Global Consensus Position Statement on the Use of Testosterone Therapy for Women.

This Statement is being simultaneously published in the journals Climacteric, Maturitas, Journal of Sexual Medicine, and Journal of Clinical Endocrinology and Metabolism on behalf of the International Menopause Society, The European Menopause and Andropause Society, The International Society for Sexual Medicine, and The Endocrine Society, respectively. This Position Statement has been endorsed by the International Menopause Society, The Endocrine Society, The European Menopause and Andropause Society, The International Society for Sexual Medicine, The International Society for the Study of Women's Sexual Health, The North American Menopause Society, The Federacion Latinoamericana de Sociedades de Climaterio y Menopausia, The Royal College of Obstetricians and Gynaecologists, The International Society of Endocrinology, The Endocrine Society of Australia, and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Female genital mutilation and pregnancy: associated risks.

Female genital mutilation (FGM) is a traditional practice that has no medical benefit and severe health consequences for girls and women. This article discusses the risks to patients who are pregnant and have had FGM. It will describe urinary tract infections caused by FGM, and how this condition increases the risk of preterm labour and delivery. It will also address the difficulty in vaginal examinations that can be caused by FGM and instances when this can delay diagnosis and treatment. In addition, it will explore a number of intrapartum risks caused by FGM and the role of deinfibulation in pregnancy. Finally, it will look at the link between maternal and fetal morbidity and mortality, and FGM.

A retrospective audit of general practitioner's referrals to Guys and St Thomas' specialist menopause clinic between 2021 and 2022.

Purpose: We performed a retrospective audit of General Practitioners' (GPs) referrals to the specialist Menopause Clinic at Guys and St Thomas's (GSTT) between 2021 and 2022. We aim to establish the indication for the referrals and whether they were compliant with the National Institute for Health and Care Excellence Guidance NICE.Background: GSTT is a teaching hospital in central London that educates gynaecologists in training as well as (GP) for specialist certification in Menopause. The menopause clinic receives approximately 580 GP referrals per month from South East London practices. The current waiting time for an initial appointment is up to 1 year. This delay reflects an increase in demand for menopause care and a deficit in service provision in many areas of the UK.NICE has recommended that GPs refer complicated cases to menopause specialists, with 11 specific criteria.Study Sample and Data Collection: We randomly selected 50 patients referred to the GSTT clinic by a GP between 2021 and 2022. Patient data were collected, including patient demographics, date of referral, indication for referral, date of consultation, waiting time, past medical history, investigations, and treatment instigated during the appointment.Results: The majority of referrals to the GSTT menopause Specialist clinic met the NICE guidelines (76%). One-sixth of the referrals could have been prevented or managed through alternative routes. Finally, although this is a small study, some patient unmet needs (PUNS) and GPs' educational needs have been identified.

Quality improvement project - Reducing the inadvertent prescribing of unopposed estrogen in primary care Dr Liz Horrocks Banstead PCN.

OBJECTIVE: The aim of the project was to reduce the risk of patients using the estrogen only part of their hormone replacement therapy (HRT) inadvertently in Banstead PCN. Although understanding about the risk of unopposed estrogen is well understood by prescribers, there are numerous flash points where this exposure can occur which was highlighted by several cases encountered during a study period of 3 months. STUDY DESIGN: Cases encountered revealed numerous reasons for this exposure which were split into three areas: Prescribing factors, dispensing checks and patient understanding. MAIN OUTCOME MEASURES: Quality improvement suggestions were tailored to the factors involved. IT system changes to EMIS, our main computer software provider, were proposed to enable safer prescribing. Following discussion with key stakeholders, increased education for pharmacists was proposed alongside an alert sticker system at the dispensing end point. Patient understanding and education for all parties was delivered through various routes. RESULTS: The IT system alterations required are complex and still awaited. Funding was obtained and stickers distributed. The results from a re-audit from this intervention are awaited. Interim education measures at an individual level were meantime explored and the impact of them assessed. Patient education and the role of social media were explored. I produced a short video which was circulated to doctors with the plan to distribute via other clinician social media accounts. CONCLUSIONS: A key discovery through this study is that many of the flash points identified can be difficult to detect and many are not measurable. The increasing number of HRT prescriptions, time pressures in primary care and the known risk from using unopposed estrogen of endometrial cancer means these changes are of potential great value.

A novel method of assessing quality of postgraduate psychiatry training: experiences from a large training programme.

BACKGROUND: Most assessments of the quality of postgraduate training are based on anonymised questionnaires of trainees. We report a comprehensive assessment of the quality of training at a large postgraduate psychiatry training institute using non-anonymised face-to-face interviews with trainees and their trainers. METHODS: Two consultant psychiatrists interviewed 99 trainees and 109 trainers. Scoring of interview responses was determined by using a pre-defined criteria. Additional comments were recorded as free text. Interviews covered 13 domains, including: Clinical, teaching, research and management opportunities, clinical environment, clinical supervision, adequacy of job description, absence of bullying and job satisfaction. Multiple interview domain scores were combined, generating a 'Combined' score for each post. RESULTS: The interview response rate was 97% for trainers 88% for trainees. There was a significant correlation between trainee and trainer scores for the same interview domains (Pearson's r = 0.968, p< 0.001). Overall scores were significantly higher for specialist psychiatry posts as compared to general adult psychiatry posts (Two tailed t-test, p < 0.001, 95% CI: -0.398 to -0.132), and significantly higher for liaison psychiatry as compared to other specialist psychiatry posts (t-test: p = 0.038, 95% CI: -0.3901, -0.0118). Job satisfaction scores of year 1 to year 3 core trainees showed a significant increase with increasing seniority (Linear regression coefficient = 0.273, 95% CI: 0.033 to 0.513, ANOVA p= 0.026). CONCLUSIONS: This in-depth examination of the quality of training on a large psychiatry training programme successfully elicited strengths and weakness of our programme. Such an interview scheme could be easily implemented in smaller schemes and may well provide important information to allow for targeted improvement of training. Additionally, trends in quality of training and job satisfaction amongst various psychiatric specialities were identified; specifically speciality posts and liaison posts in psychiatry were revealed to be the most popular with trainees.

Review of menopause advice given to patients undergoing bilateral oophorectomy.

The NICE Guideline (NG23) 2015 Menopause: Diagnosis and Management states that 'women who are likely to go through the menopause as a result of medical or surgical treatment should be offered support and information about the menopause and fertility before they have their treatment, and a referral to a Health Care Professional with expertise in the menopause'. To investigate whether discussion about the surgery causing the menopause, and advice on possible treatments had been documented, I conducted a retrospective study of women undergoing bilateral oophorectomy at a central London teaching hospital from 1st April 2018 to 30th September 2018. Only 30% of women (8 out of 27) in this study had documentary evidence of having received menopause advice around the time of bilateral oophorectomy.

Looking after our menopausal workforce: A model for NHS staff.

OBJECTIVE: To determine whether a staff menopause clinic would benefit our peri/postmenopausal hospital workforce. METHODS: The three menopause consultants, with OH administration assistance, set up a virtual clinic for staff members to address the unanswered need for access to good menopause care. Feedback was gathered from the attendees and the staff who ran the clinic. RESULTS: The clinic was an overwhelming success and has now become an established clinic at a major London teaching hospital. CONCLUSIONS: We hope that this model can be used in other trusts, and other companies to provide good menopause care to our senior female workforce to retain them. Acknowledgements: We would like to thank the OH staff who ensured the clinics ran so smoothly.

Which events are experienced as traumatic by obstetricians and gynaecologists, and why? A qualitative analysis from a cross-sectional survey and in-depth interviews.

OBJECTIVES: To explore the events perceived as traumatic by obstetricians and gynaecologists (O&G), and to examine factors contributing to the perception of trauma. DESIGN: Mixed methods: cross-sectional survey and in-depth interviews. SAMPLE AND SETTING: Fellows, members and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG). METHODS: An online survey was distributed to 6300 fellows (May-June 2017), members and trainees of RCOG; 1095 (17%) completed surveys were returned. Of these, 728 (66%) reported work-related trauma experience, with 525 providing a brief description of an event. Forty-three participants with trauma experience were purposively sampled and completed an in-depth interview (October 2017-March 2018), which were analysed using Template Analysis. Information regarding the scale and impact of trauma experience is presented elsewhere. The present analysis provides new information describing the events and perceptions of why events were traumatic. PRIMARY OUTCOME MEASURES: The nature of traumatic events in this clinical setting, taken from survey descriptions of perceived traumatic events and information from the in-depth interviews. RESULTS: Events perceived as traumatic by O&G were similar between consultants, trainees and other RCOG members no longer working in O&G. Maternal or neonatal death/stillbirth, haemorrhage and events involving a difficult delivery were most frequently reported. Sudden and unpredictable events, perceived preventability, acute sensory experiences and high emotionality contributed to trauma perception. Respondents' trauma was compounded by an absence of support, involvement in investigation procedures and pre-existing relationships with a recipient of care. CONCLUSIONS: Identification of events most likely to be perceived as traumatic, and wider circumstances contributing to the perception of trauma, provide a basis on which to focus preventative and supportive strategies for O&G. Training on the nature of traumatic events, self-help for early stress responses, processing support and rapid access to trauma-focused psychological input (where required) are needed.

Management of sleep disorders in the menopausal transition.

The menopausal transition is associated with increasing sleep disorders including sleep apnoea and restless leg syndrome. Insomnia is the most common and is recognised as a core symptom of the menopause. Guidelines to support decision making for women with sleep problems during the menopausal transition are lacking. Sleep problems are associated with negative impacts on healthcare utilisation, quality of life and work productivity. Sleep deprivation is a risk factor for cardiovascular disease, diabetes, obesity and neurobehavioral dysfunction. Declining oestrogen is implicated as a cause of menopausal sleep disruption. Vasomotor symptoms (VMS) and menopausal mood disturbance are also factors in the complex aetiology. VMS commonly precipitate insomnia and, due to their prolonged duration, they often perpetuate the condition. Insomnia in the general population is most effectively treated with cognitive behavioural therapy (CBT) (also effective in the menopausal transition.) The associations of menopausal sleep disturbance with VMS and depression mean that other treatment options must be considered. Existing guidelines outline effectiveness of hormone replacement therapy (HRT), CBT and antidepressants. HRT may indirectly help with sleep disturbance by treating VMS and also via beneficial effect on mood symptoms. The evidence base underpinning menopausal insomnia often references risks associated with HRT that are not in line with current international menopause guidelines. This may influence clinicians managing sleep disorders, leading to hesitation in offering HRT, despite evidence of effectiveness. Viewing sleep symptoms on an axis of menopausal symptoms - towards vasomotor symptoms or towards mood symptoms may help tailor treatment options towards the symptom profile.

Estrogen and COVID-19 symptoms: Associations in women from the COVID Symptom Study.

It has been widely observed that adult men of all ages are at higher risk of developing serious complications from COVID-19 when compared with women. This study aimed to investigate the association of COVID-19 positivity and severity with estrogen exposure in women, in a population based matched cohort study of female users of the COVID Symptom Study application in the UK. Analyses included 152,637 women for menopausal status, 295,689 women for exogenous estrogen intake in the form of the combined oral contraceptive pill (COCP), and 151,193 menopausal women for hormone replacement therapy (HRT). Data were collected using the COVID Symptom Study in May-June 2020. Analyses investigated associations between predicted or tested COVID-19 status and menopausal status, COCP use, and HRT use, adjusting for age, smoking and BMI, with follow-up age sensitivity analysis, and validation in a subset of participants from the TwinsUK cohort. Menopausal women had higher rates of predicted COVID-19 (P = 0.003). COCP-users had lower rates of predicted COVID-19 (P = 8.03E-05), with reduction in hospital attendance (P = 0.023). Menopausal women using HRT or hormonal therapies did not exhibit consistent associations, including increased rates of predicted COVID-19 (P = 2.22E-05) for HRT users alone. The findings support a protective effect of estrogen exposure on COVID-19, based on positive association between predicted COVID-19 with menopausal status, and negative association with COCP use. HRT use was positively associated with COVID-19, but the results should be considered with caution due to lack of data on HRT type, route of administration, duration of treatment, and potential unaccounted for confounders and comorbidities.

Global Consensus Position Statement on the Use of Testosterone Therapy for Women.

This Position Statement has been endorsed by the International Menopause Society, The Endocrine Society, The European Menopause and Andropause Society, The International Society for Sexual Medicine, The International Society for the Study of Women's Sexual Health, The North American Menopause Society, The Federacion Latinoamericana de Sociedades de Climaterio y Menopausia, The Royal College of Obstetricians and Gynecologists, The International Society of Endocrinology, The Endocrine Society of Australia, and The Royal Australian and New Zealand College of Obstetricians and Gynecologists.

Reversibility of the effects of acute ovarian hormone suppression on verbal memory and prefrontal function in pre-menopausal women.

BACKGROUND: Whilst acute loss of ovarian function is associated with memory deficits, the biological basis of this is poorly understood. We have previously reported that acute loss of function during Gonadotropin Hormone Releasing Hormone agonists (GnRHa) treatment is associated with impaired verbal memory and a disruption of corresponding left inferior frontal gyrus (LIFG) during the encoding stage. In the current study, we provide a critical extension to this work by determining whether this memory deficit is reversible following normalization of ovarian function. To do this we carried out a further imaging study using the same verbal memory recognition task after cessation of GnRHa-induced ovarian suppression. METHOD: We used event-related fMRI to study verbal episodic memory performance and brain activation at the LIFG in 13 healthy pre-menopausal women pre-, during, and post-acute ovarian hormone suppression using GnRHa. RESULTS: Following resolution of acute GnRHa-induced ovarian suppression, verbal recognition scores returned to their initial levels and this restoration was associated with a restored level of left frontal activation during successful encoding of words. CONCLUSIONS: Our findings suggest that the memory deficits associated with acute ovarian suppression are reversed following resolution of normal ovarian function and are associated with reversible attenuation of LIFG activation during encoding. These findings lend further support to the hypothesis that memory difficulties reported by some women following acute ovarian hormone withdrawal are reversible and may have a clear neurobiological basis.

A study of visuospatial working memory pre- and post-Gonadotropin Hormone Releasing Hormone agonists (GnRHa) in young women.

Gonadotropin Hormone Releasing Hormone agonists (GnRHa) produce an acute decline in ovarian hormone production leading to a 'pseudo' menopause. This is therapeutically useful in the management of a variety of gynaecological conditions but also serves as a powerful model to study the effects of ovarian hormones on cognition. Animal and human behavioral studies report that memory is particularly sensitive to the effects ovarian hormone suppression (e.g. post GnRHa). Further, it has recently been reported that ovariectomy in young women increases the risk of cognitive impairment in later life. However, the underlying brain networks and/or stages of memory processing that might be modulated by acute ovarian hormone suppression remain poorly understood. We used event-related fMRI to examine the effect of GnRHa on visual working memory (VWM). Neuroimaging outcomes from 17 pre-menopausal healthy women were assessed at baseline and 8 weeks after GnRHa treatment. Seventeen matched wait-listed volunteers served as the control group and were assessed at similar intervals during the late follicular phase of the menstrual cycle. We report GnRHa was associated with attenuation of left parahippocampal (BA 35) and middle temporal gyri (BA 21 ,22, 39) activation, with a significant group-by-time interaction at left precuneus (BA 7) and posterior cingulate cortex (PCC) (BA 31) at encoding, and with cerebellar activation at recognition in the context of unimpaired behavioral responses. Our study suggests that acute ovarian hormone withdrawal following GnRHa, and perhaps at other times, (e.g. following surgical menopause and postpartum) alters the neural circuitry underlying performance of VWM.

Endometrial effects of tibolone.

BACKGROUND AND OBJECTIVES: The Tibolone Histology of the Endometrium and Breast Endpoints Study is a multicenter, randomized, double-blind study designed to address the conflicting reports in the literature about the endometrial safety of tibolone (1.25 or 2.5 mg/d). Tibolone was compared with continuous combined conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) (0.625 + 2.5 mg/d). METHODS: Subjects were randomized in a 1:1:2 ratio to tibolone 1.25 mg/d, 2.5 mg/d, and CEE/MPA, respectively. The one-sided 95% confidence interval (CI) has been evaluated for the incidence of abnormal endometrial histology (hyperplasia or carcinoma) and hyperplasia and carcinoma separately for each of the two treatment groups and the treatment groups combined after 1 and 2 yr of treatment with tibolone, compared with CEE/MPA. RESULTS: A total of 3240 women were randomized, with 3224 receiving at least one dose of study medication. The incidence and upper one-sided 95% CI for the incidence of abnormal endometrium (hyperplasia or carcinoma), and hyperplasia and carcinoma separately, were calculated at end point, yr 1, and yr 2. The incidence (upper one-sided 95% CI) of abnormal endometrium at end point was 0.0 (0.5), 0.0 (0.4), and 0.2 (0.5) in the tibolone 1.25 mg, 2.5 mg, and CEE/MPA groups, respectively. During the entire treatment period, amenorrhea was reported more frequently with tibolone 1.25 mg (78.7%) and 2.5 mg (71.4%) than CEE/MPA (44.9%). CONCLUSION: The Tibolone Histology of the Endometrium and Breast Endpoints Study results confirm previous findings that tibolone does not induce endometrial hyperplasia or carcinoma in postmenopausal women, and it is associated with a better vaginal bleeding profile than CEE/MPA.