4 OSCE-like assessments.

This was originally a face-to-face

assessment, but we are now planning to run them remotely in the short-term.

One of the key differences with our redesigned Diploma is that we want candidates to make contact with one of our training programmes early in their journey so that they will have the support of an experienced FSRH trainer throughout. We hope that this will give them the best learning experience.

Candidate journey through the redesigned Diploma The sidebar explains the Diploma candidate journey, from when candidates first apply through to achieving our Diploma qualification.

We are proud of what we have achieved so far and hope that many of you will be interested in finding out more about what our redesigned Diploma offers. ► Look out for applications

4.

Complete the DFSRH learning and assessments within a maximum of two years.

5.

Undertake the evaluation as part of the completion of your DFSRH.

6.

Become a FSRH Diplomate member.

7.

Recertify your DFSRH every five years.

opening soon at www.fsrh.org/diploma.

Her Life Her Health | Winter 2021 | 11

EARLY YEARS

HOW CAN HEALTHCARE PROFESSIONALS SUPPORT WOMEN GOING THROUGH EARLY MENOPAUSE? • Provide group meetings for women with others going through the same experience, so they have a support network. Dealing with it alone is not good for mental health. Women need reassurance they are still ‘normal’.

• More awareness that premature menopause happens – when doctors/pharmacists/nurses sympathise with me when I have to explain to them why I’m on HRT, it is degrading.

• Workshops and informative meetings to encourage women not to suffer in silence. Many women are dismissed by doctors as they don't believe they are perimenopausal because they are younger. Others, such as me, are put on HRT and antidepressants and left to get on with it.

Finding hope HAYLEY COCKMAN was just 14-years-old when she went through an early menopause. Having been left alone to deal with the fallout, Hayley is now calling for more understanding of premature menopause.

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

EARLY YEARS

I WAS TOLD I HAD A WOMB BUT A SMALL ONE AND THAT THEY COULD ONLY FIND ONE OVARY. THAT WAS THE FIRST AND THE LAST TIME I SAW MY CONSULTANT

A

WORDS BY HAYLEY COCKMAN

t the age of 12 I started my periods like a normal teenager. Then after a year they just stopped. I was struggling to concentrate at school and the nights were hell. I’d wake up dripping with sweat and just feeling weird. That’s how I described it to my Mum, “I don’t feel like me Mum, I feel weird.” We went to the doctor, I explained what was going on and I was referred for a blood test and an ultrasound. Then two weeks later a consultant gynaecologist confirmed I had gone through the menopause and that I needed to start hormone replacement therapy.

I was told I had a womb but a small one and that they could only find one ovary. That was the first and the last time I saw my consultant. I am now 39-years-old. I haven’t been contacted since. No follow up appointments, no help, no guidance to understand

what had happened to me. No one mentioned the words ‘premature ovarian failure’. I was put on HRT and left to get on with it.

When the brand I’d been using was discontinued a few years back I wasn’t informed by my doctor. The pharmacist told me when I went to pick up my prescription. I needed to take them daily and I had none left, but after a long phone call I managed to get an appointment with a GP the next day. She told me there was no exact alternative and she was putting me on another brand.

That was a horrendous experience – my hormone levels went crazy, my symptoms returned, and my bleeds were so painful. I was then changed onto another type of HRT which I now take and luckily have no problems with. Even my bleed isn’t as painful anymore as I have to have one monthly to keep the lining of my womb working properly, in case I was to decide I wanted to try IVF. I have decided against this, as I couldn’t go through a grieving process again if it wasn’t successful.

As a child I needed to learn what it all meant, but back then there was hardly anything on the internet to read. Even to this day there is limited material for a teenager experiencing this. I felt lost for years as I just didn’t understand it all. Medical professionals looked at me like I was some sort of freak.

If I had a pound for the amount of times a doctor or nurse has said to me “You poor girl” when I answer the dreaded question, “What medication do you take?”… When I was growing up I hated what I saw looking back at me in the mirror.

The one job a woman is given to do, and I couldn’t even do that properly.

I felt like a failure as a woman. But I just learned how to cope.

I struggled with relationships with guys as I knew I had it looming over me that one day I was going to have to tell them. Even when I did tell them or my friends, neither understood. I even lost a friend over it as she said I was lying and that it was a sick thing to make up.

The response I got from the close few I did tell was always the same; it will happen, loads of women are told they can’t have kids and they do.

Nobody understood what I was saying. Because no one was/is educated enough, no one knows what it means.

Even to this day people still do not understand. So, in my own words – to produce a baby, you need an egg and a sperm, and I don’t have eggs, end of.

After all this time, I decided I am ready to talk about my experience and to try and get this recognised more. To get people to speak out and not hide it all inside.

My own diagnosis was quick and efficient, just one blood test told us the answer. But there was no followup with a specialist, no mental health support offered. Of course at 14 I wasn’t thinking of starting a family, but as I got older and saw friends having children, it hit me. Signposting younger women going through early menopause to information on the different ways to become a parent, including IVF and adoption, would be so helpful. To be given that bit of hope can help a woman’s mental health so much more.

I’m calling for more menopause education, including early menopause, in primary care, in workplaces, for all people. I have hope now, I’m in the process of adopting a child. I know how much love I have to give, and for me to be able to give that to a child whose own parents cannot do this is wonderful. My husband and I have made it to the second stage now so we are working towards a date to go to panel to become approved adoptive parents. Wish us luck!

Her Life Her Health | Winter 2021 | 13

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The menstrual cycle, oral contraceptives & exercise performance

A historic lack of research into the hormonal effects of the menstrual cycle and contraceptive pills on performance means that little is understood, and meta-analyses appear to raise more questions than answers.

R WORDS BY KELLY MCNULTY

ecently there has been an exponential rise in the number of women participating in exercise, from physical activity to elite sport 1.However, research into female reproductive endocrinology and exercise performance has not kept pace. Of all the papers in the top 3 sports science and medicine journals for a 1-year period, only 4% of the research was done exclusively on women 2 .

This sex gap in research limits our ability to adopt an evidenceinformed approach when working with sportswomen, and as such, at the moment, in sport, women athletes usually train in a similar way to their male counterparts, which means we are likely failing to maximise their performance potential.

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

The menstrual cycle & exercise performance One unique performance consideration for women athletes is the menstrual cycle. A ‘textbook’ menstrual cycle lasts 28 days, and is commonly divided into 3 phases, each having significantly different hormonal profiles 3: 1 The early follicular phase: low oestrogen and progesterone.

2 The ovulatory phase: high oestrogen and low progesterone.

3 The mid-luteal phase: high oestrogen and progesterone.

Although research into womenspecific performance started in 1876, surprisingly little is known about the direction or magnitude of the effects of the menstrual cycle on performance.

In our recent paper, we investigated whether changes in hormone levels across the menstrual cycle affects exercise performance by conducting a systematic review and meta-analysis on the previous studies on this topic 4 .

We also examined the quality of the studies we identified, so we could rate our confidence in the evidence.

Our search found 78 relevant studies, which included data from over 1000 participants. The results indicated that exercise performance might be trivially reduced during the early follicular phase of the menstrual cycle, compared to all other phases. This means that exercise performance might be slightly reduced in some sportswomen when oestrogen and progesterone are low, usually during days 1 to 5 of the menstrual cycle. However, it is important to understand that a large proportion (42%) of these studies were classified as ‘low’ in quality. Additionally, the effect of the menstrual cycle on performance was variable between studies. When you add the small size of the effect, the poor quality of the research and the inconsistency between studies, general guidelines on exercise performance across the menstrual cycle cannot, and should not, be formed. Instead, we recommend that a personalised approach should be taken based on each athlete’s individual response to exercise performance across the menstrual cycle.

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Conclusions & recommendations Currently, there are no evidencebased guidelines on managing exercise performance across the menstrual cycle or with OC use.

Additionally, as every woman’s cycle is different and changes across her lifespan, there might never be a universal set of guidelines that practitioners can exclusively use to direct performance. We therefore recommend that: 1 Awareness should be provided to encourage a cultural shift away from period-based silencing to unrestricted conversations about menstrual cycles and hormonal contraception.

2 Education for athletes, practitioners and coaches on the menstrual cycle and OCs, with these aspects considered in the same light as other physiological functions.

3 Practitioners/coaches should develop their own bespoke athlete guidelines. Athletes should track their menstrual cycle or OC use and monitor any characteristics/symptoms and changes in performance, as well as using the research base (caution should be exercised when interpreting published data) in order to maximise the rewards and minimise the risks, so that every sportswoman can achieve their full potential.

Oral contraceptives and exercise performance The menstrual cycle is just 1 hormonal profile; a large number of sportswomen use oral contraceptives (OCs) which result in a different hormonal profile5. Oral contraceptives are designed to prevent pregnancy, but are also used by some athletes to manipulate their menstrual cycle, in order to control the timing of, or eliminate entirely, their periods6.

However, few in the area of sport and exercise science truly understand the implications of OCs on exercise performance.

The most popular type of OC has a 28-day cycle, whereby 1 pill is taken every day for 21 continuous days, followed by 7 pill-free days.

Oral contraceptives have two concurrent physiological consequences7: 1 They reduce the amount of natural oestrogen and progesterone in the body throughout the 28-day cycle.

1 They provide an artificial oestrogen and progestin in the body during the 21 pill-taking days.

In our sister meta-analysis8, we investigated whether these two coexisting hormonal profiles affect exercise performance by examining previous studies that looked at OC pill-taking versus pill-free days, and by comparing OC users to naturally menstruating women.

Our search found 42 studies which included data from over 500 participants.

The results indicated that on average OCs might result in slightly poorer exercise performance when compared to naturally menstruating women.

However, again the small size of the effect, the poor quality of the research and the inconsistency between studies meant that general guidelines could not be formed. As such, it is better to take an individualised approach to OC use, focusing on each athlete’s response to their OC. Additionally, our investigation showed that exercise performance did not change between the pill-taking and pill-free days, meaning that sportswomen do not need to worry about which day of their OC cycle they are on when considering performance.

REFERENCES 1. Sport England, Active People Survey 10. (2016). Available: www.sportengland.org/research/about-our-research/active-people-survey/ 2. Costello, J.T., Bieuzen, F., & Bleakley, C.M. (2014). Where are all the female participants in sports and exercise medicine research?

European Journal of Sport Science, 14, 847-851.

3. Janse de Jonge, X., Thompson, B. & Han, A. (2019). Methodological recommendations for menstrual cycle research in sports and exercise. Medicine and Science in Sports and Exercise, 51, 2610-2617.

4. McNulty, K. L., Elliott-Sale, K. J., Dolan, E., Swinton, P. A., Ansdell, P., Goodall, S., ... & Hicks, K. M. (2020). The effects of menstrual cycle phase on exercise performance in eumenorrheic women: a systematic review and meta-analysis. Sports Medicine, 1-15.

5. Martin, D., Sale, C., Cooper, S.B. and Elliott-Sale, K.J., 2018. Period prevalence and perceived side effects of hormonal contraceptive use and the menstrual cycle in elite athletes. International Journal of Sports Physiology and Performance, 13(7), 926-932.

6. Schaumberg, M., Jenkins, D., Janse de Jonge, X. J., Emmerton, L., & Skinner, T. (2013). Oral contraceptive use for manipulation of menstruation in active women and competitive female athletes. Journal of Science and Medicine in Sport, 16, e68-e69.

7. Elliott-Sale, K. & Hicks, K. (2018). Hormonal-based contraception and the exercising female. In J. Forsyth, & C-M. Roberts (Eds.), The exercising female: science and its application (pp. 30-43). UK: Routledge.

8. Elliott-Sale, K. J., McNulty, K. L., Ansdell, P., Goodall, S., Hicks, K. M., Thomas, K., ... & Dolan, E. (2020). The effects of oral contraceptives on exercise performance in women: a systematic review and meta-analysis. Sports Medicine, 1-28.

Resources I have recently launched a project – The Period of The Period – which aims to change the narrative for women’s health in sport and exercise, by promoting awareness, increasing education and providing support. Please follow @periodoftheperiod on Instagram and @periodofperiod on Twitter for updates. Season 1 of the podcast can be found on Spotify and Apple podcasts. If you would like to get involved whether that be as a guest or to share research, please get in contact.

Her Life Her Health | Winter 2021 | 15

FERTILE YEARS

WE HEAR A LOT OF STORIES AND EXPERIENCES FROM BLACK WOMEN WHO SAY THEIR CONCERNS WERE NOT TAKEN SERIOUSLY

Born into inequality According to a 2019 report, Black mothers are 5 times more likely to die during pregnancy and after childbirth as their white counterparts. Meet the women campaigning to change that.

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

T

o mark the first meeting of the Royal College of Obstetricians and Gynaecologists’ (RCOG) Race Equality Taskforce in Autumn 2020, RCOG announced the launch of ‘Five steps for healthcare professionals’, a joint campaign created with Five X More to tackle racial disparities in maternity care.

Founded by two young black women, Atinuke Awe (Tinuke) and Clotilde Rebecca Abe (Clo), Five X More was created to address the inequalities that pregnant black mothers face, which was shown in stark detail with the

WORDS BY AMY SCHOFIELD

Five Steps for HCPs Summary

1.

These steps have been created by RCOG’s Race Equality Taskforce, whose members include doctors, midwives, policy makers and service users to better understand and tackle racial disparities in women’s healthcare and racism within the obstetric and gynaecology workforce.

If a pregnant woman expresses concern, feels like something is not quite right or is in pain, take time to listen to her concerns and anxieties without making assumptions or presumptions.

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Listen

publication of the Mothers and Babies Reducing Risk through Audit and Confidential Enquiries (MBRRACE) Report1’ in 2018. The statistics showed that black women are 5 times more likely to die in pregnancy, childbirth or in the 6-week postpartum period compared with white women and the risk for Asian women is twice as high.

In addition, during the peak of the COVID-19 pandemic, a large UK study 2 on the outcomes of 427 pregnant women and their babies found that 55% of pregnant women admitted to hospital with coronavirus were from a Black, Asian or other minority ethnic background. 13% of the UK population identify themselves as Black, Asian or minority ethnic.

In 2017, Tinuke had a distressing experience when giving birth to her son, despite the onset of a lifethreatening condition. “I had all the symptoms of pre-eclampsia, protein in my urine and high blood pressure, but no one was listening. I felt ignored.”

After the birth, Tinuke began talking to other black women about their birth experiences, and found that she was not alone. Then she heard about the MBRRACE statistics and was shocked.

As a “self-proclaimed nerd” Tinuke set about doing more research into these inequalities on maternity care, finding that black women have been more likely to die during pregnancy in comparison to a white woman for a long time and that the issue was still not being addressed.

2.

Remove any barriers to communication

Use translation services if required and remember that your body language and tone are vital in helping women to feel at ease.

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Clo is mum to two young boys and is the founder of @_Prosperitys, a mental wellbeing social enterprise which supports black and south Asian mums in Lambeth and Southwark.

She works in a Foetal Medicine/Day Assessment Unit in a South London hospital and is also the co-chair for Lambeth and St Thomas Hospital Maternity Voice Partnerships. She has a passion for black and South Asian women’s wellbeing during pregnancy and a year after birth.

In 2018, Tinuke, who is also founder of @mumsandtea which supports black mothers, joined forces with Clo to raise awareness of these disparities and bring about change for black mothers by empowering them on how they can support and advocate for themselves during pregnancy and labour. #fivexmore was the result.

“From running our campaign, we hear a lot of stories and experiences from black women who say their concerns were not taken seriously by the health professionals providing them with care or that they didn’t feel listened to during pregnancy and childbirth,” says Tinuke.

As the movement grew, the RCOG approached them to work with its Race Equality Taskforce to create a patientfacing and a healthcare professionalfacing campaign. It took a while for the campaign to gain traction: “Midwives didn’t even know about the MBRRACE statistics,” says Clo. Things accelerated after the death of George

3.

Check you are providing clear information

After you have explained a woman’s options and made recommendations about her care, it is important that you recap or ask her to recap the information and check she understands the choices available to her.

Floyd and the growth of the Black Lives Matter Movement, then Five X More’s petition, ‘Improve Maternal Mortality Rates and Health Care for Black Women in the UK’, followed as awareness grew. The petition sought an ‘urgent explanation and tangible action’ to commit to funding the changes necessary to eradicate the statistics on maternal outcomes and improve maternal healthcare outcomes for black women. “We had 100,000 signatures within a week,” says Clo. The petition has closed now, with over 187,500 signatures.

At the time of going to press, they were waiting for a date for the petition to be debated in Parliament.

Tinuke and Clo have spent many hours talking to HCPs on the issue, and have given talks to obs and gynae teams and midwifery schools, in an effort to ensure that issues around racial disparities in maternal care will be taught as part of their maternity training. These activities led to the RCOG asking Tinuke and Clo to help in creating cultural safety training, which has led to the creation of steps for adoption by both HCPs and pregnant women. At the launch of the Race Equality Taskforce, Chair Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “We are proud to have worked with Five X More to create this campaign as a tool for healthcare professionals to use when communicating with women.

4.

Provide access to detailed documentation

Support continuity of care by accurately recording any action, treatment or medication you recommend or prescribe, a woman’s response to treatment, if she has declined any interventions and why.

“Personally, I will be using these 5 steps when providing care as a reminder of what we all work hard to try and do every day, but sometimes forget when under pressure at work. We have a duty, as a College and as healthcare professionals, to work together to eradicate these shocking disparities.”

Although the message is serious, Tinuke and Clo want #fivexmore to also tell the positive stories, to show that action works. “The statistics may be bleak but things can change,” says Tinuke. “I gave birth to my daughter in April during lockdown, and it was a good experience.”

5.

Be a champion

Inspire others by championing positive change in your maternity or obstetric unit. ► Go to fivexmore.com to read the steps in full and find out more about support for black women patients. #fivexmore

THE STATISTICS MAY BE BLEAK BUT THINGS CAN CHANGE

REFERENCES 1. Knight M, Bunch K, Tuffnell D et al.

MBRRACE-UK reports | MBRRACE-UK | NPEU. Npeu.ox.ac.uk. https:// www.npeu.ox.ac.uk/ mbrrace-uk/reports.

Published 2019.

Accessed December 15, 2019.

2. https://www.npeu. ox.ac.uk/downloads/ files/ukoss/annualreports/UKOSS%20 COVID-19%20 Paper%20preprint%20draft%20 11-05-20.pdf

Her Life Her Health | Winter 2021 | 17

FERTILE YEARS

Remote management of HMB Managing heavy menstrual bleeding during COVID-19 and beyond.

H WORDS BY DR ANNE CONNOLLY

IN ORDER TO UNDERSTAND THE CAUSES OF HMB AND WHO REQUIRES A FACE TO FACE APPOINTMENT, A BASIC APPRECIATION OF THE MENSTRUAL CYCLE AND OF ENDOMETRIAL RISK FACTORS IS REQUIRED

eavy menstrual bleeding 1 (HMB) is a common concern affecting an estimated 1 in 5 women and one that has a significant impact on a woman’s quality of life.

Women are often embarrassed at the first presentation. They have often delayed making the appointment because of lack of appreciation of what is ‘normal’ and often present after a ‘flooding’ episode or when empowered to by a friend or family member.

NICE guideline Heavy Menstrual Bleeding: Assessment and Management (NG88) was updated in 2018. The recommendations of this guideline continue to remind us of the significant impact that HMB can have on a woman’s life, sometimes restricting her social and career ambitions, causing a psychological as well as a physical impact. The guideline provides a method of logically determining who requires examination and/or investigations and who can be managed remotely without requiring further intervention. This is particularly

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

useful with the increased use of telephone triage during 2020 because of the Covid-19 pandemic.

In order to understand the causes of HMB and who requires a face to face appointment, a basic appreciation of the menstrual cycle and of endometrial risk factors is required. Understanding this dictates the information required from the phone consultation which in turn determines any intervention required while allowing holistic care and psychological support to be offered.

In May 2020 the Royal College of Obstetricians and Gynaecologists (RCOG) issued guidance in conjunction with the British Society for Gynaecological Endoscopy (BSGE) and British Gynaecological Cancer Society (BGCS) for the Management of abnormal uterine bleeding in the evolving COVID-19 pandemic2 .

This was modified by the Primary Care Women’s Health Forum3 for use in primary care. Although these recommendations were initially written and agreed for a time when face to face contact opportunities

and specialist referrals were reduced, there is much learning to be gained for the future to allow us to rethink how we manage a woman’s bleeding concern.

Putting the guideline into practice Farah is a 42yo mother of 2 who is on the telephone appointment list for the morning clinic. She is not well known to the surgery as she rarely appears to have any medical problems, and she becomes emotional during the consultation. She is a teaching assistant at the local primary school and although her periods have become heavier recently she has tolerated them because she considers this to be part of ‘getting older’.

But yesterday she was using a super plus tampon and a large pad and still managed to ‘flood’ during the morning lessons.

A menstrual history provides the information required to allow an understanding of the severity of the concern, whether urgent assessment is required and to help determine if management can be performed remotely. The important points to ask Farah during the consultation are listed in 1.

FERTILE YEARS

1 HISTORY • How is this heavy bleeding affecting her physically, emotionally and socially?

• Is this a single episode or has this been a concern for a while?

• Is she noticing symptoms of anaemia (breathlessness or excessive tiredness)?

• Does she have any non-menstrual (inter-menstrual or post-coital) bleeding?

• Is she experiencing dysmenorrhoea or pelvic pain or urinary symptoms?

• Is she using or does she require contraception?

• Could she be pregnant?

• Is she at risk of a sexually transmitted infection?

• Has she completed her family?

• Is she up to date with her cervical screening?

• Does she have a history suggestive of a clotting disorder? Or is she taking anticoagulants?

• Does she have any risk factors for endometrial hyperplasia, eg obesity (BMI>35), diabetes, polycystic ovary syndrome?

• Does she have any significant family history?

As with any abnormal uterine bleeding complaint excluding pregnancy, infection and cervical problems are required first.

Once those have been excluded then the need for any additional intervention is dictated by the history according to NICE1: • A ny symptoms of pelvic pressure, urinary frequency or pelvic mass require an examination. If there is any concern about structural pathology i.e. large fibroids, a pelvic and trans-vaginal ultrasound scan is recommended.

• A ny findings indicating a risk of endometrial pathology, i.e. persistent intermenstrual bleeding, endometrial risk factors (See 2) or failed medical management require hysteroscopy.

• Generally the risk of malignancy in women with HMB but without significant risk factors is negligible 4 . So if, as in the majority of women, there are no additional concerns then treatment can be commenced without the need for investigations or examination provided the cytology history is normal and up-to-date.

2 ENDOMETRIAL RISK FACTORS • A ge >45 years • Obesity • Diabetes • Polycystic ovarian syndrome (unopposed oestrogens from anovulatory cycles) • Nulliparity • Unopposed oestrogen therapy in a woman with an intact uterus • Tamoxifen in postmenopausal women • Endogenous oestrogens e.g. ovarian granulosa cell neoplasm • Family history of breast or endometrial cancer, or colonic cancer.

As Farah has no medical concerns and no abnormal bleeding pattern, a full blood count is the only investigation required.

This is recommended for all women with HMB to exclude the insidious onset of iron deficiency anaemia that many develop.

Other blood tests to consider when investigating HMB: • FSH, LH, TFTs, prolactin only with co-existing oligomenorrhoea.

• Clotting screen only if HMB a lifelong concern.

Treatment options, as recommended by NICE NG88,1 are listed in 3 and depend on imminent and future fertility ambitions. Providing immediate relief of symptoms by prescribing tranexamic acid 1-1.5gms tds for 4 days is recommended while waiting for any further investigations or a decision about longer term treatment. The NICEendorsed decision making aid, Heavy periods: what are my options? 5 provides information about the benefits and risks of each option and is useful for women to consider before a follow-up consultation.

Her Life Her Health | Winter 2021 | 19

FERTILE YEARS

3 TREATMENT OPTIONS Hormonal • Levonorgestrel intrauterine system • Combined hormonal contraception; after exclusion of contra-indications • Medroxyprogesterone acetate; long cycle (21 days followed by a 7 day break) or continuous treatment Non-hormonal • T ranexamic acid • A ny non-steroidal anti-inflammatory drug Surgical – non-reversible • Endometrial ablation

THE USE OF INITIAL REMOTE CONSULTING HAS BECOME THE NORMAL FIRST POINT OF CONTACT FOR PRIMARY CARE

The levonorgestrel intrauterine system remains the recommended treatment of choice for management of HMB, achieving a 80-90% reduction in menstrual loss, low treatment cost and low risk of complications5.

Alternative options are outlined in 3 and include the non-reversible option of endometrial ablation.

Endometrial ablation is a choice for women who want a treatment that is non-reversible and is only appropriate for those who have completed their family. The newer techniques can be performed in the outpatient setting using local anaesthesia and analgesia.

Hysterectomy for management of HMB has been included in the list of inappropriate interventions produced by the Evidence-Based Intervention Programme published by NHS England6 and is not indicated as a first line treatment option.

Sally is a 48yo lady known well at the practice as she regularly attends clinic with her poorly controlled diabetes. Her latest recorded BMI is 39.4. She works at the local supermarket and is regularly missing days at work because she is so concerned about ‘flooding’ while working at the checkout. She has been called to see her supervisor following this latest episode of sick leave and she phones for an appointment.

The history requirements are the same as in the case of Farah – making sure her latest cytology result is within the dates of the screening programme. However, it is clear from her risk factors that Sally will require a referral for hysteroscopic endometrial assessment. A full blood count is required and treatment with tranexamic acid to help while she is waiting for her appointment.

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

Summary Since the start of the COVID-19 pandemic and necessary changes in access to healthcare in order to reduce infection transmission, the use of initial remote consulting has become the normal first point of contact for primary care. Primary care clinicians have rapidly learned to triage and arrange face to face consultation or remote management appropriately.

With an understanding of the menstrual cycle and endometrial risk factors, many consultations can be managed without the requirement of a face to face consultation other than to insert a levonorgestrel intrauterine system or treatment with endometrial ablation.

The majority of women do not require investigations other than cervical screening if not in date, full blood count in all and pregnancy testing and STI screening if indicated.

Women who do require further assessment should be referred for the correct investigation first time, by an improved understanding of the limitations of ultrasound scanning versus direct endometrial visualisation by hysteroscopy.

Finally, the NICE HMB Quality Standard (QS47)7 was recently updated and includes 3 quality standards.

The relevant ones for primary care are the first and third, providing an excellent opportunity to audit care: 2 People presenting with symptoms related to heavy menstrual bleeding have a focused history taken that includes the impact on their quality of life.

3 People with heavy menstrual bleeding have a discussion with their healthcare professional about their treatment options.

REFERENCES 1. National Institute for Health and Care Excellence (NICE) 2018. Heavy Menstrual Bleeding: Assessment and Management.

NICE NG88 https:// www.nice.org.uk/ guidance/ng88 2. https://www.rcog. org.uk/globalassets/ documents/ guidelines/2020-0521-joint-rcog-bsgebgcs-guidance-formanagement-ofabnormal-uterinebleeding-aub-in-theevolving-coronaviruscovid-19-pandemic-updated-final180520.pdf 3. https://pcwhf. co.uk/resources/ how-to-managewomen-presentingwith-abnormal-vaginalbleeding-in-primarycare-without-face-toface-contact/ 4. Pennant ME et al. Premenopausal abnormal uterine bleeding and risk of endometrial cancer.

BJOG 2017;124:404-411 5. NICE-endorsed resource: Shared decision making aid for heavy menstrual bleeding. https:// www.nice.org.uk/ guidance/ng88/ resources/endorsedresource-shareddecision-making-aidfor-heavy-menstrualbleeding-6540669613 6. https://www.england. nhs.uk/wp-content/ uploads/2018/11/ ebi-statutoryguidance-v2.pdf 7. NICE HMB QS 47 https://www.nice.org. uk/guidance/QS47

As seen on BBC Breakfast

OVER HALF THE POPULATION WILL BE AFFECTED

BY MENOPAUSE.

WHY DON’T WE TALK ABOUT IT MORE?

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

The menopause is inevitable; get ready to rock it.

ROCKMYMENOPAUSE.CO.UK @RockMyMenopause # RockMyMenopause

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EXPERTISE FROM PCWHF

FERTILE YEARS

Endometriosis diagnosis & management

W

hen I was asked to write this piece, my remit was to draw upon my experience of managing endometriosis both as a GP and a GPSI. Having reflected on what key messages I wanted to share, it struck me that I am not likely to tell you anything you do not already know.

However, what I do hope to do is unravel the complexities of managing endometriosis and replace it with a simplified and practical approach.

How to tackle the complexities of managing endometriosis.

Endometriosis is more common than you think, affecting approximately 10% of women of reproductive age Why is that important? Well, without stating the obvious, you will come across it. However, given that it is such a common condition I have noticed an apprehension amongst clinicians to mention endometriosis to their patients. I suspect the perceived concern is about navigating diagnostic difficulties and possibly managing patients’ expectations of having a diagnostic laparoscopy soon after.

I would highly recommend the opposite. Sharing the possibility of endometriosis with the patient at the point at which you suspect, which may even be the first consultation.

It provides a platform for you then to share the difficulties of diagnosis

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

and formulate a personalised plan on how to navigate it. This is so important to keep your patient engaged and to understand the rationale for any future suggestions you make.

Clinical history is your key diagnostic tool NICE guidance states that laparoscopy is the diagnostic tool of choice. However, if 10% of women in the population have endometriosis then is this realistic or reasonable to achieve? My opinion as a GP and GPSI is that it is not easy to get a woman listed for laparoscopy and I work within a community clinic that has access to consultants and integrated pathways with our local Trust.

So, my recommendation is to trust your clinical judgment and use your history taking skills as your key diagnostic tool. It is achievable to have a high index of suspicion from the clinical history alone that you may be dealing with endometriosis. The symptoms can be obvious, such as cyclical pelvic pain, dysmenorrhea, dyspareunia and irregular vaginal bleeding. However, there can be some less obvious symptoms to watch out for too: • Chronic non-cyclical pelvic pain • Period-related or cyclical gastrointestinal symptoms; painful bowel movements, cyclical rectal bleeding • Period-related or cyclical urinary symptoms; dysuria, haematuria • S ymptoms from extrapelvic sites; hemoptysis, epistaxis.

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Before you worry about a laparoscopy – do the basics!

Think about the potential differentials diagnoses you are dealing with and try to rule them out with some basic investigations.

Potential differentials diagnoses:

• PID • O varian cyst • F ibroids • IBS • U TI • Interstitial nephritis • Renal colic.

Recommended primary care tests:

• Pelvic examination with STI screen if indicated • M SU • USS.

In my experience we have had a number of women referred to community clinic with PID and kidney/bladder pathology as suspected endometriosis. Simple things such as taking a sexual history +/- STI screen and urine dip +/- MSU could have detected this cohort.

On a separate note, ultrasound, preferably transvaginal, is recommended to exclude endometriomas or adenomyosis.

However, a normal result does not exclude endometriosis.

To treat or not to treat – that is THE question The only way to navigate this is to have an open and honest conversation with your patient about what the options are. They do not have to be detailed, but more broad principles.

In real terms, I describe what a laparoscopy is, the potential risks of surgery, the possible need for further surgery in the event of recurrence and possible benefits. I also offer the medical options as an alternative, such as COCP, POP, IUS etc. Lastly, I feel it is important to mention that the condition is hard to predict and often trial and error is needed to find out which option may be most effective for your patient.

Obviously, you will also have your own levels of concern. Those patients in whom you feel more comfortable offering medical treatment first, and those in whom you feel surgery should be offered sooner. I group these women as follows: Treat medically

• Patient does not want laparoscopy • Surgically high risk • I f previous laparoscopy not effective

on the effectiveness of the COCP compared with placebo. In contrast, a systematic review by Grandi et al (Jan 20192) stated COCP and POPs are effective and furthermore some COCPs decreased the risk of disease recurrence after surgery.

Again, this highlights the unpredictability of the condition and response to treatment. All the more reason to keep our patients engaged and informed that this may occur.

TRUST YOUR CLINICAL JUDGMENT AND USE YOUR HISTORY TAKING SKILLS AS YOUR KEY DIAGNOSTIC TOOL

Treat surgically

• Severe, persistent or recurrent symptoms of endometriosis • Initial management is not effective, not tolerated or is contraindicated • Suspected or confirmed deep endometriosis involving the bowel, bladder or ureter (USS or MRI) • Infertility If you start with medical treatment first, what should you use?

It is reasonable to offer simple analgesia, combined hormonal contraception or desogestrel at the first visit. Unfortunately there is conflicting evidence to support this.

A Cochrane review by Brown et al (20181) concluded there is insufficient evidence to make a judgement

L is for Laparoscopy The most useful point to highlight in any conversation about laparoscopy is that it is not curative. What I mean by that is to outline realistic potential benefits from surgery.

This is summarised clearly in a national cohort study published in BJOG (2017 3) which looked into the impact of endometriosis and the risk of further surgery.

• 62% of women with endometriosis had further surgery • Median time of less than 2 years to a second surgical procedure • Half of all women with endometriosis had undergone repeat surgery within 5.5 years • 1 in 5 women had hysterectomy or removal of one or both ovaries.

SURGERY FREE INTERVAL

2 YEARS

5 YEARS

7 YEARS

Local excision

79.4%

53.3%

44.6%

Hysterectomy with ovarian preservation

95.7%

86.6%

77.0%

Hysterectomy without ovarian preservation

96.0%

91.7%

91.7%

WORDS BY DR AAMENA SALAR

Beware! A total hysterectomy is not curative This was published by Shakiba et al Obstet Gynecol (2008 4) and looked at the 7-year follow-up on the requirement for further surgery.

91.7% of women were surgery free following a total hysterectomy.

I always use this summary in teaching sessions to remind myself and others how difficult this condition is to treat.

Her Life Her Health | Winter 2021 | 23

FERTILE YEARS

ENDOMETRIOSIS AUDIT CLINICAL STANDARDS TO AUDIT NICE guidelines on endometriosis support making an early ‘provisional diagnosis’ and starting hormonal treatment in primary care. On review (ideally 6 months after treatment has started) those not responding to treatment should be referred on to a gynaecologist.

Endometriosis: diagnosis and management NICE guideline [NG73] 2017 (Standards 1 & 2) includes the following recommendations against which your practice could be audited to encourage diagnosis and early treatment.

THIS AUDIT RELIES ON A WORKING DIAGNOSIS BEING MADE. • If you suspect the patient of having symptoms of endometriosis, on how many women have you carried out an abdominal, and (if appropriate), pelvic examination?

• Proportionally, how many women have you seen with symptoms or signs suggesting endometriosis for whom a pelvic examination would not be appropriate, who then have an abdominal examination? (For example LD, not sexually active.)

• How many working diagnoses of endometriosis have been made, following initial presentation?

• If initial hormonal treatment for endometriosis is not effective, not tolerated or contraindicated, what proportion of women have been referred to a gynaecology service?

• Proportionally, how many women with a working diagnosis of endometriosis have you assessed at 6 months (or sooner) after starting hormonal treatment?

Trying to conceive is a game changer If you determine that your patient is trying to conceive or has had difficulty conceiving, then accordingly she would benefit from an early referral for laparoscopy.

This is a summary of NICE guidance 5:

• excision or ablation of endometriosis plus adhesiolysis for endometriosis (not involving the bowel, bladder or ureter) improves the chance of spontaneous pregnancy.

• laparoscopic ovarian cystectomy with excision of the cyst wall to women with endometriomas improves the chance of spontaneous pregnancy and reduces recurrence.

• Keep calm – it’s a chronic condition!

Endometriosis is a common condition much like many others we manage in primary care and let’s face it – we are The Masters of managing chronic conditions.

Just like other common chronic conditions this may require an MDT approach and there are resources available to support you and your patient.

Support for you – Endometriosis centre (tertiary centre) Find out where your local endometriosis centre is, what they offer, and referral criteria. This service includes: • g ynaecologists with advanced laparoscopic surgical skills • colorectal surgeon with an interest in endometriosis • u rologist with an interest in endometriosis • endometriosis specialist nurse • pain management service with expertise in pelvic pain • advanced diagnostic facilities • fertility services.

Support for your patients Signpost your patients to endometriosis-uk.org, which offers online resource and support to women with endometriosis.

I hope I have given you some broad principles and confidence in navigating the complexities of diagnosing and managing endometriosis in primary care.

REFERENCES 1. www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001019.pub3/abstract 2. www.researchgate.net/publication/330528405_Hormonal_contraception_in_women_with_ endometriosis_a_systematic_review 3. https://pubmed.ncbi.nlm.nih.gov/28952173/ 4. https://journals.lww.com/greenjournal/Pages/articleviewer 5. https://cks.nice.org.uk/topics/endometriosis/ management/management-of-endometriosis/ aspx?year=2008&issue=06000&article =00007&type=Fulltext

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

ESTRIOL 50 micrograms/g VAGINAL GEL

A drop of bliss

Sometimes a topical discussion is difficult to start

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

References 1. Blissel SmPC, April 2019 2. Cano et al. 2012 3. NICE CKS Guidelines. Menopause. March 2017 BLISSEL® (ESTRIOL 50 micrograms/1g) VAGINAL GEL PRESCRIBING INFORMATION: Please refer to Summary of Product Characteristics (SmPC) before prescribing. ACTIVE INGREDIENT: 1g vaginal gel contains 50 micrograms estriol.

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

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

Intravaginal applicator may cause minor local trauma, especially in women with serious vaginal atrophy. Discontinue immediately if a contraindication is discovered and in cases of jaundice or deterioration in liver function,significant increase in blood pressure, new onset

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

NHS List Price

Pack Size

Marketing Authorisation Number

Blissel

£ 18.90

30g

PL 20663/0003

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

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to Flynn Pharma Ltd. Medical Information: Tel 01438 727822, E-mail medinfo@flynnpharma.com.

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

DATE OF REVISION OF PRESCRIBING INFORMATION: May 2019.

Blissel® is a registered trademark of Italfarmaco S. A., San Rafael 3, 28108 Alcobendas (Madrid), Spain.

RENAISSANCE YEARS

Libido & the menopause THE CAUSES OF LOW SEX DRIVE MAY BE MULTIPLE AND INTERLINKED FOR MANY WOMEN

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

What to do

This consultation can be challenging in primary care where time is pressured.

The causes of low sex drive may be multiple and interlinked for many women, but unpicking the root cause can help target the most appropriate management option.

Always actively manage physical symptoms.

Loss of libido is a common occurrence in perimenopausal and postmenopausal women. What can you do to support your patients?

R

eduction in sex drive, or loss of libido, is very common for women as they transition through the menopause and beyond.

Surveys report 50% and higher of peri and postmenopausal women experience reduced sex drive1. Low sex drive causes distress for many women but less than 1/3 seek help2 .

When considering exactly what a low sex drive is, it is difficult to quantify. What is thought ‘normal’ varies from person to person, each having their own standards and expectations. What therefore becomes important is change and the degree to which this causes distress.

In practice we take a pragmatic approach to our assessment, but there is a recognised condition called female hypoactive sexual desire disorder (HSDD) – a deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty.

1.

Talking about it is a good first step. Encourage her to talk to her partner about how she is feeling. Couples therapy may be needed if there are issues within the relationship. Relate can be a helpful resource.

Other places to find counsellors – British Association for Counselling and Psychotherapy and the College of Sexual and Relationship Therapists.

2.

Non-hormonal vaginal lubricants and moisturisers used during sex can improve dryness and dyspareunia, therefore improving the pleasure of sex and sexual desire6.

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

3.

DEFINITION The World Health Organization defines sex drive as ‘…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity 3 .’

Libido can be split into desire, arousal, orgasm and resolution.

Desire incorporates sex drive. Arousal refers to the physical responses of sexual readiness involving increased blood flow to the genitals, increased moisture to the vaginal mucosa and systemic response also. Orgasm, then resolution when the muscles relax, blood pressure drops and the body slows down from its aroused state.

HRT can improve menopause symptoms including psychological ones, which may have been identified as an important factor. Systemic oestrogen replacement can improve sexual desire and libido and may help vaginal symptoms, though many women will also need a vaginal, topical oestrogen.

4.

Topical vaginal estrogen replacement can improve dyspareunia secondary to vaginal atrophy, through its proliferative affect on the vulval and vaginal epithelium.

Can also help arousal.

RENAISSANCE YEARS

CAUSES Desire can decrease with age for some, but not all – men and women alike. Hormonal changes related to the menopause, however, can have a significant impact; psychological and physical changes having a negative impact as women transition through the menopause. Falling oestrogen levels can contribute to and cause low mood and anxiety4 .

Physical symptoms of the menopause can undermine sex drive. If sex is less pleasurable, desire decreases. Hot flushes and night sweats can result in negative body image. Poor sleep has many knock-on effects including low mood, fatigue and increased stress. Vulvovaginal atrophy can result in uncomfortable and painful intercourse. Vaginal dryness is an important factor. Vaginal and vulval tissue becomes more delicate and more prone to microabrasions and tears. Loss of elasticity can lead to pain and even lack of ability to have penetrative sex. Blood flow to the genital organs can decrease

5.

Systemic testosterone has been shown to result in significant improvement in sexual function, including sexual desire, and orgasm7. Testosterone therapy is not licensed for women in the UK, but was recommended

by NICE for menopausal women with low sexual

and the experience of orgasm can be diminished. Low self-esteem can result from physical changes of the body as age increases, decreasing how attractive and desirable women feel.

Age-related decrease in testosterone may reduce desire in midlife women, as this hormone plays a role in women’s sex drive, arousal and orgasm. The precise role of testosterone in desire is complex and does not seem to be important for all women. Women who undergo oopohorectomy have a sudden drop in testosterone. Some (but not all) may experience a more significant decline in libido than women who have a natural menopause5.

Environmental and social stresses, directly and indirectly related to the menopause, can be significant factors.

Women can feel stressed and worn out as they juggle multiple work and family related factors. They may experience fatigue. There may be relationship issues, particularly if partners are perceived as being unsupportive or lacking understanding.

desire if HRT alone is not effective8. It can therefore be prescribed off license where appropriate9. The British Menopause Society has published clear, practical prescribing advice10.

It may be an important addition for women who have undergone oophorectomy.

6.

Some find using a vibrator can help arousal.

7.

Physiotherapy can help pain during intercourse if related to muscle tension.

Pelvic floor exercises can improve pleasure experienced during sex.

LOW SEX DRIVE CAUSES DISTRESS FOR MANY WOMEN BUT LESS THAN 1/3 SEEK HELP

WORDS BY DR CLARE SPENCER

In summary, libido is complex, with physical, psychological and social factors interlinking.

Women should be encouraged to talk about it and seek help. HRT can play an important part, but further time is often needed to help work through different contributing factors and input from psychological therapies may also be important.

REFERENCES 1. Nappi RE, Nijland EA. Women's perception of sexuality around the menopause: outcomes of a European telephone survey. Eur J Obstet Gynecol Reprod Biol. 2008 Mar;137(1):10-6. doi: 10.1016/j. ejogrb.2006.10.036. Epub 2007 Jan 4. PMID: 17207567; Cumming GP, Currie HD, Moncur R, Lee AJ. Web-based survey on the effect of menopause on women's libido in a computer-literate population.

Menopause Int. 2009 Mar;15(1):8-12. doi: 10.1258/mi.2009.009001.

PMID: 19237616 2. Cumming GP, Currie HD, Moncur R, Lee AJ. Web-based survey on the effect of menopause on women's libido in a computer-literate population. Menopause Int. 2009 Mar;15(1):8-12. doi: 10.1258/mi.2009.009001. PMID: 19237616 3. (WHO, 2006) https://www.who.int/health-topics/sexual-health#tab=tab_2.

Accessed Nov 2020. 4. Effect of estrogen-serotonin interactions on mood and cognition. Amin Z, Canli T, Epperson CN Behav Cogn Neurosci Rev. 2005 Mar; 4(1):43-58 5. Sarrel PM, Hormone replacement therapy in young women with surgical primary ovarian insufficiency. Fertil Steril. 2016;106(7):1580–1587. doi:10.1016/] 6. Association of lubricant use with women's sexual pleasure, sexual satisfaction, and genital symptoms: a prospective daily diary study. Herbenick D, Reece M, Hensel D, Sanders S, Jozkowski K, Fortenberry JD. J Sex Med. 2011 Jan; 8(1):202-12 7. Panay N, Al-Azzawi F, Bouchard C, et al. Testosterone treatment of HSDD in naturally menopausal women: the ADORE study. Climacteric 2010; 13: 121–131.

8. Menopause:diagnosis and management. 2015 NG23. Accessed Nov 2020 9. GMC: Good practice in prescribing and managing medicines and devices (2013). https://www.gmc-uk.org/ethicalguidance/ethical-guidance-for-doctors/prescribing-and-managingmedicines-and-devices/prescribing-unlicensed-medicines.

10. https://thebms.org.uk/publications/tools-for-clinicians/ testosterone-replacement-in-menopause/ 11. Finley N. Lifestyle Choices Can Augment Female Sexual Well-Being. Am J Lifestyle Med. 2017;12(1):38-41. Published 2017 Nov 9. doi:10.1177/1559827617740823

8.

Psychosexual therapy is aimed at helping people who have difficulties in their sexual relations, whether from a physical, emotional or psychological source, or a combination of these.

Referrals can be made on the NHS.

9.

Yoga and other relaxation techniques may help some.

Exercise improves mood and sense of wellbeing, can transiently increase serum levels of natural testosterone, and has been shown to have a positive impact on sexual desire11.

Her Life Her Health | Winter 2021 | 27

WIDE AWAKE AT

NIGHT?

Isolation and loneliness can affect our quality of sleep1

• • •

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

Circadin® 2mg (prolonged-release melatonin) Tablets Prescribing Information: Please refer to the Summary of Product Characteristics before prescribing. Presentation: Circadin 2mg prolonged-release tablets containing 2mg melatonin.

Indication: Monotherapy for the short-term treatment of primary insomnia characterised by poor quality sleep in patients aged 55 or over. Dosage and administration: 2mg orally once daily, 1-2 hours before bedtime and after food. Swallow whole, do not crush or chew. This dosage may be continued for up to thirteen weeks. Children and adolescents (<18 years): Safety and efficacy not yet established. Contraindications: Hypersensitivity to the active substance or to any excipients. Special warnings and precautions for use: Use caution when administered to patients with renal insufficiency. Not recommended for use in patients with hepatic impairment. Circadin may cause drowsiness, therefore use with caution if the effects of drowsiness are likely to be associated with a risk to safety. Not recommended in patients with autoimmune diseases. Patients with rare hereditary problems of galactose intolerance, the LAPP lactase deficiency or glucose-galactose malabsorption should not take this medicine. Fertility, pregnancy and lactation: Circadin use in pregnancy and in women intending to become pregnant is not recommended and breast-feeding is not recommended in women receiving melatonin. Driving: Circadin has moderate influence on the ability to drive and use machines. Interactions: Fluvoxamine should be avoided. Caution should be used in patients on 5- or 8-methoxypsoralen (5- and 8-MOP), cimetidine and oestrogens.

Cigarette smoking may decrease melatonin levels. CYP1A2 inhibitors such as quinolones may give rise to increased melatonin exposure. CYP1A2 inducers such as carbamazepine and rifampicin may give rise to reduced melatonin exposure. Alcohol should not be taken with Circadin. Sedative properties of benzodiazepines and non-benzodiazepine hypnotics may be enhanced. Undesirable effects: In clinical trials the rate of patients with adverse events per References 1. Simon, E.B. and Walker, M.P. (2018) Nature Communications 9; 3146.

2. Circadin SmPC August 2019.

100 patient weeks was higher for Placebo than Circadin (5.743 placebo vs. 3.013 Circadin).

There are no very common (≥1/10) or common (≥1/100 to <1/10) adverse reactions.

Uncommon (≥1/1,000 to <1/100) adverse reactions include hypertension, chest pain, migraine, headache, irritability, abnormal dreams, nightmares, dermatitis, menopausal symptoms, abdominal pain, abnormal liver function test and asthenia. Rare (≥1/10,000 to <1/1,000) adverse reactions include loss of consciousness, angina, palpitations, depression, visual impairment, disorientation, vertigo, haematuria, leukopenia, thrombocytopenia and abnormal laboratory test. Prescribers should consult the full Summary of Product Characteristics for further information on adverse reactions. Legal category: POM. Packs and Prices: Circadin 2mg, 30 tablets, £15.39. Marketing Authorisation number: EU/1/07/392/003. Marketing Authorisation holder: RAD Neurim Pharmaceuticals EEC SARL, 4 rue de Marivaux, 75002 Paris, France. Further information available from: Flynn Pharma Ltd. Hertlands House, Primett Road, Stevenage, Hertfordshire, SG1 3EE. Date of last revision of PI: March, 2019.

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 April 2020

UK/CIR/2020/966

RISING STARS

of primary BRCA-related cancer, the gender and the age at diagnosis, with only one unaffected female relative between generations allowed in the equation. The scores are totalled and if greater than or equal to 15, a referral can be made 4 . By having rigid but scientifically based criteria, it limits the testing to those at highest risk of having the mutation, making the service financially sustainable and effective.

It also means that the system is not flooded with tests increasing waiting times for testing and results, which could increase the anxiety for families2.

To test or not to test The TARGET OVARIAN CANCER ESSAY PRIZE winner explores the impact of BRCA mutation awareness in high risk women, ovarian cancer patients and their families.

I WORDS BY JESSICA DOWLE

OVARIAN CANCER IS SOMETIMES KNOWN AS THE ‘SILENT KILLER’ AS IT OFTEN PRESENTS LATE, WITH ONLY 30% BEING DETECTED IN THE EARLY STAGES

n the UK, ovarian cancer has an incidence of around 7500 per year and is the 6th most common cancer in women1.

Globally, it accounts for 4% of cancer deaths and has the worst prognosis of all the gynaecological cancers; with a 5-year survival rate of around 35%.

As with all cancers, the earlier it is detected, the higher the survival rate.

Ovarian cancer is sometimes known as the ‘silent killer’ as it often presents late, with only 30% being detected in the early stages. Therefore, it is essential to identify those most at risk of developing the cancer in the hope of aiding an earlier diagnosis, prevention, and treatment.

The BRCA Gene In the general population, the lifetime risk of developing ovarian cancer is around 1.3%, however inheriting a BRCA (breast ovarian cancer gene) mutation increases this risk to 44% for a BRCA 1 mutation and 17% for those who inherit a BRCA2 mutation.

Around 15% of people diagnosed with ovarian cancer may have inherited the mutation 2 . BRCA genes help to repair damaged DNA and produce tumour suppressor proteins, resulting in the stabilisation of the genetic material during the cell cycle, preventing cells from growing and dividing in a rapid and uncontrolled way. Mutations in the gene produce a version of the

BRCA protein that is too short or unable to be replicated. This leads to less of this protein being readily available to repair damaged DNA; an accumulation of these defects leads to uncontrolled cell mitosis and tumour growth. BRCA mutations are inherited in an autosomally dominant fashion, meaning if 1 parent has the mutation there is a 50% chance of inheriting the gene 3 .

Testing Testing for the mutation varies regionally and internationally. Those in countries with less developed healthcare and resources, including financial barriers in private healthcare systems, may not be able to access testing or prophylactic treatments.

In England, genetic testing for BRCA mutations is available on the NHS should the patient meet the criteria of having at least a combined BRCA mutation of 10% pre-test carrier probability. So long as this is above 10%, a person regardless of whether they have a personal history of cancer, or an available affected relative, may obtain a test. Those who are eligible are referred to a specialist genetic clinic where they are counselled and potentially tested.

The probability is calculated using personal and family history against the Manchester score. As seen in Figure 1, the Score assigns a number to each affected relative based on the type

Treatment In England, should a woman be diagnosed with the mutation there are various interventions to reduce their risk. This includes: More frequent monitoring with earlier, and more intensive screening, along with preventative medications and surgeries.

Additionally, the treatment options for cancer arising from the gene may be different than those who do not have it. Currently, the risk-reduction treatments for ovarian cancer consist of a prophylactic bi-lateral salpingooophorectomy and oral contraceptives.

There is currently no screening as it is controversial as to whether it is effective, however recommendations using CA125 and regular ultrasounds have been discussed5. Additionally, there is increased screening and surgical options to protect against breast cancer6.

Public awareness The BRCA gene is known in the general population for its association with breast cancer, but possibly less so for its role in the development of ovarian cancer. It was brought to the spotlight in 2013, when Angelina Jolie had a preventative mastectomy and a further salpingo-oopherectomy to prevent against breast and ovarian cancer after she discovered that she had the mutation after a significant family history of both cancers.

However, there was less attention when she had a prophylactic salpingooopherectomy two years later to prevent against ovarian cancer.

Her Life Her Health | Winter 2021 | 29

RISING STARS

THE POSITIVE AND NEGATIVE IMPACTS OF OBTAINING A BRCA TEST MUST BE WEIGHED UP BY THE INDIVIDUAL GETTING TESTED

Publishing her story had an impact on women worldwide, with the resulting awareness of the mutation creating a sustained increase in testing, as well as cancer referrals in general. A systematic review into the impact of the ‘Angelina Jolie effect’ found that the increase in BRCA tests was up by 80% and referrals by up to 285%, but that there was no significant increase in preventative measures. This could have been due to negative BRCA tests and an informed decision that the risk of developing the cancer did not outweigh the risk of a significant and life-altering surgery. They also noted that a lot of the patients from lower levels of education asking for more information about the disease. If they are part of the referral numbers then that may explain why there was a lack of protective measure uptake.

This high-profile awareness campaign shows the power of celebrity influence on BRCA gene mutation awareness and the population’s attitude and behaviours towards screening and further treatment.

Moreover, it is reassuring that there was not a large increase in those undergoing pre-emptive surgeries and shows that despite celebrities and the media raising awareness, it is not pushing certain treatments and negatively affecting the autonomy of individual patients. Nevertheless, despite the importance of this awareness, it is only beneficial if the information portrayed to the public is accurate and valid as false information can be equally as potent; this highlights the necessity for liaison between the media and awareness organisations to ensure a level of scientific rigidity is maintained and updated resources promoted7.

Positive impacts of testing: Knowledge is power

For women who wish to receive a BRCA mutation test, there are numerous factors to weigh up. For high risk women, receiving a positive result could empower them to make prophylactic choices long before an actual diagnosis. If they underwent a salpingo-oopherectomy, there would be relief that they would not

suffer as their relatives did, which they may have witnessed. This empowerment would come with a deeper knowledge of the cancer and how it presents, meaning they are more likely to present earlier than an unaware but predisposed woman who is likely to present later with more advanced symptoms and a worse prognosis. This knowledge would also help clinicians identify ovarian cancer as a differential diagnosis to rule out earlier before it became more advanced, particularly as vague ovarian cancer symptoms such as abdominal bloating have a large list of potential causes. There would be less dismissal of the symptoms as benign as the clinician would understand the patient’s worry 8.

This early identification would lead to more treatment options, with reduced morbidity and mortality.

If they are nulliparous, it enables them to make an informed choice when planning for a family due to the potential of passing on the mutation; although that could be a source of a lot of stress and potential guilt for knowingly passing it on. Additionally, an awareness of being a BRCA carrier makes it more likely that the patient will adhere to regular screening and monitoring, and potentially adhere to a healthy lifestyle to prevent additional factors contributing to development of cancer 9.

Furthermore, for those diagnosed with ovarian cancer, a positive result can mean a better prognosis, with more treatment options available; hopefully resulting in fewer side effects caused by systemic chemotherapies.

Studies have shown that patients with a BRCA mutation are more responsive to targeted therapies, as well as it being an identified target for future therapy development. For an ovarian cancer patient, a positive test result could signal a poignant time to test their family, particularly children, so they could prevent it happening to them, whilst a negative test would provide reassurance that their lifetime risk is as low as rest of the general population.

As a BRCA carrier, they can also be susceptible to developing breast

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

cancer, so should their ovarian cancer go into remission, they would then be able to protect against developing further primary tumours such as breast or at least have more intensive screening6.

Negative impacts of testing: Ignorance is a blessing

The awareness of a ‘mutation present’ result can also have profound negative impacts. The positive result could cause permanent anxiety for the woman, in particular those who are young and have watched family members’ experiences; knowing that they could end up going through the same is extremely difficult, scary and stressful. Additionally, the preventative measures are permanent and life-altering decisions that come with undergoing major surgeries that themselves have risks. For younger BRCA carriers, they have to weigh up whether to undergo a salpingooopherectomy, that brings on an early menopause to prevent the cancer, as well as a potential mastectomy; they may suffer from low self-esteem, and a loss of identity and femininity 10.

Furthermore, should they not choose a more permanent route of prophylaxis, the alternative of regular transvaginal ultrasounds and examinations, which are intimate and invasive, will keep the risk of cancer at the fore and potentially exacerbate any mental health impacts.

Chemoprophylaxis in the form of the oral contraceptive pill is an option, if not contraindicated, however it is another form balanced risk with the potential for side effects, such as thromboembolism, weighed against the potential development of cancer. For those who decide against preventative measures, they could become overly worried at a vague, non-concerning symptom due to anxiety that it will develop. Additionally, those who receive a negative result may be overly reassured and believe their risk is low to the point that they ignore symptoms and present at an advanced stage.

Moreover, those receiving a ‘variant of unknown significance’ result face a certain limbo. There is relief that the BRCA mutation is not there, but they are faced with an unknown quantity of risk, with no further family members eligible to be tested.

RISING STARS

For ovarian cancer patients also, there is guilt and worry they may have passed the mutation down to their children, possibly straining the family dynamics. Financially, it could affect future health and life insurance applications, although there is a ban on asking people for the results of the genetic predictive test, there is no guarantee that this won’t be overturned in the future. This creates financial implications for a population which, arguably, needs it most6.

Interrelationship impacts The positive and negative impacts of obtaining a BRCA test must be weighed up by the individual getting tested, balancing the effect of a positive result not only on themselves but on the whole family.

People have different mindsets regarding their health status. Some would want to know to prevent it and would prefer the uncertainty to be quelled. Others would rather not know about their risk and only want to be told should they develop the cancer. By one family member being tested, there is a loss of autonomy to other family members who would rather not know if they are a carrier. This could lead to strained familial relationships, changed relationships and reduced communication resulting in increased tension; causing further stress to a sensitive situation10.

Especially, if the relative has had previous cancer and does not want to undergo the test, when they are the best person to donate a sample. This establishes the necessity for genetic counselling, given before and at every testing appointment with a gap of 4 weeks, allowing the individual to understand, reflect and discuss the impacts of whatever result they received and ensuring they can make a balanced decision not only for themselves but for their families too, before they get tested. On the other hand, it may be reassuring for the family to know why there are many cases of cancer in the family and relief that there are ways to prevent it happening to other relatives.

Summary Overall, ovarian cancer is a significant gynaecological cancer impacting thousands annually. Scientific advances have identified inheritable mutations in the BRCA1 and BRCA2 genes as a cause of increased risk of developing ovarian cancer; they are also now able to test for it, provided on the NHS in England, and take prophylactic measures to prevent it. Awareness has greatly increased internationally due to celebrities speaking up about their experiences. For those women, they must make a judgement call. They must weigh up the positive and negative effects of knowing if they, or a family member, is a carrier of the mutation and decide whether the test is worth potential permanent anxiety and interfamilial tensions, or to remain with the uncertainty. To test or not to test? Ultimately, there is no universal answer as it is down to patient choice. For healthcare staff, it is essential to ensure this by providing enough information and counselling to empower the patient and their families to make an informed choice. ► Go to www.targetovariancancer.org.uk

Figure 1: THE MANCHESTER SCORE USED TO CALCULATE THE PRE-TEST PROBABILITY OF A BRCA MUTATION

NB: One unaffected intervening allowed.

Further unaffected allowed if had risk reducing surgery <50 years.

CANCER

AGE AT DIAGNOSIS

SCORE

Breast Cancer

<30

11

Breast Cancer

30-39

8

Breast Cancer

40-49

6

Breast Cancer

50-59

4

Breast Cancer

>59

2

Breast Cancer

<60

13

Breast Cancer

>59

10

Ovarian Cancer

<60

13

Ovarian Cancer

>59

10

Pancreatic Cancer

1

Prostate Cancer

<60

2

Prostate Cancer

>59

1

REFERENCES 1. About ovarian cancer | Cancer Research UK [Internet]. [cited 2020 Jun 27]. Available from: https://www.cancerresearchuk.org/about-cancer/ovariancancer/what-is-ovarian-cancer 2. Specialised Commissioning Team, NHS England. Clinical Commissioning Policy: Genetic Testing for BRCA1 and BRCA2 Mutations [Internet]. NHS England; 2015 [cited 2020 Jun 27]. Available from: https://www.england.nhs.uk/commissioning/wp-content/uploads/ sites/12/2015/10/e01pb-brca-ovarian-cancer-oct15.pdf 3. BRCA Mutations: Cancer Risk and Genetic Testing Fact Sheet - National Cancer Institute [Internet]. 2018 [cited 2020 Jun 27]. Available from: https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet 4. Guys Hospital Trust. GUY’S REGIONAL GENETICS: HEREDITARY BREAST AND OVARIAN CANCER REFERRAL FORM. 2019;2. Available from https:// www.guysandstthomas.nhs.uk/resources/our-services/grida/genetics/breast-and-ovarian-cancer-genetics-referral-form.pdf 5. Justin C Chura.

Ovarian Cancer | BMJ Best Practice [Internet]. BMJ Best Practice; 2017 [cited 2020 Jun 27]. Available from: https://bestpractice.bmj.com/topics/engb/260/pdf/260/Ovarian%20cancer.pdf 6. Target Ovarian Cancer. Genetic testing and hereditary ovarian cancer | A guide for women with ovarian cancer and their families. 2016;25. Available from: https://www.targetovariancancer.org.uk/sites/default/files/TOC-Hereditary-Guide.pdf 7. Troiano G, Nante N, Cozzolino M. The Angelina Jolie effect – Impact on breast and ovarian cancer prevention A systematic review of effects after the public announcement in May 2013. Health Educ J. 2017 Oct 1;76(6):707–15. 8. Hamilton W. Cancer diagnosis in primary care. Br J Gen Pract. 2010 Feb 1;60(571):121–8.Available from: http://bjgp.org/lookup/doi/10.3399/bjgp10X483175 9. Dorval M, Bouchard K, Maunsell E, Plante M, Chiquette J, Camden S, et al. Health behaviors and psychological distress in women initiating BRCA1/2 genetic testing: comparison with control population. J Genet Couns. 2008 Aug;17(4):314–26 10. Van Oostrom I, Meijers-Heijboer H, Lodder LN, Duivenvoorden HJ, van Gool AR, Seynaeve C, et al. Long-term psychological impact of carrying a BRCA1/2 mutation and prophylactic surgery: a 5-year follow-up study. J Clin Oncol Off J Am Soc Clin Oncol. 2003 Oct 15;21(20):3867–74

Her Life Her Health | Winter 2021 | 31

GOLDEN YEARS

MC IS SOMETHING THAT COULD HAVE A HUGE IMPACT AND WE COULD MANAGE IT SO MUCH BETTER WITH THE RESOURCES THAT WE ALREADY HAVE

INTERVIEW BY DR ANDREW JENKINS

H

aving initially trained and practised in London, Nasreen (Naz) Ahmed has been working as a GP in a 23,000 patient practice in Birmingham for the last 3 and a half years. In common with many GPs she sees a number of patients who present with chronic watery diarrhoea, however, it wasn’t until recently that she had heard of microscopic colitis (MC).

How did you learn about MC? I found out about MC in an odd way.

A good friend, Kevin Barrett (GP and Chair of the Primary Care Society for Gastroenterology), asked me if I was free for ‘A panel about microscopic colitis’. I had no idea what it was, which made me feel a) sheepish, b) I’ve signed up for something that I have never heard of and I am going to sit on a panel and talk about it, and c) it brought up the question of “Should I not have heard about this?”

I consider myself fairly well read but I had never heard of microscopic colitis or seen it in my general practice.

Microscopic colitis A JOBBING GP’S PERSPECTIVE An interview with GP DR NASREEN AHMED on facilitating the diagnosis and management of microscopic colitis in primary care.

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

What were the main things you learnt about MC from the panel?

The presentation that I got from the secondary care clinicians who deal with MC patients is that these patients have significant symptoms which can be debilitating; they have chronic watery diarrhoea, they’ve had to change their lifestyle and manage their condition because we haven’t been able to give them a satisfactory answer. When they can’t manage they slowly make their life smaller, avoiding or missing the things they enjoy. It’s having an impact on their quality of life, and as primary care clinicians we can play a part in identifying it earlier.

Now that you are more aware of MC, what would a potential MC patient look like?

(Also see Table 1 and case study.)

A person who is slightly older, possibly female, in their 50s, who has vague symptoms of increased frequency of stool motion, abdominal discomfort, sometimes waking at night to open their bowels, having to modify their routine and behaviours to manage that increased frequency and urgency of stools, possibly not weight loss, possibly not bleeding. Some of the symptoms that I may be worried about for cancer are not really there, however it may be a slightly longer history of this, but just not quite right.

How do you diagnose a patient with MC? Where I work we have access to faecal calprotectin, an indicator of gut inflammation. Where it’s over 100 my lab suggests this is possible irritable bowel disease (IBD) and further investigation may be required, but under 100, treat as irritable bowel syndrome (IBS). However, for some patients that does not seem to fit quite right; these patients may well have IBS but they may also have other conditions which we haven’t considered, such as MC, particularly as the secondary care nurses said they have a cohort of MC patients where their calprotectin is below 100. It seems a little short-sighted to write

GOLDEN YEARS

Table 1: A COMPARISON OF THE KEY DIFFERENTIATING FACTORS BETWEEN MICROSCOPIC COLITIS & IRRITABLE BOWEL SYNDROME1 MICROSCOPIC COLITIS

IRRITABLE BOWEL SYNDROME

First occurrence of disease

Commonly older than 50 years of age

Commonly younger than 50 years of age

Stool consistency

Watery/soft

Soft – variable – hard

Abdominal pain/discomfort

Variable

Obligatory

Nocturnal diarrhoea

Possible

Very rare

Feeling of incomplete bowel evacuation

No

Common

Feeling of fullness/bloating

Rare

Common

Weight loss

Common

Rare

Faecal incontinence

Common

Rare

Accompanying autoimmune disease

Yes

No

that off, as MC patients also have a few symptoms that don’t fit with IBS (see Table 1). I also ask myself if this person needs other investigations. At the moment we don’t have a non-invasive test that says this is MC; currently the patient will need a colposcopy with biopsies to check for microscopic inflammation, as there is no visible inflammation as would be seen in Crohn’s disease/ulcerative colitis.

Once a patient receives a diagnosis of MC how would you then manage and treat them?

The European guidelines for MC were published recently and reference that budesonide is first line for treatment 2 .

This may initially be better managed by secondary care, which deals with this more often. However, if the patient had a diagnosis, was seen and initially treated by secondary care and had a management plan which stated that they can be discharged from secondary care but should they have a flare this is their action plan; this is the GPs remit.

That is a fairly reasonable approach, just like we do with Crohn’s and ulcerative colitis; we could do that for MC. For a lot of conditions, where they

don’t need to be seen by a secondary care clinician if they are well and stable, we don’t want people to go to the hospital if they don’t have to.

What can primary care clinicians do?

In order to identify these patients it is a primary care responsibility, but we need to have that awareness to consider it as a diagnosis in the first place.

General practice is always changing and adapting; we are dealing with more and more complex medical issues, and I find it incredibly frustrating when patients have to go to the GP or even hospital multiple times because we keep asking the same questions and getting the same unsatisfactory answers. MC is something that could have a huge impact and we could manage it so much better with the resources that we already have. We are not reinventing the wheel – we are just looking at it slightly differently and considering a different option.

That might not work for everyone, but if it means that one patient’s life gets dramatically better through an improved use of resources, it’s worth it. ► Read more on the Bowel Interest Group’s website at www.tinyurl.com/y6bmjqgk.

AT THE MOMENT WE DON’T HAVE A NON-INVASIVE TEST THAT SAYS THIS IS MC; CURRENTLY THE PATIENT WILL NEED A COLPOSCOPY WITH BIOPSIES TO CHECK FOR MICROSCOPIC INFLAMMATION

Case study Patient: Female 40s, teacher Symptoms: Frequently relapsing chronic non-bloody watery diarrhoea (10+ stools per day) for 11 years Previous diagnosis: IBS Previous management advice: Medication: Loperamide – little effect, Diet: Reduction in gluten – helped symptoms initially (MC is often accompanied by other autoimmune diseases including coeliac disease1) Reason for re-presentation to GP: Flaring consistently for a year and a half, going to the toilet over 10 times per day, ‘got used to being on the toilet’; Faecal Calprotectin (FC) on presentation: FC=51, prompted referral to secondary care IBD nurse as FC referral threshold had recently been lowered from 100 to 50 due to nurse recognising more MC Diagnosis: Colonoscopy with biopsies taken, MC confirmed Treatment: Short course (8 week) treatment with budesonide, symptoms resolved Further management plan: Patient has had no symptoms since and said that getting a diagnosis had alleviated stress. If symptoms do return a repeat budesonide course has been advised, if symptoms return and persist maintenance treatment can be explored.

REFERENCES 1. Munch A et al. 2019. Undiagnosed microscopic colitis: a hidden cause of chronic diarrhoea and a frequently missed opportunity. Frontline Gastroenterology.

2. Miehlke et al. 2020. European guidelines on microscopic colitis: United European Gastroenterology (UEG) and European Microscopic Colitis Group (EMCG) statements and recommendations

Her Life Her Health | Winter 2021 | 33

PIONEERS IN WOMEN'S HEALTH

Education, education, education DR HEATHER CURRIE has been a leading light in menopause education for many years. Here she shares her vision for the future of menopause care.

Associate Medical Director for Dumfries and Galloway Royal Infirmary, while still being involved clinically in gynaecology. I have been Clinical Lead for Gynaecology for Modernising Patient Pathways Programme for Scotland, and I am now Clinical Advisor for the Scottish Government for the development of the Women's Health Plan for Scotland. My work with Menopause Matters and the British Menopause Society (BMS) is separate to my NHS work.

What do you enjoy most about your work? The variety,

but mostly helping patients to understand their own health and treatments, at the level of my own clinics, then more widely by education; through education for women, but also education for healthcare professionals to achieve the aim that women receive consistent advice. I also enjoy being able to influence teams across the organisation.

THERE ARE CERTAIN POINTS IN A WOMAN'S REPRODUCTIVE AND POSTREPRODUCTIVE LIFE THAT CAN INFLUENCE LATER HEALTH, AND AROUND WHICH THERE ARE OPPORTUNITIES TO EDUCATE AND INFLUENCE

What does Menopause Matters (MM) do to support and educate primary care clinicians?

W

hat is your background in medicine?

I trained to be a GP then switched to obstetrics and gynaecology, where I have worked in Dumfries since 1986. During my studying for MRCOG I realised how important menopause is and subsequently started a hospitalbased specialist menopause clinic in 1993. I also have special interests in colposcopy, sub fertility and PMS. I’ve held various leadership and management roles and am now

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

The website is open to all and I am aware that many clinicians, especially across primary care, access it, and advise their patients to use it. MM therefore supports them directly, but also helps their patients to be better informed so that they can then have a more useful discussion. I am very much involved with the work of the BMS, being trustee and past Chairman, and I’m very actively involved in providing direct education through day meetings (now online) and the newly launched education programme – ‘Principles and Practice of Menopause Care (PPMC)’.

INTERVIEW BY AMY SCHOFIELD

PIONEERS IN WOMEN'S HEALTH

What are the greatest challenges facing those working on the frontline in women’s post reproductive health today?

Having women’s health recognised as a priority. For example, I am aware of some menopause services having their funding withdrawn.

You were instrumental in raising standards of education about menopause delivery at a time when this was not really appreciated – how have things changed? Thank

you so much – I’ve never thought of my work in this way! In recent years there has been a huge increase in awareness of the importance of menopause, not least helped by the NICE Guideline (NG23) published in November 2015, on the diagnosis and management of menopause. It was a monumental menopausal moment! It spawned many websites and support groups for women, and several TV programmes as well as radio coverage. There is much better recognition among healthcare professionals for the need for education, with members of the BMS continuing to increase, and great attendance at meetings, especially now it’s online. However, much work is still needed to implement the BMS Vision for Menopause Care in the UK, which was recently updated.

How can we promote better working across the system for women’s health? While the BMS vision is about

menopause, the principles can apply to other aspects of women’s health, with each primary care team having an identified individual or team with a special interest in women’s health, who can link closely with relevant specialist services for advice and education. Also, promoting the concept of the life course approach would be really helpful. The fact is that there are certain points in a woman’s

reproductive and post-reproductive life that can influence later health, and around which there are opportunities to educate and influence. We need better understanding by girls, women and healthcare professionals about hormonal changes throughout the reproductive and post reproductive years, such as the impact of pregnancy related problems on later heart health, and of menopause on later heart and bone health. Improved education for all in this regard is essential.

What more can primary care clinicians do to support women’s post reproductive health?

Keep up to date, there are loads of resources available, and get to know your local specialist services.

The delivery of healthcare for women has been rapidly transformed because of restrictions imposed by the pandemic – what are your hopes for the future of the delivery of menopause education and post-reproductive healthcare postCOVID-19? Our (BMS’) experience

of delivering online education has been fantastic. It’s been a steep learning curve but really worthwhile.

Hopefully some in-person education events will be possible again in the future, since such a big plus of these events is the networking, learning over coffee etc, but online education is here to stay, from the comfort of your own home, with no travel or accommodation costs! Menopause consultations can often be carried out through telephone and video, and should continue to be offered in this format, with face to face appointments available when an examination or procedure is needed. ► Go to www.menopausematters.co.uk. Read

THERE IS MUCH BETTER RECOGNITION AMONG HEALTHCARE PROFESSIONALS FOR THE NEED FOR EDUCATION

the BMS Vision for Menopause Care in the UK at www.thebms.org.uk/publications/bms-vision

Her Life Her Health | Winter 2021 | 35

PATIENT VOICE

I COULD NOT FIND A CHARITY OR PAGE JUST FOR VULVAL CANCER, SO I STARTED MY OWN, VULVAL CANCER UK AWARENESS

Opportune time The Founder of VULVAL CANCER UK AWARENESS on the importance of training in vulval skin conditions to improve care.

I

was diagnosed with lichen sclerosus (LS) and stage 3 vulval cancer (VC), in May 2016 at the age of 43. Both conditions were a shock to hear, as I had not heard of either, nor had my family or friends.

I had not heard the word vulva before either: I had referred to my vulva as vagina like many others.

Once I started researching LS, I realised I’d had it since I was a small child, but had been misdiagnosed with cystitis. As I got older, I was told it was thrush multiple times. At no time was my vulva examined and no swabs were taken. I had regular smear tests, however nothing was observed by the nurses regarding my vulva, although I had typical signs of LS.

WORDS BY CLARE BAUMHAUER

During my late 30s a swab and blood test were taken. These came back clear and I was told that my symptoms were menopausal vaginal dryness. A few years later I got a tear which did not heal and turned into an ulcer. I was still having regular smear tests but in my case, nothing was noted.

Once it got bigger and more painful for me to sit, I went back to a see a GP. Initially I was told it was herpes and to go to a genitourinary clinic. I looked so shocked that the doctor examined me again and said it could be vulval cancer.

During my first year of surgery and treatment I searched for more information and awareness and I could not find any. I searched for charities and awareness on social media and nothing specific came up.

I felt very alone so I started a private support group on Facebook for those

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

diagnosed in the UK with VC. I could not find a charity or page just for vulval cancer, so I started my own, Vulval Cancer UK Awareness. I’m not a charity, it’s myself and Emma (Norman), who has LS. In my experience, some health professionals have never heard of LS. This means that many people will go to see the doctor and may say that they have burning or itching, which can be typical of thrush. However, there could be visible signs on the vulva that indicate LS. If more primary care clinicians were able to access training in vulval health conditions, these signs could be picked up and managed more in primary care.

The vulva can be so painful, and the burning/itching can be relentless.

Intercourse can be painful. It impacts on a woman’s self-worth, self-confidence and her ability to do everyday things. Many women report that LS impacts their mental health as well as their physical health and relationships.

More training is needed for nurses to recognise the symptoms, including those that carry out cervical screening. GPs can help support with treatment and regular check-ups.

LSVC UK Awareness offers help and support with self-care and reminders to check the vulva regularly. It is important that women know how to check and what to look out for. We also provide advice and tips to help with symptoms. To be able to share in a safe environment with other people that understand goes a long way in terms of emotional and mental support.

Women find LS and vulval cancer especially embarrassing because it’s taboo. Many women say that they would feel more alone and isolated if it wasn’t for the support groups.

PATIENT VOICE

IF PRIMARY CARE CLINICIANS WERE TRAINED IN VULVAL HEALTH CONDITIONS, THESE COULD BE PICKED UP AND MANAGED WITH TREATMENT IN PRIMARY CARE

TIPS FOR HCPS • Clarify terminology when talking to patients – some will use ‘vagina’ when they mean ‘vulva’.

• Refer to the British Association of Dermatology’s treatment guidelines.

• If you haven’t seen many patients with LS and are not sure, refer to a specialist in vulval diseases for biopsy.

Useful resources • E ve Appeal has launched an online training resource on vulval diseases to help train HCPs in primary care so that nurses are aware of vulval conditions. Enhanced training is also available to GPs. • Clinicians such as Victoria Howell are available to provide education on LS & VC (Also see HLHH Autumn).

• Patient resources are available from the British Association of Dermatologists.

• O ur website has a variety of resources to download and print such as posters, leaflets and link to support groups for patients. ► Go to www.lsvcukawareness.weebly.com,

www.victoriahowellhealth and wellbeing.co.uk, www.BAD.org.uk. Twitter and Instagram #KnowYourVulva

THE FACTS Vulval cancer is a rare cancer – there are 1300 cases of VC a year and 442 deaths.

On average each year more than 40 out of 100 (over 40%) of new cases are in women aged 75 and over.

LS SYMPTOMS LS causes patches on the skin that are usually: • itchy • white • smooth or crinkled • easily damaged – they may bleed or hurt if rubbed or scratched.

The patches can appear anywhere, but are most often on the: • area around the opening of the vagina (vulva) and anus.

• Patients diagnosed with vulval cancer should be referred to the relevant specialists to help with all the side effects, such as early menopause, lymphoedema, sexual health therapy, counselling.

• Patients should be aware of which emollients to use and how to use them, as well as other advice such as lubricants, wearing cotton underwear, no perfumed products. Some may need topical oestrogen to help.

• Use every opportunity to talk about vulval health and examine vulval skin for example at coil fitting appointments, pill checks, postnatal, and women’s health checks.

Her Life Her Health | Winter 2021 | 37

CHARITY FOCUS

Right care, right time

E

ndometriosis UK is the UK’s leading charity supporting people affected by endometriosis. We raise awareness, support research, and provide support services for those with endometriosis including a helpline, online forum and UK Support Groups.

In October 2020, the All-PartyParliamentary-Group (APPG) on Endometriosis launched its report on endometriosis care in the UK. It highlighted the devastating impact that endometriosis can have on all aspects of a person’s life, including their physical and mental health, education, career, and relationships.

In order to support those with endometriosis, the APPG has called on all Governments in the UK to commit to a series of support measures for those with the condition.

These measures would help reduce diagnosis time and ensure access to a minimum level of treatment and support for all those with endometriosis – saving on GP, hospital and A&E visits, and in turn, enabling those with the disease to manage their condition more effectively.

As well as vital support from healthcare practitioners, we recognise that there are also many other challenges in getting patients to present with symptoms of endometriosis and access to prompt diagnosis. The embarrassment, shame and stigma that has long been associated with menstrual health conditions is still very much embedded within our society, and

there is work to be done to raise awareness of endometriosis and ensure that everyone recognises the signs and symptoms and that they are not embarrassed to seek help. A recent survey by Endometriosis UK found that 64% of women between the ages of 16-24 had never heard of endometriosis, and education is pivotal in turning this around.

Menstrual wellbeing was included in the school curriculum in England from September 2020, and we hope that will go a huge way in reducing the taboos associated with menstrual health and that young people will themselves recognise the signs and symptoms of menstrual health conditions and know when and how to seek help.

There are also additional complexities and barriers that those from black, Asian and minority ethnic communities may face in talking about menstrual health and accessing support. More must be done to understand the inequalities and barriers faced by those with endometriosis from black, Asian and minority ethnic communities and to ensure that everyone has access to the right support at the right time.

For those who don’t identify as female, endometriosis can also be especially complex. For example, those who do not identify as female may find it distressing to attend appointments in a women’s hospital or dedicated women’s unit, and may need to be seen in another clinic or setting. People’s individual needs should always be addressed to prevent barriers in accessing healthcare.

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

PRIMARY CARE PRACTITIONERS ARE THE GATEWAY IN ENSURING THOSE WITH SUSPECTED OR CONFIRMED ENDOMETRIOSIS HAVE ACCESS TO THE RIGHT SPECIALIST TREATMENT

CHARITY FOCUS

APPG inquiry shows no improvement in diagnosis times in a decade – ENDOMETRIOSIS UK says it’s time for change

MORE MUST BE DONE TO UNDERSTAND THE INEQUALITIES AND BARRIERS FACED

BY THOSE WITH ENDOMETRIOSIS FROM BLACK, ASIAN AND MINORITY ETHNIC COMMUNITIES

WORDS BY FAYE FARTHING

As well as the need for societal education, there needs to be greater education amongst the medical community. Endometriosis UK is delighted to be working with the Royal College of General Practitioners (RCGP) to develop a menstrual wellbeing toolkit and e-learning for GPs, to ensure recognition of the symptoms of endometriosis and other menstrual conditions by all GPs. Rapid diagnosis and good support start in primary care; recognising the signs and symptoms of endometriosis, and believing and listening to patients. Primary care practitioners are the gateway in ensuring those with suspected or confirmed endometriosis have access to the right specialist treatment.

Getting access to the right treatments and support, at the right time and in the right place with access to skilled and experienced healthcare practitioners, gives the best chance for endometriosis to be managed effectively. During the APPG Inquiries, we heard from women about being dismissed and having to repeatedly attend GP appointments before being signposted to secondary care. In contrast, we also heard from women whose rapid diagnosis has meant they have been able to manage their condition more effectively, having had prompt access to treatment and support.

A key practice that would enable rapid diagnosis and prompt access to support is by healthcare practitioners following the NICE Guideline [NG73] on Endometriosis:

diagnosis and management (2017) which sets out the NHS baseline for endometriosis care. The Guideline says that endometriosis should be suspected when a patient presents with one or more of the common symptoms and people should be referred to a specialist endometriosis service (endometriosis centre) if they have suspected or confirmed deep endometriosis involving the bowel, bladder or ureter.

Following the NICE Guideline and the associated NICE Quality Standards on Endometriosis would be a significant, positive step change in improving endometriosis diagnosis, treatment and care.

Streamlining the diagnosis process will reduce wasted appointments with GPs, in hospitals and in A&E, and save many years of suffering and distress for the undiagnosed.

We also need research to uncover a simple diagnostic tool so that surgery is not the only means to definitively diagnose endometriosis.

Currently the only way to do this is through surgery, and research is vital to improving diagnosis, treatment options, discovering the cause of the disease, and one day a cure.

There is undoubtedly a long way to go in ensuring that everyone with endometriosis has access to the right care at the right time. But awareness is increasing, the Government is starting to listen, and change definitely feels on the horizon. ► Go to www.endometriosis-uk.org.

To read the APPG report and to see a full list of recommendations, visit: www.endometriosis-uk.org/endometriosis-appg

Her Life Her Health | Winter 2021 | 39

PCWHF PEOPLE

PCWHF MEMBER PROFILE

INTERVIEW BY AMY SCHOFIELD

A time to thrive Introducing PCWHF Executive Committee member DR LOUISE PRICE.

Tell us about what you do. I am a GP

with a special interest in gynaecology and women’s health and a busy mother of 2 young children. I work part time at a semi-rural GP surgery in the South West of England and part time as a GPSI at St Michaels’s Hospital in Bristol in tertiary gynaecology.

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

passionate about changing the way menopause is perceived and managed. I have a strong belief that the impact of the menopause is under recognised in medicine and society as a whole, and I am wholly committed to improving training and raising awareness of this hugely important area of women’s health. I strongly believe that women in this stage of life should be enabled to achieve and thrive at work and at home!

I AM CONSTANTLY INSPIRED BY WOMEN WHO MANAGE TO BALANCE THE CHALLENGES OF PROFESSIONAL EXPERTISE AND FAMILY LIFE

What does it mean to you to be part of the PCWHF’s Executive Committee? I feel honoured to have

been invited to work with such an incredible group of clinicians. I first discovered the PCWHF during my GPSI training and am consistently inspired by the accessible and practical resources. It is clearly produced by ‘real life’ clinicians and it is exciting to witness/be part of the progress and positive development in women’s health.

Who or what has influenced your career the most? I am constantly

inspired by women who manage to balance the challenges of professional expertise and family life. I admire those who remain grounded and focused on what I believe to be the most important aspect of medicine – patient centred care.

What are the greatest challenges facing women’s healthcare today?

I HAVE A STRONG BELIEF THAT THE IMPACT OF THE MENOPAUSE IS UNDER RECOGNISED IN MEDICINE AND SOCIETY AS A WHOLE

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

I believe passionately in equality.

At the PCWHF we are dedicated to embracing diversity and enabling empowerment of all women so that they are informed and involved in their own healthcare journey.

We face enormous challenges in achieving this but remain dedicated to overcoming the barriers that women face in being able to prioritise their own health and to access specialist women’s healthcare.

Do have patients Do you you have have patients with chronic watery with chronic chronic watery diarrhoea? diarrhoea? diarrhoea?

1 Have you checked for microscopic colitis?

Have Haveyou youchecked checkedfor formicroscopic microscopiccolitis? colitis?1 1

Diagnose Diagnose Diagnose Early with Early Earlywith with Endoscopist Endoscopist Endoscopist&& & 1 11 Pathologist Pathologist Pathologist 2 Often in patients >50 2 2 Often Often in in patients patients >50 >50

®® ® Prescribe Entocort CR by brand for the induction Prescribe PrescribeEntocort Entocort CR CRby bybrand brandfor forthe theinduction induction 33 3 and maintenance of remission in microscopic colitis andmaintenance maintenanceof ofremission remissionin inmicroscopic microscopiccolitis colitis

ENTOCORT CRCR 3mg Capsules (budesonide) Prescribing ENTOCORT ENTOCORT CR 3mg 3mg Capsules Capsules (budesonide) (budesonide) --Prescribing - Prescribing Information Information Information Please consult thethe Summary of Product Product Characteristics (SmPC) Please Please consult consult the Summary Summary of of Product Characteristics Characteristics (SmPC) (SmPC) fullfull prescribing Information for full for prescribing prescribing Information Information Presentation: Hard gelatin capsules for oral administration with Presentation: Presentation: Hard Hard gelatin gelatin capsules capsules for for oraloral administration administration with with opaque, light grey body andand anopaque, opaque, pink cap marked CIR an opaque, an opaque, light light grey grey body body and an an opaque, pink pink cap cap marked marked CIR CIR in inblack black radial print.

Contains 3mg budesonide.

3mg3mgin blackradial radialprint. print.Contains Contains3mg 3mgbudesonide. budesonide.

Indications: Induction of remission remission with mild Indications: Indications: Induction Induction of of remission inin patients inpatients patients with with mild mild toto to moderate Crohn’s disease affecting thethe ileum and/or thethe moderate moderate Crohn’s Crohn’s disease disease affecting affecting the ileum ileum and/or and/or the ascending colon.

Induction of remission remission patients with active ascending ascending colon. colon.

Induction Induction of of remission inin patients in patients with with active active microscopic colitis.

Maintenance remission patients with microscopic microscopic colitis. colitis.

Maintenance Maintenance ofof remission of remission inin patients in patients with with Active microscopic colitis.

Dosage and administration: Active Active microscopic microscopic colitis. colitis.

Dosage Dosageand andadministration: administration: 9mg once daily the morning forfor upto to to Crohn’s disease (Adults): 9mg 9mg once once daily daily ininthe in the morning morning for up up Crohn’s Crohn’s disease disease (Adults): (Adults): eight eight weeks. weeks.

Full effect effect achieved achieved in in 2-4 weeks. weeks.

When When treatment treatment isis is weeks.

FullFull effect achieved in2-4 2-4 weeks.

When treatment to be to discontinued, be discontinued, dose dose should should normally normally be be reduced ininfinal in final 2-4 discontinued, dose should normally bereduced reduced final 2-42-4 Active Active microscopic microscopic colitis colitis (Adults): (Adults): 9mg 9mg once once daily daily ininthe in weeks. weeks.

Active microscopic colitis (Adults): 9mg once daily thethe weeks.

(Adults): (Adults): 6mg 6mg once once morning. morning.

Maintenance Maintenance of of microscopic colitis colitis (Adults): 6mg once morning.

Maintenance of microscopic microscopic colitis daily daily in the in the morning, morning, or or the the lowest lowest effective effective dose. dose.

Paediatric Paediatric in the morning, or the lowest effective dose. Paediatric Older Older people: people: No special special dose dose population: population: Not recommended. recommended.

Older people: NoNo special dose population: NotNot recommended. adjustment adjustment recommended. recommended.

Swallow Swallow whole whole with with water. water.

Do not adjustment recommended.

Swallow whole with water.

DoDo notnot chew. chew.Contraindications: Contraindications:Hypersensitivity Hypersensitivitytoto tothe active chew.

Contraindications: Hypersensitivity thetheactive active substance substance or any or any of the of the excipients. excipients.

Warnings Warnings and and Precautions: Precautions: substance or any of the excipients. Warnings and Precautions: SideSide effects effects typical typical of corticosteroids corticosteroids may may occur. occur.

Visual Visual effects typical of of corticosteroids may occur.

Visual disturbances disturbances may may occur. occur.

IfIfaaIfpatient a patient presents presents with with symptoms symptoms such such disturbances may occur. patient presents with symptoms such as blurred as blurred vision vision or or other visual visual disturbances disturbances they they should should be blurred vision or other other visual disturbances they should bebe considered considered for for referral referral to an to ophthalmologist an ophthalmologist for for evaluation evaluation of the of considered for referral to an ophthalmologist for evaluation of thethe possible possible causes. causes.

Systemic Systemic effects effects may may include include glaucoma glaucoma and and possible causes.

Systemic effects may include glaucoma and when when prescribed prescribed at at high doses doses for prolonged prolonged periods, periods, Cushing’s Cushing’s when prescribed at high high doses forfor prolonged periods, Cushing’s syndrome, syndrome, adrenal adrenal suppression, suppression, growth growth retardation, retardation, decreased decreased syndrome, adrenal suppression, growth retardation, decreased bone bone mineral mineral density density and cataract. cataract.

Caution Caution inin patients inpatients patients with with bone mineral density andand cataract.

Caution with infection, infection, hypertension, hypertension, diabetes diabetes mellitus, mellitus, osteoporosis, osteoporosis, peptic infection, hypertension, diabetes mellitus, osteoporosis, peptic peptic ulcer, ulcer, glaucoma glaucoma or or cataracts or or with aafamily a family history history ofofdiabetes of diabetes oror or ulcer, glaucoma or cataracts cataracts orwith with family history diabetes glaucoma. glaucoma.

Particular Particular care care in in patients with with existing existing or or previous glaucoma.

Particular care in patients patients with existing orprevious previous history history of severe of severe affective affective disorders disorders in them in them or their or their first first degree degree history of severe affective disorders in them or their first degree relatives. relatives.

Caution Caution when when transferring transferring from from glucocorticoid glucocorticoid ofofhigh of high relatives.

Caution when transferring from glucocorticoid high systemic systemic effect effect to to Entocort CR. Chicken Chicken pox pox and and measles measles may may systemic effect to Entocort Entocort CR.CR. Chicken pox and measles may have have aa more a more serious serious course course in in patients on on oral steroids. steroids.

They They may may have more serious course inpatients patients onoral oral steroids.

They may also also suppress suppress the the HPA HPA axis axis and and reduce reduce the the stress stress response. response. also suppress the HPA axis and reduce the stress response.

Reduced Reduced liver liver function function may may increase increase systemic systemic exposure. exposure.

When When Reduced liver function may increase systemic exposure. When treatment treatment is is discontinued, reduce reduce dose dose over over last 2-4 weeks. weeks. treatment is discontinued, discontinued, reduce dose over lastlast 2-42-4 weeks.

Concomitant use inhibitors, such and Concomitant Concomitant use use ofofCYP3A ofCYP3A CYP3A inhibitors, inhibitors, such such asasketoconazole asketoconazole ketoconazole and and cobicistat-containing products, risk cobicistat-containing cobicistat-containing products, products, isisexpected isexpected expected toto increase toincrease increase thethe the risk risk of ofof systemic side effects and should avoided unless the benefits systemic systemic side side effects effects and and should should bebebe avoided avoided unless unless the the benefits benefits outweigh the risks.

Excessive grapefruit juice may increase outweigh outweigh the the risks. risks.

Excessive Excessive grapefruit grapefruit juice juice may may increase increase systemic exposure and should Patients with fructose systemic systemic exposure exposure and and should should bebeavoided. beavoided. avoided.

Patients Patients with with fructose fructose intolerance, glucose-galactose malabsorption sucroseintolerance, intolerance,glucose-galactose glucose-galactosemalabsorption malabsorptionorororsucrosesucroseisomaltase insufficiency should not take Entocort CR. Monitor isomaltase isomaltase insufficiency insufficiency should should not not take take Entocort Entocort CR. CR. Monitor Monitor height children who use prolonged glucocorticoid therapy height height ofofchildren of children who who use use prolonged prolonged glucocorticoid glucocorticoid therapy therapy forfor for risk growth suppression.

Interactions: Concomitant risk riskofof ofgrowth growthsuppression. suppression.Interactions: Interactions:Concomitant Concomitant colestyramine may reduce Entocort CR uptake.

Concomitant colestyramine colestyramine may may reduce reduce Entocort Entocort CR CR uptake. uptake.

Concomitant Concomitant oestrogen and contraceptive steroids may increase effects. oestrogen oestrogen and and contraceptive contraceptive steroids steroids may may increase increase effects. effects.

CYP3A4 inhibitors may increase systemic exposure.

CYP3A4 CYP3A4 CYP3A4 inhibitors inhibitors may may increase increase systemic systemic exposure. exposure.

CYP3A4 CYP3A4 inducers may reduce systemic exposure.

May cause low values inducers inducers may may reduce reduce systemic systemic exposure. exposure.

May May cause cause low low values values in inin ACTH ACTH stimulation stimulation test. test.

Fertility, Fertility, pregnancy pregnancy and and lactation: lactation: ACTH stimulation test.

Fertility, pregnancy and lactation: Only Only totobe to used used during during pregnancy pregnancy when when the the potential potential benefits benefits to toto Only bebe used during pregnancy when the potential benefits the mother mother outweigh outweigh the the risks risks forforfor the the foetus. foetus.

May May bebe used beused used during during thethe mother outweigh the risks the foetus.

May during Common: Cushingoid Cushingoid breast breast feeding. feeding.

Adverse Adverse reactions: reactions:Common: Common: Cushingoid breast feeding.

Adverse reactions: features, features,hypokalaemia, hypokalaemia,behavioural behaviouralchanges changessuch suchasasas features, hypokalaemia, behavioural changes such nervousness, nervousness,insomnia, insomnia,mood moodswings swingsand anddepression, depression, nervousness, insomnia, mood swings and depression, palpitations, palpitations, dyspepsia, dyspepsia, skin skin reactions reactions (urticaria, (urticaria, exanthema), exanthema), palpitations, dyspepsia, skin reactions (urticaria, exanthema), Uncommon: Uncommon: anxiety, anxiety, muscle muscle cramps, cramps, menstrual menstrual disorders. disorders.

Uncommon: anxiety, muscle cramps, menstrual disorders.

Rare: Rare: aggression, aggression, glaucoma, glaucoma, tremor, tremor, psychomotor psychomotor hyperactivity. hyperactivity. tremor, psychomotor hyperactivity. Rare: aggression, glaucoma, Very Very rare: rare: Anaphylactic Anaphylactic cataract, cataract, blurred blurred vision, vision, ecchymosis. ecchymosis.

Very rare: Anaphylactic cataract, blurred vision, ecchymosis. reaction, reaction, growth growth retardation. retardation.

Prescribers Prescribers should should consult consult thethe the reaction, growth retardation.

Prescribers should consult summary summary ofofproduct ofproduct product characteristics characteristics ininrelation inrelation relation totoother toother other adverse adverse summary characteristics adverse reactions. reactions.

Marketing Marketing Authorisation Authorisation Numbers, Numbers, Package Package reactions. Marketing Authorisation Numbers, Package Quantities Quantities and and basic basic NHS NHS price: price: PLPL36633/0006.

PL36633/0006.

36633/0006.

Packs Packs of of 50 of50 50 Quantities and basic NHS price: Packs capsules: capsules: £37.53. £37.53.

Packs Packs ofofof 100 100 capsules: capsules: £75.05. £75.05.

Legal Legal capsules: £37.53.

Packs 100 capsules: £75.05.

Legal category: category: POM. POM. Marketing Marketing Authorisation Authorisation Holder: Holder: Tillotts Tillotts category: POM. Marketing Authorisation Holder: Tillotts Pharma Pharma UK Ltd, Ltd, The The Stables, Stables, Wellingore Wellingore Hall, Hall, Wellingore, Wellingore, Lincoln, Lincoln, Pharma UKUK Ltd, The Stables, Wellingore Hall, Wellingore, Lincoln, LN5 LN5 0HX. 0HX. Date Date of preparation of preparation of PI: of February PI: February 2020 2020 LN5 0HX. Date of preparation of PI: February 2020

Adverse Adverse events events should should be reported. reported.

Adverse events should bebe reported.

Reporting Reporting forms forms and and information information can can bebe be found found atatat Reporting forms and information can found https://yellowcard.mhra.gov.uk. https://yellowcard.mhra.gov.uk.

Adverse Adverse events events https://yellowcard.mhra.gov.uk.

Adverse events should should also also be reported reported totoTillotts toTillotts Tillotts Pharma Pharma UKUK UK Ltd. Ltd. should also bebe reported Pharma Ltd. Tel: Tel: 01522 01522 813500.

813500.

Tel: 01522 813500.

Life feels good when microscopic Life Life feels feels good good when when microscopic microscopic 4,54,5 colitis is under control colitis colitis isis under under control control4,5

References: References: 1. Ingle Ingle SB SB et SBal. World al.World World J Gastrointest Gastrointest Pathophysiol Pathophysiol 2014; 2014; References: 1.1.Ingle etetal.

JJ Gastrointest Pathophysiol 2014; 5(1): 5(1): 48–53.

48–53.

2. 2.

Macaigne 2.Macaigne Macaigne GG etG et al. et al.

Am al. Am Am J Gastroenterol Gastroenterol 2014; 2014; 109(9): 109(9): 5(1): 48–53.

JJ Gastroenterol 2014; 109(9): ® ® 1461–1470.

1461–1470.

3. 3.

Entocort 3.Entocort Entocort CR 3mg 3mg Capsules Capsules – Summary Summary of Product of Product Product ® CR CR 3mg Capsules –– Summary of 1461–1470.

Characteristics.

Characteristics.

4. 4.

Madisch 4.Madisch Madisch A et al. et al.

Int al. Int JIntColorectal Colorectal DisDis Dis 2005; 2005; 20(4): 20(4): Characteristics.

AA et JJ Colorectal 2005; 20(4): 312–316.

312–316.

5. Miehlke Miehlke S etSSal. Gastroenterology al.Gastroenterology Gastroenterology 2008; 2008; 135:135: 135: 1510–1516.

1510–1516.

312–316.

5.5.Miehlke etetal.

2008; 1510–1516.

Date Date of of preparation: ofpreparation: preparation: February February 2020.

2020.

PU-00335.

PU-00335.

Date February 2020.

PU-00335.

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