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 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.

Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time.

Unscheduled bleeding on hormone replacement therapy (HRT) can affect up to 40% of users. In parallel with the increase in HRT prescribing in the UK, there has been an associated increase in referrals to the urgent suspicion of cancer pathway for unscheduled bleeding. On behalf of the British Menopause Society (BMS) an expert review panel was established, including primary and secondary care clinicians with expertise in the management of menopause, with representatives from key related organisations, including the Royal College of Obstetricians & Gynaecologists, the British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Royal College of General Practitioners and Faculty of Sexual and Reproductive Health, and service development partners from NHS England and GIRFT (Getting it Right First Time). For each topic, a focused literature review was completed to develop evidence led recommendations, where available, which were ratified by consensus review within the panel and by guideline groups.

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.

Intravaginal dehydroepiandrosterone for genitourinary symptoms of the menopause: Is the evidence sufficient?

Intravaginal dehydroepiandrosterone (DHEA) is a locally metabolised estrogen and androgen precursor, licensed in 2018 in the EU for moderate to severe vulvovaginal atrophy in postmenopausal women. A literature search revealed four original trials suitable for appraisal, three evaluating change in dyspareunia or dryness as a primary outcome, one evaluated safety as a primary outcome. In two trials of 255 and 558 women without cancer, the benefit of placebo (nightly vaginal suppositories with a lipophilic base) was a 0.9 and 1 point reduction in dyspareunia as measured on a 3 point scale, an unvalidated outcome measure. With nightly DHEA, dyspareunia was reduced by an additional 0.4 points compared to placebo. When 464 women with gynaecological cancer were randomised, those using nightly plain moisturiser gel reported a reduction of 'most bothersome symptom' (either dyspareunia or dryness) of 1.5 points on a 3 point scale. Those using nightly DHEA reported an additional symptom reduction of 0.3 points. This is also an unvalidated outcome measure. Data evaluating the efficacy of DHEA over placebo is unconvincing and based on unvalidated primary outcome measures that also do not reflect the complex psycho-sexual and socio-cultural components of genitourinary menopausal symptoms. The efficacy and safety data excluded women taking systemic HRT, applies to postmenopausal, not perimenopausal, women and had relatively short follow up. It is important further independent trials use sophisticated and validated assessment tools to better establish the efficacy, safety and cost effectiveness of intravaginal DHEA in clinically representative groups of women before being routinely prescribed.

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.

Clinical update on hormone replacement therapy.

There has been much change concerning the menopause in clinical practice, research and prescribing since the 1990s, with conflicting information and uncertainties. The use of hormone replacement therapy (HRT) has declined and women have often stopped taking it with no discussion with healthcare professionals. The uncertainties have led to confusion for healthcare professionals and women alike, with some women being denied HRT when it would be appropriate for them to take it, and others taking alternative or complementary therapies when there is little or no information on their efficacy. This article aims to give an update on HRT, what it is, why women take it and alternatives to HRT, including lifestyle advice.

Nursing considerations in patients with vaginitis.

Vaginitis is defined as an inflammation of the vagina. It can result in symptoms of any or all of the following: discharge, itching and pain, and often irritation or infection of the vulva. There is no specific cause for vaginitis, and many other conditions can cause the symptoms. Vaginitis is a distressing condition that affects many women of reproductive age and beyond, and encompasses candidiasis (also known as thrush), bacterial vaginosis, and trichomoniasis. It can occur in a single episode, or recur throughout a woman's lifetime. Some women will seek medical help, but many more self-treat with over-the-counter medications, suspecting the recurrence of Candida in particular. This article aims to explore the causes, signs and symptoms, and treatments of vaginitis to provide nurses with the necessary background information to feel more confident in dealing with women's health issues.

The role of Endometriosis Clinical Nurse Specialists in British Society for Gynaecological Endoscopy registered centres: A UK survey of practice.

Aim: To identify Endometriosis Nurse Specialists' roles and responsibilities in accredited Endocentres, how these align with the Royal College of Nursing Skills Framework and potential for development to improve patient care. Design: Cross-sectional national survey. Methods: Data were collected from an online survey distributed to all 66 Endometriosis Nurse Specialists working across 58 UK-based Endometriosis registered centres. The response rate was 58% (N = 38). Data from closed questions were analysed using descriptive statistics, and free text responses were collated and analysed thematically. Results: Unlike Nurse Specialists in other fields of practice, most Endometriosis Nurse Specialists (N = 33, 87%) had another nursing role. The median hours worked per week as an endometriosis nurse was only 13.5 hr. Most respondents (N = 35, 92%) spent all or most of their allocated hours collecting and inputting endometriosis data, whilst over a third (N = 13, 34%) were not undertaking any autonomous, nurse-led patient consultations.

Menopause Symptom Management in the United Kingdom.

Menopause is a complex time in a woman's life. It is an increasingly a midlife event, when health care professionals should be aiming to optimize a woman's health for the next 30 years or so. Nurses need to be able to give up-to-date information and evidence for all forms of treatment based on a background of complex and ever-changing research. This article covers the main presenting complaints and treatments, from lifestyle to hormone replacement therapy, by drawing on guidelines from national bodies.

Bone density changes in premature ovarian insufficiency patients who have had term pregnancies.

Premature ovarian insufficiency affects 1% of women under the age of 40 and is associated with a hypoestrogenic state, potentially leading to multiple comorbidities including reduced bone density and fertility. An unpredictable ovarian function is observed in 50% of patients with 5-10% being able to achieve a pregnancy. Longitudinal studies have shown a temporary decline in bone mineral density of up to 5% during pregnancy and lactation in healthy women, with the loss of bone density post-partum being proportional to the period of breastfeeding. Effects of pregnancy in women with premature ovarian insufficiency have not been widely documented. Nevertheless, a lower bone mineral density baseline has been observed pre-conceptually, associated with both the hypoestrogenic state of the condition and the possibility that premature ovarian insufficiency was developed prior to achieving peak bone mass. This may suggest that breastfeeding could cause further deterioration in bone mineral density that may not be easy to recover from due to the reduced baseline levels.

The use of hormone therapy and its alternatives in women with a history of hormone dependent cancer.

OBJECTIVE: Treating the effects of menopause in women with history of oestrogen-dependent cancers presents a clinical dilemma. Endocrine adjuvant agents like tamoxifen and other cancer treatments, often induce premature menopause. Vasomotor, psychological and somatic symptoms may be more severe in these women. The risk of hormone therapy (HT) and its efficacy must be balanced. Currently, there are no consensus guidelines for the management of these patients. STUDY DESIGN: This is a retrospective study carried out between 10/01/2011 and 27/01/2012 in a tertiary referral menopausal clinic. MAIN OUTCOME MEASURES: Data was collected about cancer type and treatment, symptoms, prior use of T, bone density analyses and menopause treatments. RESULTS: 590 patient records were scanned and 146 patients (24.7%) had a history of cancer. Of these, 45.9% were younger than 50 years old. 67.1% comprised breast cancer patients, of which 69.4% were on adjuvant endocrine agents. 24.7% consisted of gynaecological cancer patients who were predominantly treated with surgery in conjunction with adjuvant therapies. 90.4% of the women had at least one menopause-related symptom, vasomotor symptoms being most prevalent, followed by psychological and vaginal symptoms. Women used a variety of HT and non-HRT therapies for their symptoms. Of the 77 women who had a personal history of oestrogen receptor positive cancers, 19.5% chose to take HT in spite of it being contraindicated. CONCLUSIONS: Prescribing HT to women with a history of hormone dependent cancer remains controversial. Patient 'Quality of Life' must be considered. More research is required in this area.