Her Life Her Health Spring 2023

Peaches Womb Cancer

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EDITOR-IN-CHIEF

Dr Anne Connolly MBE

EDITOR

Emma Cooper

MEDICAL EDITOR

Dr Jane Davis

CREATIVE DIRECTOR

Emma Warfield

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Sigrid Dalland

HEAD OF MARKETING & CONTENT

Emma Morriss

MANAGING DIRECTOR

Hazel Lodge

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Sophie Mead

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Fiona Beard

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Karl Hamer

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COMMITTEE:

Dr Amy Tatham

Dr Silvia MoensLecumberri

Dr Stephanie Cook

Lesley Wylde

The PCWHF recognises that not all those born with a womb identify as a woman and that not all women have wombs. We recognise both the biological experience of being born with a womb and the gendered experience of identifying and presenting as a woman.

From the Editor-in-Chief

Welcome to the Spring issue of Her Life Her Health .

Following the announcement from the Prime Minister of an urgent review of Relationships, Sex and Health Education this year, our Early Years feature showcases the very relevant work the Sex Education Forum has carried out, asking young people about their experiences of RSHE to determine the extent and effectiveness of the current legislation. The results are interesting and insightful, take a look on page 12.

On the theme of surveys and polls, the PCWHF has been increasingly concerned about the viability of long-acting reversible contraception (LARC) fitting in primary care and the implications for wider women’s health and contraceptive care in the future if this is not addressed and prioritised.

We will be publishing a report based on first-hand evidence from healthcare professionals in primary care, providing an up-to-date overview of LARC fitting in the UK, comparing where we are in 2023 with the previous study from 2020. We are grateful to everyone who took part in the survey and gave us invaluable feedback. For now, you can read an executive summary of the forthcoming report on page 32.

This issue of Her Life Her Health also sees the introduction of a regular feature which covers the fundamentals of an important topic. Presented in a practical way, we would encourage you to pull out the feature and pop it on your wall and share it with colleagues and trainees in your practice. We’ve started the series with contraceptive safety and a quick glance at UKMEC guidance.

Our feature on page 15 focuses on chronic pelvic pain and examines the complexity that can come with certain cases, as symptoms are often vague and can be similar to other common conditions presented to us in primary care. As primary care clinicians, we play a crucial role in the care of women with CPP and this article address some of the challenges we face and how we can overcome them.

The symptoms of menopause can be varied, as well as their severity. In our article on page 22, Dr Louise Oliver discusses how the risk of sleep disordered breathing increases as women transition through the menopause, which can have a big impact on quality of life. Louise discusses the importance of raising awareness and the importance of taking action.

Our charity focus this issue is on Peaches Womb Care Trust. Womb cancer is the most common gynaecological cancer and, unlike other cancers, incidence of womb cancer is rising due to increased life expectancy, reduced hysterectomy rates, and increasing prevalence of obesity. Read about the great work the charity is doing on page 34.

Providing an opportunity to showcase and share learnings is invaluable, so please do feel free to contact us at submissions@pcwhf.co.uk if you would like us to consider publishing an article or audit in your own area of interest.

We hope you enjoy this issue,

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

OUR EARLY YEARS FEATURE SHOWCASES THE VERY RELEVANT WORK THE SEX EDUCATION FORUM HAS CARRIED OUT

Contributors

DR ANNE CONNOLLY MBE, EDITOR-IN-CHIEF

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

DR JANE DAVIS, MEDICAL EDITOR

Jane is a GP based in Cornwall with a special interest in women’s health. She is a member of the PCWHF’s Board and spokesperson for the Forum’s publicfacing menopause campaign, Rock My Menopause.

DR CLAUDIA CHISARI

Claudia is an academic, chartered psychologist in pelvic pain and the world’s top 10th most cited scientist in vulvodynia. She is the founder of Femspace. Claudia carried out the first PhD in Vulvodynia in the UK at King’s College London, developing digital treatments that tackle women’s mental and physical health.

DR LOUISE OLIVER

Louise is a GP, Functional Breathing Practitioner and Therapeutic Life Coach. With over 20 years’ experience of working in the NHS, Louise has developed skills to help people, with her own mindfulness journey starting by exploring ways of improving psychological distress and chronic pain in her patients, without medication.

DR HELENA O’FLYNN

Helena is a GP and Trustee of Peaches Womb Cancer Trust. She has an interest in the early detection of gynaecological cancers in primary care and women’s health and currently works in Manchester.

LISA HALLGARTEN

Lisa Head of Policy and Public Affairs at Brook.

PRIMARY CARE CLINICIANS PLAY A CRUCIAL ROLE IN THE CARE OF WOMEN WITH CPP. MANY OF YOU FACE SIGNIFICANT CHALLENGES WITH THESE CONDITIONS, INCLUDING THEIR COMPLEXITY AND LACK THE RESOURCES TO PROVIDE COMPREHENSIVE LONG-TERM CARE

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). This publication contains promotional information from our industry sponsors – including Gedeon Richter.

DR CLAUDIA CHISARI, THE SILENT EPIDEMIC OF CHRONIC PELVIC PAIN, PAGE 15

ON THE GROUND

CHARITY FOCUS

HORMONAL CONTRACEPTIVES AND BREAST CANCER RISK

Apaper, Combined and progestogen only hormonal contraceptives and breast cancer risk: A UK nested case-controlled study and metanalysis, by Fitzpatrick et al, is the latest in a series from the Oxford based group led by the late Valerie Beral.

The paper looked at the risk of breast cancer in women aged 20–49 who took all forms of hormonal contraception and compared it to controls. The aim was to provide information in respect of progestogen only methods where high-quality evidence had been limited. Data from nearly 10,000 women with breast cancer was analysed and compared to other published evidence. They looked at, and adjusted for, other factors which are known to affect breast cancer risk such as number of prior pregnancies, alcohol use, removal of ovaries and prior contraceptive use. Family history and exercise were not looked at. Women’s reasons for using contraception was not assessed.

Response from the PCWHF

Dr Sarah Gray and Dr Kristyn Manley, on behalf of the PCWHF, commented: “The data suggests that all hormonal methods of contraception carry a 20–30% increased risk of breast cancer diagnosis over a 15-year period (during the five years of current use and the excess risk 10 years after stopping). For women to understand how this risk affects them, as this initially appears a significant increase, this data needs to be explained in relation to their small existing baseline risk:

• Women aged 16–20: a 0.084% baseline incidence (<1:1000) increases to 0.093%.

• Women aged 25–29: incidence increases from 0.50% to 0.57%.

• Women aged 35–39: incidence increases from 2% (1:65) to 2.2%.

“Medical decision making is always complex. Information such as this should be used to assist rather than direct decision making. For some women this very small increase in risk may be enough to dissuade contraceptive use; the anxiety surrounding screening and the impact of breast cancer treatments should not be undervalued. However, informed consent is key, and the risks and benefits across multiple body systems need to be taken into consideration and individualised.

“Contraception is important to allow women control over their fertility. The effect of an unplanned pregnancy on the woman, the child and her family cannot be underestimated. Heavy periods and gynaecological conditions such as endometriosis, which can have debilitating quality of life effects, can be effectively managed with hormonal interventions. Surgical options may not be acceptable (for women wishing to maintain fertility) and carry risks such as clots and injury to bowel and bladder which are higher than the cancer risk reported in this study.”

► Go to www.pcwhf.co.uk/news/the-pcwhfs-response-to-research-onhormonal-contraceptives-and-breast-cancer-risk

£25 MILLION FOR WOMEN’S HEALTH HUB EXPANSION

Over the next two years, £25m worth of new funding has been allocated to create new women’s health hubs, as part of the Women’s Health Strategy for England . Designed to improve access and quality of care for services for menstrual problems, contraception, pelvic pain, and menopause care, the new hubs could reduce pressure on secondary care, waiting lists and tackle wider health inequalities.

WORLD'S FIRST RECYCLABLE PREGNANCY TEST LAUNCHED

Fertility wellness brand OVUM has launched the world’s first recyclable pregnancy test. Jenny Wordsworth, North Face ProEndurance athlete and polar explorer is behind the invention, which has been launched to provide the trying-to-conceive community with early pregnancy detection and minimise the impact on the environment. Approved by the FDA and the MHRA, the tests have a sensitivity of 10mIU/ml, amongst the most sensitive pregnancy tests available in the UK market.

CONTRACEPTION IS IMPORTANT TO ALLOW WOMEN CONTROL OVER THEIR FERTILITY

WHO regional meeting on human papilloma virus (HPV) vaccination

The World Health Organization (WHO) regional meeting has brought together national immunisation programme managers, chairs of national immunisation technical advisory groups (NITAGs) and representatives of NITAG secretariats from 12 middle-income countries, territories and areas that have introduced HPV vaccines.

Outcomes and deliverables of the meeting include:

• Increased awareness of tools available for national immunisation programmes to improve acceptance of HPV vaccines and generate demand for vaccination.

• Better understanding of updated WHO recommendations on reduced-dose HPV vaccination schedules.

• Improved NITAG capacity to make evidence-based recommendations on HPV vaccination schedules.

• Tailored future WHO support to countries in increasing HPV vaccine coverage and making informed decisions on HPV vaccination.

Women more likely to change eating habits than get cancer symptom checked

A survey by Target Ovarian Cancer shows that over half (55%) of women in the UK would make a change to their eating habits if they experienced persistent bloating that doesn’t go away, whereas only one in three (34%) would contact their GP.

Annwen Jones OBE, Chief Executive of Target Ovarian Cancer, said: “These findings are extremely concerning, and

provide further evidence that there remains an awareness crisis in ovarian cancer. Target Ovarian Cancer won’t accept that 11 women die every day from ovarian cancer in the UK. Not when survival rates in other countries are so much higher. And not when we can do something about it right now.

“We know that early diagnosis increases

the chances of survival and knowing the symptoms is vital to achieving this. This is why we continue to demand that the UK governments invest in awareness campaigns so that everyone knows the potential significance of persistent bloating – alongside abdominal pain, feeling full quickly and needing to wee more often –and seeks the appropriate medical advice.”

FIRST IMMUNOTHERAPY DRUG FOR ADVANCED CERVICAL CANCER AVAILABLE

Hundreds of people with cervical cancer are set to receive the first immunotherapy drug for an advanced form of the disease after the National Institute for Health and Care Excellence (NICE) published final draft guidance recommending its use in the Cancer Drugs Fund (CDF).

It is estimated that around 400 people with advanced cervical cancer will be eligible for pembrolizumab (also known as Keytruda) through the CDF. NICE’s draft guidance recommends pembrolizumab with chemotherapy (with or without bevacizumab) as an option for treating persistent, recurrent or metastatic cervical cancer in adults whose tumours express programmed cell death ligand 1 (PDL1) with a combined positive score (CPS) of at least 1 if the pembrolizumab is stopped at 2 years of uninterrupted treatment.

Clinical trial evidence shows that people on the treatment have longer without their disease getting worse than people having standard care. It also suggests they may live longer overall. But it is unclear how much longer it takes for their cancer to get worse, or how much longer they live for, because the trial hasn’t finished yet.

CLINICAL TRIAL FOR POTENTIAL NEW ENDOMETRIOSIS TREATMENT OFFERS

A clinical trial to study a potential new treatment for endometriosis is set to go ahead thanks to funding made possible by a partnership between leading women’s health charity, Wellbeing of Women, and the Scottish Government.

Researchers from the Universities of Edinburgh, Aberdeen and Birmingham, who have been awarded nearly £250,000, will set up and run the clinical trial, called EPIC2, which will involve 100 women with endometriosis in Edinburgh and London. They will investigate whether a drug called dichloroacetate is an effective pain management treatment for those with the condition.

If successful, the drug could be the first ever non-hormonal and non-surgical treatment for endometriosis – and the first new treatment in 40 years.

► Go to www.wellbeingofwomen.org.uk/news/wellbeing-of-women-scottish-government-fund-new-endometriosis-clinical-trial

NEW SCHEME FOR CHEAPER HORMONE REPLACEMENT THERAPY LAUNCHES

Women in England will now be able to access cheaper Hormone Replacement Therapy (HRT) to help with menopause symptoms.

The new HRT prescription prepayment certificate (PPC), which is available to get online or in some pharmacies, will help around 400,000 women save hundreds of pounds annually, with costs reduced to just £19.30. It can be used against a list of eligible HRT items which includes patches, tablets and topical preparations. Patients can use the HRT PPC as many times as they need across the year.

AI TO BE TRIALLED IN BREAST CANCER SCREENING FOR FIRST TIME IN ENGLAND

Innovative artificial intelligence (AI) software is set to be used in breast cancer screening as part of a ground-breaking new trial in Yorkshire. The Leeds Investigation of Breast-screening AI (LIBRA) study will be conducted at Leeds Teaching Hospitals NHS Trust after NHS England’s £100m AI in Health and Care Award confirmed the funding for the project.

The programme will involve the evaluation of an AI reader, which will analyse mammograms for signs of cancer. Currently, every mammogram is reviewed by two clinicians and if an agreement can’t be reached a third human reader is brought in.

During LIBRA, if the two health professionals can both agree with the AI that a mammogram is normal, the patient will get the all-clear. If an agreement can’t be reached, additional reviewers will be brought in and the usual arbitration process will proceed.

RCOG

joint

statement on

stigma and shame in women’s health services

The Royal College of Obstetricians & Gynaecologists and women’s health organisation partners have published a joint statement on the stigma and shame in women’s health services globally. The organisations, including Baby Lifeline, Endometriosis UK, Faculty of Sexual and Reproductive Health, Florence Nightingale Foundation, Group Strep B Support, Jo’s Cervical Cancer Trust, Royal College of Midwives, The Eve Appeal and Wellbeing of Women have pledged their commitment to:

• Lobbying for the repeal of laws that perpetuate stigma, such as restrictive abortion legislation, and engaging with political leaders and policy makers on the impact of stigma in women’s health outcomes.

• Participating in research to identify effective solutions to eliminate stigma in women’s healthcare – and expanding coproduction work with those communities experiencing the greatest stigma, exploring stigma impact and solutions.

• Advocating for health systems to embed solutions that will tackle stigma in strategies, guidance and service design; providing evidence and sharing best practice to support systems to achieve this.

• Promoting workforce diversity to place lived experiences at the heart of the organisations’ plans, priorities, and decision-making.

• Ensuring publications, guidelines and education programmes include information on stigma, use inclusive language and support the delivery of culturally competent care provision.

► Go to www.fsrh.org/news/rcog-and-womens-health-organisations-joint-statement-on-stigma

PROMOTING WORKFORCE DIVERSITY TO PLACE LIVED EXPERIENCES AT THE HEART OF THE ORGANISATIONS’ PLANS

Research & Guidelines

Maximal cytoreductive surgery for patients with advanced ovarian cancers

Patients with advanced ovarian cancer are now being recommended surgery that University of Birmingham researchers have found leads to better outcomes.

The National Institute for Health and Care Excellence (NICE) has published guidance about the use of maximal cytoreductive surgery following a consultation on evidence including research from Professor Sudha Sundar and colleagues from the University’s Institute of Cancer and Genomic Sciences.

A key piece of research showed that women treated in centres where this kind of surgery is routinely conducted, (which involves operating on a number of organs and can include removal of part of the breathing muscle and bowel) had six months increased overall survival rates compared to those that only conducted less extensive surgery.

FSRH GUIDELINE: Drug interactions between HIV antiretrovial therapy and contraception

Put differently, women with late-stage ovarian cancer treated at centres that routinely conduct maximal cytoreduction surgery have a 20% reduction in their chance of dying from ovarian cancer.

The research further found that quality of life in women was the same after 12 months regardless of whether women underwent maximal cytoreductive surgery or less extensive surgery.

Sudha Sundar, Professor of Gynaecological Cancer at the University of Birmingham commented: “The SOCQER-2 trial has shown that this major surgery to fully remove all traces of cancer, despite the seemingly high levels of impact on women’s lives afterwards, made a significant difference to their quality of life as well as increasing survival time after surgery.”

► Go to www.mdpi.com/2072-6694/14/18/4362

CARDIOVASCULAR DISEASE AND BONE HEALTH IN AGEING FEMALE RHEUMATIC DISEASE POPULATIONS

A study has reviewed the risks of cardiovascular disease (CVD) and osteoporosis and resultant fractures in ageing female rheumatic disease populations. It found that the risks of CVD and osteoporosis and resultant fractures in ageing female rheumatic disease populations, especially those with autoimmune rheumatic diseases (ARD), are increased. The study highlighted that changes in the immune system in ageing populations need to be considered, especially among patients with ARD. It also found that the effective use of disease-modifying antirheumatic drugs to control autoimmune rheumatic diseases may also mitigate factors leading to cardiovascular disease and osteoporosis.

► Go to https://journals.sagepub.com/doi/ full/10.1177/17455057231155286

The FSRH has published guidance relevant to all people at risk of pregnancy and taking HIV antiretrovial therapy (ART). It provides information on expected or potential drug-drug interactions (DDIs) between ART for the prevention and management of HIV infection, and contraception.

Key findings include:

• For people who take antiretroviral therapy (ART), hormonal contraceptive options may be affected by drug-drug interactions (DDIs).

• Many safe and effective contraceptive options exist for people living with HIV on ART, despite some potential adverse pharmacokinetic DDIs between hormonal contraception and some antiretroviral drugs.

• The contraceptive effectiveness of the depot medroxyprogesterone acetate (DMPA) injectable, the levonorgestrelreleasing intrauterine device (LNG-IUD) and the copper intrauterine device (Cu-IUD) is unaffected by DDIs with ART. All offer very effective contraception.

• Where there are significant DDIs that prevent a person choosing their preferred method of contraception, and there is a clinically appropriate alternative ART, an ART switch should be considered.

• For people at-risk of sexually transmitted infections (STI), condoms are recommended for STI prevention. Condoms also reduce the risk of HIV transmission from a partner living with HIV who is not on suppressive ART.

► Go to www.fsrh.org/standards-and-guidance/ documents/fsrh-ceu-guidance-drug-interactions/

FOR PEOPLE WHO TAKE ANTIRETROVIRAL THERAPY, HORMONAL CONTRACEPTIVE OPTIONS MAY BE AFFECTED BY DRUGDRUG INTERACTIONS

Preventing secondary breast cancer in the lung

Researchers funded by Breast Cancer Now have found how breast cancer cells can be triggered to form secondary tumours in the lungs. They found that a protein called PDGF-C plays an important role in ‘waking up’ inactive breast cancer cells that have spread there.

The PDGF-C protein lives in the lungs, a common place for breast cancer to spread to. And PDGF-C levels increase as women age, or when the lungs become damaged or scarred. The scientists discovered that these high levels of PDGF-C can cause inactive cancer cells to grow and develop into secondary breast cancer.

Dr Frances Turrell, from the Breast Cancer Now Toby Robins Research Centre at the Institute of Cancer Research, added: “Cancer cells can survive in distant organs for decades by hiding in a dormant state. We’ve discovered how ageing lung tissue can trigger these cancer cells to ‘reawaken’ and develop into tumours, and uncovered a potential strategy to ‘defuse’ these ‘time bombs’.”

In the future, the researchers hope they can target PDGF-C with an existing drug called imatinib, to prevent secondary tumours.

► Go to www.breastcancernow.org/about-us/news-personal-stories/researchers-discover-new-way-help-preventsecondary-breast-cancer-in-lung

ASSOCIATION BETWEEN VITAMIN D AND CARDIOVASCULAR HEALTH

A review has summarised studies highlighting the role of vitamin D on cardiovascular health, namely atherosclerosis, hypertension, heart failure, and metabolic syndrome, a recognised significant risk factor for cardiovascular diseases.

Studies showed differences between the results of cross-sectional and longitudinal cohorts and those from intervention trials, but also between one result and another. Cross-sectional studies found a strong

association between low 25 hydroxyvitamin D (25(OH)D3) and acute coronary syndrome, and heart failure. These findings encouraged the promotion for vitamin D supplementation as a preventive measure for cardiovascular diseases in the elderly, namely in women. This fact, however, turned out to be a myth with the results of large interventional trials that did not show any benefit from vitamin D supplementation in reducing ischemic events, heart failure or its outcomes, or hypertension.

► Go to https://journals.sagepub.com/doi/full/ 10.1177/17455057231158222

RETHINKING THE REGULATION OF DIGITAL CONTRACEPTION

A research article has addressed the regulation of digital contraception under the medical devices regime. The article argues that the regulatory category into which digital contraceptives have been placed by the medical devices regime is:

• Unduly limited in scope.

• Insufficiently stringent to protect users considering the grave and life-changing effects the technology can have if things go wrong.

• Ill-conceived as a regulatory response to a technology that affects large sections of the population.

It is suggested that the broader context in which software as a contraceptive sits (i.e. within the general contraceptive market) is key to understanding the regulatory blindness that is occurring when it comes to digital contraceptives and some other forms of fertility-related femtech.

► Go to https://journals.sagepub.com/doi/fu ll/10.1177/17455057221139660

Education & Learning

E-LFH GP TRAINING COURSE FOR PELVIC MESH COMPLICATIONS

A new programme to help GPs better understand pelvic mesh complications is available through Health Education England elearning for healthcare. For many women mesh surgery is trouble-free and leads to improvements in their condition. However, this is not the case for all, and some women have experienced complications.

The resource has been developed to aid GPs’ awareness and understanding of pelvic mesh, their potential complications and the associated symptoms women experience such as irregular vaginal bleeding and pelvic pain.

Once completed, learners will develop sound knowledge of the care options available to women living with pelvic mesh complications and will gain confidence to support women, ensuring they are assessed and referred to specialist services.

UK’s first medical ultrasound degree apprenticeship launches

The UK’s first medical ultrasound degree apprenticeship has launched at Sheffield Hallam University.

According to the University, the new apprenticeship has been developed in conjunction with the NHS, professional bodies and the private sector in a bid to enable employers to more effectively upskill their workforce, as the healthcare industry continues to suffer from labour shortages.

The NHS People Plan estimates that, by 2024, approximately 27,000 extra allied health professionals will be needed – Sheffield Hallam University is anticipating that over 250 degree apprenticeships will start on allied health courses in 2023.

Apprenticeship Lead for Allied Health Professions at Sheffield Hallam, Aimee France, said: “We’re already seeing the impact our apprentices are making on the workforce in allied health professions and these new courses have the potential to continue to drive the workforce forward.

“The apprentices will already be working in a clinical setting and are comfortable in the environment. They also don’t need to wait until they graduate to put their skills into practice which is beneficial for them and their employer.”

► For more information go to www.e-lfh.org.uk/ new-pelvic-mesh-complications-elearning-for-gps

PCWHF MEMBERS RECEIVE FREE ACCESS TO ALL ELEARNING CONTENT

The PCWHF Board has made the decision to give Members access to all eLearning courses completely free of charge. This is to include the much-anticipated release of the Contraception Foundation Course Part 1 (POP) as well as Menopause for Prescribers, released later this year.

The move aims to make eLearning more accessible and highlights the importance of educational programmes to the PCWHF Board. In March and April 2023, the Board also ran its annual Educational Programme survey which gives subscribers and Members to the PCWHF a say in what the Board and Education Committee will focus on for the year ahead.

WE’RE ALREADY SEEING THE IMPACT OUR APPRENTICES ARE MAKING ON THE WORKFORCE IN ALLIED HEALTH PROFESSIONS

Perinatal mental health virtual reality training programme

England has become the first country in the world to launch clinical training in perinatal mental health using extended reality (XR) technology.

A ground-breaking patient avatar has been developed by Health Education England in partnership with Fracture Reality and allows healthcare learners to expand their skills interacting with people with perinatal mental health issues through a series of instructor-driven simulations.

Using a headset, learners interact with the avatar, called Stacey, a virtual patient who is directed by an instructor and run as a simulation on Fracture Reality’s JoinXR platform.

The technology can be used in augmented reality where learners are able to practise in their own clinical setting, as well as virtual reality that offers students the chance to experience interacting with Stacey in her own home or other clinical settings.

The project provides learners with an immersive simulated experience that allows them to have realistic and natural conversations with Stacey, asking her about her symptoms and making plans to get her the right support. These scenarios represent the types of real-life conversations health professionals may have with perinatal mental health patients – but in Stacey’s case, she is able to present to anyone who meets her in a standardised approach that enables the learner to reflect and debrief.

It has been designed to allow students to practise their skills in a safe environment until they are able to take the skills they have learnt into a real-life clinical setting.

MENOPAUSE KNOWLEDGE AND EDUCATION IN WOMEN UNDER 40

Results from a study aiming to understand what women under 40 know about the menopause, how they have acquired this knowledge and where they think menopause education should be taught, have been published. Conducted using social media, a total of 738 women’s responses were included in the analysis. Over 80% had no knowledge or just some knowledge of the menopause. Women over 30 used official websites and scientific literature significantly more than other age groups to learn about the menopause, while women under 20 were more likely to learn from family members.

► Read the results at https://journals.sagepub.com/doi/full/10.1177/17455057221139660

Asking the audience

Following concerns about age-inappropriate content being taught in schools, the Government has announced a review of Relationships, Sex and Health Education (RSHE) in 2023. But what do young people really think about what they learn? The Sex Education Forum found out.

WORDS BY EMMA COOPER

The Sex Education Forum plays a leading role in monitoring RSHE, having carried out substantial polls in the lead up to legislative change (in 2018 and 2019) and since mandatory provision (in 2021 and 2022)

In 2022, the Sex Education Forum commissioned Censuswide to carry out a poll of 1,000 young people aged 16 and 17 years old, living in England. The aim was to ask young people about their experiences of RSHE to determine the extent and effectiveness of the legislation. The fieldwork took place between 2 December 2022 and 13 December 2022.

Who took part?

Of the 1,002 young people participating:

• 517 identified as female, 454 identified as male, and 23 identified as non-binary.

• 590 identified as White, 182 as Asian, 98 as Black, 67 as Mixed Descent and 16 as Arab (these figures provide a summary of the more detailed ethnicity categories used).

• 780 identified as straight, 150 identified as lesbian, gay or bisexual, queer or questioning, and 20 identified as asexual or aromantic.

• 278 were eligible for free school meals.

The pool of data is big enough to show up if some groups of young people are more satisfied with the quality of their RSHE than others. But what about marginalised young people? The Sex Education Forum also spoke with groups of young people who are members of the LGBT Youth in Care Network and Ambitious About Autism Youth Network. After discussions about the design and purpose of the poll, changes to the questions and layout were made. Once data from the final poll was collected, The Sex Education Forum invited young people back to pre-view the findings and spoke with the Youth Network at Ambitious About Autism, asking for reactions and deeper insights.

Questions included

Q. What formats should be used more in RSHE and why? Are there any formats that you feel would be more beneficial for an autistic student?

A. “Using real-life situations is particularly helpful for autistic students. We watched the cup of tea video, but it is very metaphorical and confusing for autistic young people in particular. It didn’t show the seriousness of what the scenario is. It came across as humorous, it’s not the right way to go about it. People just laughed, we didn’t actually talk about consent.

“Give time to young people to digest questions rather than answer on the spot”.

Q. Are you surprised about the findings from the poll?

A. “At the time (I had RSHE) I was satisfied and thought “that’s good” and “that’ll do” but now I know it was missing a lot e.g. lack of representation for disabled people and LGBTQ+ couples”.

OVER A THIRD OF YOUNG PEOPLE SAID THEY WANTED MORE OPEN DISCUSSION OF ISSUES

Key findings of the survey:

• The percentage of young people saying the quality of RSHE is ‘good’ or ‘very good’ is 40% , on par with the data from 2019 – highlighting that the improved, robust RSHE the Government promised three years ago has not yet materialised.

• Topics that are often missed from the curriculum include pornography, LGBTQ+ relevant information, power imbalances and healthy relationships.

• Respondents were split about whether enough time was dedicated to RSE in school, with 37% agreeing schools offered enough hours of RSHE and 38% disagreeing.

• Over a third ( 35%) of young people said they wanted more open discussion of issues.

• 56% learnt ‘not enough’ or ‘nothing’ about how to access local sexual health services.

The gaps in RSHE topic coverage:

• 42% of respondents learnt nothing at all about sexual pleasure at school.

• 30% of respondents learnt nothing at all about pornography, and a further 28% learnt ‘some, but not enough’ about the topic.

• 28% of respondents learnt nothing at all about power imbalances in relationships, and a further 30% learnt ‘some, but not enough’ about the topic.

• 26% learnt nothing at all about sexual orientation, and 34% learnt nothing at all about gender identity.

• 24% learnt nothing at all about how to tell if a relationship is healthy (including online) and a further 31% learnt ‘some, but not enough.’

• 27% learnt nothing at all about how to access local sexual health services and just over one in five (21%) learnt nothing about HIV.

• 27% learnt nothing about cultural and faith perspectives on relationships and sex, and a further 29% learnt ‘some, but not enough’ on the topic.

• 14% learnt nothing at all about the medically correct names for genitalia (vulva, vagina, clitoris, penis, testicles).

The topics most fully covered:

• 52% learnt all they needed to about sexual harassment.

• 63% learnt all they needed to about understanding sexual consent.

• 63% learnt all they needed to about how babies are conceived and born.

• 65% learnt all they needed to about puberty.

• 70% learnt all they needed to about bullying including cyberbullying.

Following the publication of the poll, the Sex Education Forum is calling on the Government to:

1. Consult young people and update their guidance to require that young people’s views inform school curriculum development, as part of the 2023 RSHE guidance review.

2. Make good on its pledge for substantial and sustained investment in RSHE training – on par with other curriculum subjects – to build teacher confidence and skill.

► For more information go to www.sexeducationforum.org.uk/resources/evidence

Her Life Her Health asked

Based on the findings of this report, what do you think are the key areas the Government should focus on when it reviews RSHE?

“The main focus of the RSHE review should be on ensuring that RSHE is providing what young people need: a curriculum that recognises the real challenges they are experiencing in their lives right now; that prepares them for the changes they will experience, and the decisions they will have to make as they grow into adulthood; and that gives them the information, tools, skills and critical thinking to make sense of a world that is unrecognisable from the one their parents grew up in.

“The Sex Education Forum poll features really useful insights from young people and demonstrates that their voices are key to drafting new guidance that will meet their needs.

“Teachers have the considerable challenge of delivering a vast and complex curriculum that includes the traditional topics of puberty, fertility and sexual and reproductive health; mental health; bullying, healthy relationships, consent, sexual violence and harassment; the increasing challenge of misogynistic influencers; and addressing the challenges specific to living in a digital age with the access that provides to harmful information and explicit sexual imagery… to name a selection. All this must be delivered in a way which is LGBT+ inclusive, accessible and useful for disabled students and those with special educational needs, and which acknowledges the diversity of beliefs and values in every school community.”

Given the finding that 56% learnt ‘not enough’ or ‘nothing’ about how to access local sexual health services, how can primary care support young people when it comes to their sexual health?

“Many young people are familiar with accessing care through their GP practice, and primary care has a critical role in supporting young people with their sexual and reproductive health. Schools, teachers and consequently young people often have very little knowledge of where or how to access sexual health services or that they can do so through primary care. Anything local services and practices can do to make themselves visible to schools is useful. From sending information that can be provided in RSE or displayed on noticeboards, to offering to come and talk to students about their work, HCPs can play a vital role.

“Brook staff are often invited in to talk to young people about what it would be like to visit their services. Young people need repeated reassurance about their rights to access services confidentially, and really benefit from seeing a friendly face from a local service encouraging them to visit.”

PRIMARY CARE HAS A CRITICAL ROLE IN SUPPORTING YOUNG PEOPLE WITH THEIR SEXUAL AND REPRODUCTIVE HEALTH

LISA HALLGARTEN , Head of Policy and Public Affairs at Brook for her thoughts.

The silent epidemic of CHRONIC PELVIC PAIN

Chronic pelvic pain (CPP) is an umbrella term for a range of silent and debilitating conditions that impact the lives of millions of women worldwide. These include endometriosis, vulvodynia, and many others. CPP affects 15%–24% of women, and it is the most common reason why women seek gynaecological care1 In this primer, I will provide you with an overview of CPP, including symptoms, differential diagnosis, and management strategies.

DEFINITION OF CPP

DR CLAUDIA CHISARI , Founder and CEO of Femspace, on how you can support your patients with complex pain.

CPP is pain that has been present for six or more months in the lower abdomen or pelvis. The pain may be constant or intermittent. Other symptoms include dyspareunia (pain during sexual intercourse), dysmenorrhea (pain during menstruation), urinary or bowel symptoms, and problems with mobility, having a significant effect on women’s quality of life2

IT’S IMPORTANT TO ALSO ADDRESS SYMPTOMS THAT GO BEYOND THE PAIN

What are the most common causes of CPP?

Endometriosis

Endometriosis is a condition that affects 10% of women of reproductive age 3 , where tissue similar to the lining of the uterus grows outside of the uterus. Symptoms of endometriosis can include dysmenorrhea, dyspareunia, and infertility. Management strategies include hormonal therapy, such as combined oral contraceptives or progestogens, or referral for surgery4

Adenomyosis

Adenomyosis is a condition in which the tissue that lines the uterus grows into the muscular wall of the uterus. The prevalence of adenomyosis is estimated to be varying quite a lot, ranging from 5% to 70% 5 . Symptoms include heavy or prolonged menstrual bleeding, dysmenorrhea, and pelvic pain. Management strategies include hormonal therapy or referral for surgery 6

Pelvic Inflammatory Disease (PID)

PID is an infection of the reproductive organs that can cause chronic pelvic pain, affecting 1 in 500 women in the UK per year 7. Symptoms of PID can include lower abdominal pain, dyspareunia, and abnormal vaginal discharge. Management strategies include antibiotics and referral to a gynaecologist for further investigation⁸.

Vulvodynia

Vulvodynia is defined as chronic vulvar pain without an identifiable cause. The pain can be provoked by touch, penetration, or pressure in the vulva, or happen spontaneously. The prevalence of vulvodynia is 8%–28%⁹. The most successful management strategy for vulvodynia is physical therapy. Alternatively, referral to specialist is recommended 10. Vulvodynia is often misdiagnosed for thrush. It’s important to note that unlike thrush, the skin in vulvodynia is ‘healthy-looking’. When women refer to burning pain but have no evidence of thrush, vulvodynia should be considered.

Vaginismus

Vaginismus is when the muscles of the vagina involuntarily contract, making penetration difficult or impossible. Vaginismus affects 1–7% of women 11 . The most successful management strategy for vaginismus is physical therapy 12

PRIMARY CARE CLINICIANS PLAY A CRUCIAL ROLE IN THE CARE OF WOMEN WITH CPP

Management strategies

Management strategies will depend on the underlying cause. Physical therapy is effective in reducing pelvic pain in women with many pelvic pain conditions, including vulvodynia and vaginismus13 . In endometriosis and adenomyosis, hormonal therapy or surgery may be necessary. This can be complemented by physiotherapy for the pelvic floor, as pelvic floor function is often impacted by the pain.

It’s important to also address symptoms that go beyond the pain. These can include anxiety and depression, as well as the impact on sex and relationships14 A multidisciplinary approach that also includes sex-therapy or psychotherapy is the most beneficial way of managing these conditions.

REFERENCES

1. Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6(1):177. doi:10.1186/1471-2458-6-177

2. Howard FM. Chronic Pelvic Pain. Obstet Gynecol. 2003;101(3):594-611. doi:10.1016/s0029-7844(02)02718-6

3. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):1789-1799. doi:10.1016/ S0140-6736(04)17403-5

4. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29(3):400412. doi:10.1093/humrep/det457 5. Harada T. Dysmenorrhea and endometriosis in young women. Yonago Acta Med. 2013;56(2):43-48.

6. Leyendecker G, Wildt L. A new concept of adenomyosis: adenomyosis is not an invasive disease. Ann NY Acad Sci. 2004;1034:221-233. doi:10.1196/annals.1335.028

7. Price MJ, Ades AE, De Angelis D, Welton NJ, Macleod J, Soldan K. Risk of pelvic inflammatory disease following Chlamydia trachomatis infection: analysis of prospective studies with a multistate model. Am J Epidemiol. 2013;178(3):484-492. doi:10.1093/aje/kws560

8. Ross J, Judlin P, Jensen J. Pelvic inflammatory disease: a clinical update. Int J Womens Health. 2013;5:589-601. doi:10.2147/IJWH.S40926 9. Pukall CF, Baron M, Amsel R, Khalifé S. Vulvodynia: a critical review. Pain Res Manag. 2005;10(4):243-254. doi:10.1155/2005/703810

10. Arnold LD, Bachmann GA, Rosen R, et al. Vulvodynia: characteristics and associations with comorbidities and quality of life. Obstet Gynecol. 2006;107(3):617-624. doi:10.1097/01.

AOG.0000199152.43435.2 11. Graziottin A. Vaginismus: review of current concepts and treatment using botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. J Sex Med. 2014;11(1):89-102. doi: 10.1111/ jsm.12340 12. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 602: Sexual pain. Obstet Gynecol. 2014;123(1):233-238. doi: 10.1097/01. AOG.0000443279.51792.af 13. FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor I. Background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14(4):261-268. doi: 10.1007/s00192-003-1076-1 14. International Pelvic Pain Society. Patient Centered Guide to CPP. International Pelvic Pain Society. Accessed February 28, 2023. www.pelvicpain.org/docs/patientcenteredguide.pdf

15. American Academy of Family Physicians. Chronic pelvic pain in women. American Family Physician. 2008;77(11):1535-1542. Accessed February 28, 2023. www.aafp.org/ afp/2008/0601/p1535.htmlˆ16. Women’s College Hospital. Chronic Pelvic Pain. Women’s College Hospital. Accessed February 28, 2023. www.womenscollegehospital.ca/healthinformation/health-topics/chronic-pelvic-pain 17. Harvard Health Publishing. Beyond endometriosis: Other possible causes of pelvic pain. Harvard Women’s Health Watch. 2020;28(10): 3-4. Accessed February 28, 2023. www.health.harvard.edu/womens-health/ beyond-endometriosis-other-possible-causes-of-pelvic-pain

Myth 1

CPP is all in the person’s head

Fact: Chronic pelvic pain is real, with physical and emotional components. Ignoring the physical component and dismissing the patient’s pain as “all in their head” can be detrimental to their mental health and delay appropriate treatment 15

Myth 2

CPP is a normal part of being a female

Fact: While some degree of discomfort during menstruation may be normal, pain that significantly impacts a woman’s quality of life is not normal and should be evaluated by a healthcare professional 16

Myth 3

CPP is always caused by a gynaecological issue

Fact: While gynaecological issues can certainly cause CPP, other causes, such as gastrointestinal issues like irritable bowel syndrome, should also be considered 17

Your role

Primary care clinicians play a crucial role in the care of women with CPP. Many of you face significant challenges with these conditions, including their complexity and lack the resources to provide comprehensive long-term care.

At Femspace, we provide accessible resources and long-term care for pelvic pain, which some of the women you’ll be seeing might benefit from. Femspace is an evidencebased online platform that provides accessible and comprehensive care for women with CPP, designed to complement your care. It provides specialist psychological support, physiotherapy, and free educational resources specifically for pelvic pain.

Behind Femspace is a team of pelvic pain specialists, including world-leading academics and pain scientists supported by King’s College London, physiotherapists, psychologists, and sex therapists with a mission to provide better care for CPP.

► For more information go to www.femspace.co.uk

COMMON MYTHS ABOUT CPP

This poster is intended for UK healthcare

OF…

CONTRACEPTIVE SAFETY

A glance at UKMEC guidance on safe use of contraception, to pull out and pop on your wall.

The UK Medical Eligibility Criteria for Contraception Use (UKMEC) provides evidence-based (or expert opinion where evidence is lacking) guidance on safe use of contraception based on individual health conditions or personal characteristics.

It does not:

• Address the use of contraceptives for non-contraceptive benefits

• Consider the efficacy of methods

Do you recommend?

Probably yes

• Replace clinical judgement

It does:

TIP: This document should be consulted and findings referenced in the patient record where there are any concerns about contraceptive use for an individual patient FUNDAMENTALS

• Provide guidance on safety of contraceptive methods using numerous medical conditions and patient characteristics

Definition

UKMEC Category

Probably not

No

A condition where there is no restriction for use of the method.

A condition where the advantages of using the method generally outweigh the theoretical or proven risks.

A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/ or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable.

A condition which represents an unacceptable health risk if the method is used.

1

Yes 2

POP = Progestogen-only pill

CHC = Combined hormonal contraception

IoM = Initiation of method C = Continuation of method

Cu-IUD = Copper-containing intrauterine device

LNG-IUS = Levonorgestrel containing intrauterine system

SDI = Subdermal implant

DMPA = Depo medroxyprogesterone acetate

Example of case typically presenting in primary care

To access more free resources, visit • Full guidance www.fsrh.org/standards-and-guidance/uk-medical-eligibility-criteria-for-contraceptive-use-ukmec

www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets

TIP: Download summary sheets onto desktop for easy access

Prescribing Information – Lenzetto

Refer to Summary of Product Characteristics (SmPC) for further details.

Product name: Lenzetto 1.53 mg/spray, transdermal spray, solution.

Composition: Each spray delivers 90 microliter of transdermal spray, solution containing 1.53 mg of estradiol (equivalent to 1.58 mg of estradiol hemihydrate) and 65.47mg ethanol.

Indications: Hormone Replacement Therapy (HRT) for oestrogen deficiency symptoms in postmenopausal women (in women at least 6 months since last menses or surgical menopause, with or without a uterus). The experience in treating women older than 65 years is limited.

Dosage and administration: Starting dose is one metered-dose spray is administered once daily to the dry and healthy skin of the forearm as a starting dose; this may be increased to two metered-dose sprays daily based on clinical response and only after at least 4 weeks of continuous treatment with Lenzetto. The maximum daily dose is 3 metered-dose sprays (4.59 mg/day) to the forearm. Dose increase should be discussed with the physician. For patients who have difficulty applying the prescribed dose to distinct, non-overlapping areas of the same forearm, Lenzetto may also be applied to the alternate forearm or the inner thigh. The lowest effective dose for the shortest duration should be used; when menopausal symptoms are not reduced after a dose increase, the patient should be back-titrated to the previous dose. Re-evaluate continued need for treatment periodically (e.g. 3-month to 6-month intervals). In women with a uterus: Lenzetto should be combined with a progestagen approved for addition to oestrogen treatment in a continuous - sequential dosing scheme: the oestrogen is dosed continuously and progestagen added for at least 12 to 14 days of every 28-day cycle, in a sequential manner. In the combined oestrogen-progestogen phase, withdrawal bleeding can occur. A new 28-day treatment cycle is started without a break. In women without a uterus: Unless there is a previous diagnosis of endometriosis, it is not recommended to add progestagen for women without a uterus. Overweight and obese women: The rate and extent of absorption of Lenzetto can be reduced in overweight and obese women necessitating dose adjustment which should be discussed with the physician. Paediatric population: There is no relevant use of Lenzetto in the paediatric population. Missed dose: A missed dose should be taken as soon as remembered unless it is almost time for the next dose; the following dose is taken at the usual time. If one or more doses are missed one primer spraying with the cover on is needed. Forgetting a dose may increase the likelihood of breakthrough bleeding and spotting. Method of administration: Hold container upright and vertical for spraying. Before a new applicator is used for the first time, prime the pump by spraying three times into the cover. If two or three sprays are prescribed as the daily dose, they should be applied to adjacent non-overlapping (side-by-side) 20 cm2 areas on the inner surface of the arm between the elbow and the wrist and allowed to dry for approximately 2 minutes. Do not allow another person to touch the site of application; cover the application site with clothing if another person may come into contact with that area of skin after the spray dries. Do not wash the application site within 60 minutes of application. Cover the application site with clothing if another person may come into contact with that area of skin after the spray dries. Do not allow children to come in contact with the area of the arm where Lenzetto was sprayed. If this occurs, wash the child’s skin with soap and water as soon as possible. Use within 56 days of first use.

Elevated skin temperature: Clinically relevant changes in absorption of Lenzetto have not been demonstrated with increased ambient temperatures; however, use with caution in extreme temperature conditions, such as sun bathing or sauna. Application of sunscreen: When sunscreen is applied about one hour following Lenzetto, estradiol absorption may be decreased by 10%; when sunscreen was applied about one hour prior to Lenzetto, no effect on absorption was observed.

Contraindications: Known, past or suspected breast cancer. Known or suspected oestrogen-dependent malignant tumours (e.g. endometrial cancer). Undiagnosed genital bleeding. Untreated endometrial hyperplasia. Previous or current venous thromboembolism (deep venous thrombosis, pulmonary embolism). Known thrombophilic disorders (e.g. protein C, protein S, or antithrombin deficiency). Active or recent arterial thromboembolic disease (e.g. angina, myocardial infarction). 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.

Warnings and precautions: HRT for menopausal symptoms should only be initiated for those that adversely affect quality of life. Assess the risks and benefits at least annually and continue HRT only as long as benefit outweighs risk. Medical examination/follow-up: Before initiating or reinstituting HRT, a complete personal and family medical history should be taken. Physical (including pelvic and breast) examination should be guided by this and by the contraindications and warnings for use. During treatment, periodic check-ups are recommended in accordance with currently accepted screening practices and of a frequency and nature adapted to the individual woman. Women should be advised what changes in their breasts should be reported to their doctor or nurse. Investigations, including appropriate imaging tools, e.g. mammography, should be carried out in accordance with currently accepted screening practices, modified to the clinical needs of the individual. Conditions which need supervision: If any of the following conditions are present, have occurred previously, and/or have been aggravated during pregnancy or previous hormone treatment, the patient should be closely supervised. It should be taken into account that these conditions may recur or be aggravated during treatment with Lenzetto, in particular: leiomyoma (uterine fibroids) or endometriosis; risk factors for thromboembolic disorders; risk factors for oestrogen- dependent tumours, e.g. first-degree heredity for breast cancer; hypertension; liver disorders (e.g. liver adenoma); diabetes mellitus with or without vascular involvement; cholelithiasis; migraine or (severe) headache; systemic lupus erythematosus; history of endometrial hyperplasia; epilepsy; asthma; otosclerosis. Reasons for immediate withdrawal of therapy: Discontinue therapy if a contraindication is discovered and in the following situations: jaundice or deterioration in liver function; significant increase in blood pressure; new onset of migraine-type headache; pregnancy. Endometrial hyperplasia and carcinoma: In women with an intact uterus the risk of endometrial hyperplasia and carcinoma is increased when oestrogens are administered alone for prolonged periods. The addition of a progestagen cyclically for at least 12 days per month/28 day cycle or continuous combined oestrogen–progestagen therapy in non-hysterectomised women prevents the excess risk associated with oestrogen-only HRT. Breakthrough bleeding and spotting may occur during the first months of treatment. If breakthrough bleeding or spotting appears after some time on therapy, or continues after treatment has been discontinued, the reason should be investigated, which may include endometrial biopsy to exclude endometrial malignancy. Unopposed oestrogen stimulation may lead to premalignant or malignant transformation in the residual foci of endometriosis. Therefore, the addition of progestagens to oestrogen replacement therapy should be considered in women who have undergone hysterectomy because of endometriosis if they are known to have residual endometriosis. Breast cancer: The overall evidence suggests an increased risk of breast cancer in women taking combined oestrogen-progestagen or oestrogen-only HRT, that is dependent on the duration of taking HRT. The increased risk in users of oestrogen-only therapy is lower than that seen in users of oestrogen-progestagen combinations. HRT, especially oestrogen-progestagen combined treatment, increases the density of mammographic images, which may adversely affect the radiological detection of breast cancer. Consult the SmPC for more information on HRT and breast cancer. Ovarian cancer: Epidemiological evidence suggests a slightly increased risk in women taking oestrogen-only or combined oestrogen-progestagen HRT.

Venous thromboembolism: HRT is associated with a 1.3- 3-fold risk of developing venous thromboembolism (VTE), i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of HRT than later. HRT is contraindicated in patients with known thrombophilic states. Generally recognised risk factors for VTE include, use of oestrogens, older age, major surgery, prolonged immobilisation, obesity (BMI > 30 kg/m2), pregnancy/ postpartum period, systemic lupus erythematosus (SLE), and cancer. There is no consensus about the possible role of varicose veins in VTE. As in all postoperative patients, prophylactic measures need be considered to prevent VTE following surgery. If prolonged immobilisation is to follow elective surgery temporarily stopping HRT 4 to 6 weeks earlier is recommended. Treatment should not be restarted until the woman is completely mobilised. In women with no personal history of VTE but with a first degree relative with a history of thrombosis at young age, screening may be offered after careful counselling regarding its limitations. If a thrombophilic defect is identified which segregates with thrombosis in family members or if the defect is ‘severe’ (e.g., antithrombin, protein S, or protein C deficiencies or a combination of defects) HRT is contraindicated. Women already on chronic anticoagulant treatment require careful consideration of the benefit- risk of use of HRT. If VTE develops after initiating therapy, Lenzetto must be discontinued. Patients should be told to contact their doctors immediately when they are aware of a potential thromboembolic symptom (e.g. painful swelling of a leg, sudden pain in the chest, dyspnoea). Coronary artery disease (CAD): There is no evidence from randomised controlled trials of protection against myocardial infarction in women with or without existing CAD who received combined oestrogen-progestagen or oestrogen-only HRT. Ischaemic stroke: Combined oestrogen-progestagen and oestrogen- only therapy are associated with an up to 1.5-fold increase in risk of ischaemic stroke. The relative risk does not change with age or time since menopause. However, as the baseline risk of stroke is strongly age-dependent, the overall risk of stroke in women who use HRT will increase with age. Visual abnormalities: Retinal vascular thrombosis has been reported in women receiving oestrogens. Medication must be discontinued immediately, pending examination if there is sudden partial or complete loss of vision, or a sudden onset of proptosis, diplopia, or migraine. If examination reveals papilledema or retinal vascular lesions, oestrogens should be permanently discontinued. ALT elevations: Concomitant use of products containing ethinylestradiol and antiviral drugs combinations for hepatitis C, or some protease inhibitors (glecaprevir/pibrentasvir), may lead to elevations of ALT more than 5 times the upper limit of normal (ULN). The rate of ALT elevations in women using products containing other oestrogens (eg. oestradiol) was similar to that in women not using any oestrogens; however, caution is warranted for co-administration of other oestrogens with the combination drug regimen ombitasvir/paritaprevir/ritonavir with or without dasabuvir and also the regimen glecaprevir/ pibrentasvir, due to the limited number of women taking these combinations. Other conditions: Oestrogens may cause fluid retention, and therefore patients with cardiac or renal dysfunction should be carefully observed. Exogenous oestrogens may induce or exacerbate symptoms of hereditary and acquired angioedema. Closely monitor women with pre-existing hypertriglyceridemia during oestrogen replacement or hormone replacement therapy; rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition. There is some evidence of increased risk of probable dementia in women who start using continuous combined or oestrogen-only HRT after the age of 65. Excipient: Ethanol may cause a burning sensation on damaged skin. Alcohol based products are flammable. Avoid fire, flame or smoking until the spray has dried. Paediatric population: Estradiol spray can be accidentally transferred to children from the area of the skin where it was sprayed on. Post-marketing reports of breast budding and breast masses in prepubertal females, precocious puberty, gynaecomastia and breast masses in prepubertal males following unintentional secondary exposure to estradiol spray have been reported. The physician should identify the cause of signs and symptoms (breast development or other sexual changes) in a child that may have been exposed accidentally to estradiol spray. In most cases, the condition resolved with removal of estradiol spray exposure. Consideration should be given to discontinuing Lenzetto if conditions for safe use cannot be met.

Undesirable effects: Common (≥1/100 to <1/10): Headache; abdominal pain; nausea; rash; pruritus; breast pain; breast tenderness; uterine/vaginal bleeding including spotting; metrorrhagia; weight increased; weight decreased. Uncommon (≥1/1,000 to <1/100): Hypersensitivity reaction; depressed mood; insomnia; dizziness; visual disturbances; vertigo; palpitations; hypertension; diarrhoea; dyspepsia; erythema nodosum; urticaria; skin irritation; myalgia; breast discolouration; breast discharge; cervical polyp; endometrial hyperplasia; ovarian cyst; vaginitis; oedema; axillary pain; gamma-glutamyltransferase increased; blood cholesterol increased. Rare (≥1/10,000 to <1/1,000): Anxiety; libido decreased; libido increased; migraine; contact lens intolerance; bloating; vomiting; hirsutism; acne; muscle spasms; dysmenorrhoea; premenstrual-like syndrome; breast enlargement; fatigue. Frequency not known: Alopecia, chloasma, skin discolouration. Breast cancer risk: An up to 2-fold increased risk of having breast cancer diagnosed is reported in women taking combined oestrogen- progestagen therapy for more than 5 years. The increased risk in users of oestrogen-only therapy is lower than that seen in users of oestrogen-progestagen combinations. The level of risk is dependent on the duration of use. Consult SmPC for detailed information on breast cancer, endometrial cancer, ovarian cancer and venous thromboembolism.

Packs and NHS Price: Lenzetto 1.53mg/spray x 1 - £6.90 and Lenzetto 1.53mg/spray x 3 - £20.70.

Legal Classification: POM.

MA Number: PL 04854/0130.

Marketing Authorisation Holder: Gedeon Richter Plc, Gyömrői út 19-21, 1103 Budapest , Hungary. Further information is available from: Gedeon Richter UK Ltd, 127 Shirland Road, London W9 2EP. Tel: +44 (0) 207 604 8806. Email: medinfo.uk@gedeonrichter.eu

Date of Authorisation: August 2015.

Date of preparation of PI: October 2022. UK-LENZ-2200252.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard, or you can report via the Yellow Card app which is available to download from the Apple App Store or Google Play Store. Adverse events should also be reported to Gedeon Richter (UK) Ltd on +44 (0) 207 604 8806 or by email to drugsafety.uk@gedeonrichter.eu

References: 1. Buster JE et al. Obstet Gynecol. 2008;111:1343-51. 2. Gedeon Richter. Lenzetto® Summary of Product Characteristics. 3. Algin-Yapar E et al. J. Pharm Res 2014;13:469.

... IN A SIMPLE SPRAY

Lenzetto reduces both the frequency and intensity of moderate to severe hot flushes compared to placebo.1

Gedeon Richter have developed the following materials to support you and your patients with Lenzetto:

Lenzetto placebo device to help demonstrate Lenzetto’s ease of use. Reach out to your local Gedeon Richter representative to order a placebo.

Resources aimed at patients and/or healthcare professionals can be provided by your Gedeon Richter representative or accessed and downloaded from www.lenzetto.co.uk.

This is a promotional website aimed at UK healthcare professionals.

Lenzetto is indicated as HRT for oestrogen deficiency symptoms in postmenopausal women (women at least 6 months since their last menses or surgical menopause, with or without a uterus). There is limited experience in treating women older than 65 years.2

How hormones affect how we breathe

Sex hormones (progesterone, oestrogens, androgens) and breathing affect each other mutually. It is not clear which hormone is crucial however the effect of hormones on breathing is a subject that is often overlooked 1 Breathing is generally an unconscious process, however this does not mean it is automatically efficient.

Aware

Women generally have a smaller airway, ribcage size, lung volume and a shorter diaphragm than men. In addition, the movement of the ribs during an inhalation is different in women compared to men 2 . All these factors impact how easily air enters and leaves the female body. A large population-based study showed lung function declined more rapidly among perimenopausal and menopausal women. This decline was greater than the normal expected deterioration in lung function related to ageing 3 . There is an increased loss of muscle mass around the menopause 4 , but how often do we discuss muscle loss from the muscles involved in breathing and perform specific exercises to strengthen these muscles?

Although the exact mechanism is not clear, studies have shown an increased risk of sleep disordered breathing (SDB) after menopause5 SDB refers to a wide spectrum of sleep-related conditions including increased resistance to airflow through the upper airway, heavy snoring, marked reduction in airflow (hypopnea), and complete cessation of breathing (obstructive sleep apnoea (OSA))6

The Wisconsin Sleep Cohort Study demonstrated that there is a 3-times greater risk of moderate or worse OSA in postmenopausal women compared to pre-menopausal women5 Women with OSA are less likely to report snoring or witnessed gaps in breathing (apnoea) but are more likely to complain of daytime fatigue, lack of energy, insomnia, morning headaches, mood disturbance and nightmares compared to men7 More research is needed into how hormonal changes affect breathing.

Assess

Effective breathing is through the nose and is slow and gentle. The exhale should be longer than the inhale, there should be a short pause after the exhale,

and it should be driven by the diaphragm (the lower ribs should expand sideways on the inhale). Over the next week check in with your breathing during the day, whilst moving and when asleep, to assess whether it matches this description. Breathing inefficiency (dysfunctional breathing) lacks a rigorous definition and a clear method of assessment. Kiesel and colleagues⁸ explored different assessment methods, leading them to propose a breathing screening procedure which consists of measuring breath hold time and answering four questions (see www.tinyurl.com/ dysfunctionalbreathing).

Action

Breathing re-education improves breathing efficiency 9,10 and consists of two main aspects:

• Ensuring the air way is open, strong, and combined with nasal breathing.

The risk of sleep disordered breathing increases as women transition through the menopause, which can impact quality of life.

WORDS BY DR LOUISE OLIVER

• Ensuring the amount of air an individual is breathing matches their metabolic need, they are using the correct breathing muscles and the speed of breathing encourages synchrony between the heart and lungs. Breathing through the upper airway can be compared to drinking a thick milkshake through a paper straw. Choosing a wide, strong straw increases the chance of drinking the milkshake with ease.

Tongue position

The back of the tongue forms part of the airway. If the tongue is in the correct position, it opens the airway. The correct position for the tongue is flat against the roof of the mouth, not touching the front teeth, lips sealed and not clenching the teeth. If the mouth is open, the tongue naturally sits in the lower part of the mouth and narrows the airway. Training the body to maintain the tongue in the correct position during the day makes it more likely the tongue will remain in this position whilst sleeping.

Oropharyngeal exercises

It is thought the tone of the upper airways muscles decreases after the menopause. This may

TIPS FOR PRIMARY CARE

AWARE – Raise awareness of how breathing is altered by hormones and how this can lead to inefficient breathing.

ASSESS – Offer an opportunity for women to assess their breathing efficiency.

ACTION – Encourage and empower women to improve their breathing efficiency.

cause increased resistance to air passing through the upper airway or the throat to vibrate (snoring) or collapse (OSA). Practising oropharyngeal exercises11 can improve muscle strength. Mr Vik Veer, the consultant lead for the Sleep Surgery at the Royal National ENT Hospital in London has created a YouTube video of oropharyngeal exercises which have been shown to improve snoring and sleep apnoea in some studies. Watch it here: www.tinyurl.com/ oropharyngeal

Nasal breathing

Breathing should only occur through the nose including when we are at rest, during exercise and sleep. The nose is designed to pressurise, warm, and moisten the air we breathe as well filter out impurities and pathogens, whereas the mouth has no role in breathing. Mouth breathing brings dry, cold, unpressurised air into the lungs which can trigger bronchospasm or trigger the cough reflex.

Training the body to have the mouth closed whilst awake increases the likelihood that an individual will nasal breathe during sleep. If an individual continues to mouth breathe whilst sleeping, they need

to retrain their body using an aid to keep the mouth closed whilst asleep. It is sensible to get used to wearing such an aid for short periods during the day before moving on to wearing it at night. The aid should not be used if under the influence of alcohol or sedative drugs. Typically, it takes around three months of daily use before this becomes a natural, unconscious habit. Nasal breathing at night can result in profound improvement in energy levels and concentration.

Breathe light, slow and low I have talked about the importance of keeping the airway as open and strong as possible, but we also need to consider how much air and the speed with which individuals are breathing. Let’s compare breathing to drinking thick milkshake through a paper straw again. If we suck fast and hard to drink a large volume of milkshake it is much more likely that the paper straw (upper airway) will collapse or vibrate. However, if we suck lightly and slowly, we can drink the milkshake without the straw collapsing. Some features of modern-day society such as stress, sedentary lifestyle and poor diet increase the likelihood of ‘over breathing’

A LARGE POPULATIONBASED STUDY SHOWED LUNG FUNCTION DECLINED MORE RAPIDLY AMONG PERIMENOPAUSAL AND MENOPAUSAL WOMEN

(breathing in excess of the body’s metabolic requirements). This can lead to hyperventilation symptoms and fatigue as described by Dr Lum 12

There is a misconception that a bigger breath increases oxygen delivery to the tissues so people may have concerns about retraining their body to breathe lightly and slowly. However, 75% of inhaled oxygen is exhaled during rest. Even during physical exercise, when the muscles need a much greater supply of oxygen, as much as 25% of inhaled oxygen is exhaled. The issue is therefore not getting oxygen to the lungs but getting the blood cells to release oxygen to the body’s cells. Oxygen does not dissolve very well in blood, so it is carried bound to haemoglobin. As described in the Bohr effect, carbon dioxide helps oxygen release to the tissues. An individual can be trained to be less sensitive to carbon dioxide, allowing haemoglobin to more readily release oxygen to cells. This can result in a reduction in breathing volume, breathing rate, breathlessness, and an improvement in the ability to exercise. Also ensuring individuals breathe with their diaphragm (breathing low) leads to an improved ventilation perfusion ratio.

Typically, it takes five sessions of an hour’s duration to help people re-educate their body to breathe efficiently. This can lead to reduced or even cessation of snoring and episodes of sleep apnoea resulting in better quality sleep and improved ability to exercise. If symptoms of sleep disordered breathing persist beyond three months, further investigations should be considered.

Aspirations

We should be aspiring to:

• Make women become more aware that hormones affect how we breathe and how we breathe affects our health and well-being. This may be a small or large piece in their perimenopausal/menopausal jigsaw puzzle.

• Help women to assess their breathing efficiency.

• Offer continuous encouragement and empowerment for women to improve their breathing efficiency by dedicating time to regular breathing exercises. Over time, the learned techniques will become part of natural breathing and enable self-regulation of the autonomic nervous system.

► For more information, go to www.drlouiseolivertherapeuticlifecoaching.com

REFERENCES

1. Ruchała M, Bromińska B, CyrańskaChyrek E, Kuźnar-Kamińska B, Kostrzewska M, Batura-Gabryel H. Obstructive sleep apnea and hormones - a novel insight.

Arch Med Sci. 2017 Jun;13(4):875-884.

doi: 10.5114/aoms.2016.61499. Epub

2016 Aug 5. PMID: 28721156; PMCID: PMC5507108. 2. LoMauro A, Aliverti A. Sex differences in respiratory function.

Breathe (Sheff). 2018 Jun;14(2):131-140.

doi: 10.1183/20734735.000318. PMID: 29875832; PMCID: PMC5980468. 3. Triebner K, Matulonga B, Johannessen A, Suske S, Benediktsdóttir B, Demoly P, Dharmage SC, Franklin KA, Garcia-Aymerich J, Gullón Blanco JA, Heinrich J, Holm M, Jarvis D, Jõgi R, Lindberg E, Moratalla Rovira JM, Muniozguren Agirre N, Pin I, Probst-Hensch N, Puggini L, Raherison C, Sánchez-Ramos JL, Schlünssen V, Sunyer J, Svanes C, Hustad S, Leynaert B, Gómez Real F. Menopause Is Associated with Accelerated Lung Function Decline. Am J Respir Crit Care Med. 2017 Apr 15;195(8):1058-1065. doi: 10.1164/ rccm.201605-0968OC. PMID: 27907454. 4. Greising SM, Baltgalvis KA, Lowe DA, Warren GL. Hormone therapy and skeletal muscle strength: a meta-analysis. J Gerontol A Biol Sci Med Sci. 2009 Oct;64(10):1071-81. doi: 10.1093/gerona/glp082. Epub 2009 Jun 26. PMID: 19561145; PMCID: PMC2737591.

5. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004 Apr 28;291(16):2013-6. doi: 10.1001/jama.291.16.2013. PMID: 15113821.

6. American Thoracic Society https://qol. thoracic.org/sections/specific-diseases/sleepdisordered-breathing.html

7. Saaresranta

T, Anttalainen U, Polo O. Sleep disordered breathing: is it different for females? ERJ Open Res. 2015 Nov 3;1(2):00063-2015. doi: 10.1183/23120541.00063-2015. PMID: 27730159; PMCID: PMC5005124. 8. Kiesel

K, Rhodes T, Mueller J, Waninger A, Butler

R. DEVELOPMENT OF A SCREENING PROTOCOL TO IDENTIFY INDIVIDUALS WITH DYSFUNCTIONAL BREATHING. Int J Sports Phys Ther. 2017 Oct;12(5):774-786. PMID: 29181255; PMCID: PMC5685417. 9. CarrascoLlatas M, O’Connor-Reina C, Calvo-Henríquez

C. The Role of Myofunctional Therapy in Treating Sleep-Disordered Breathing: A Stateof-the-Art Review. Int J Environ Res Public Health. 2021 Jul 8;18(14):7291. doi: 10.3390/ ijerph18147291. PMID: 34299742; PMCID: PMC8306407. 10. McKeown P, O’ConnorReina C, Plaza G. Breathing Re-Education and Phenotypes of Sleep Apnea: A Review. J Clin Med. 2021 Jan 26;10(3):471. doi: 10.3390/ jcm10030471. PMID: 33530621; PMCID: PMC7865730. 11. Hsu B, Emperumal CP, Grbach VX, Padilla M, Enciso R. Effects of respiratory muscle therapy on obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2020 May 15;16(5):785-801. doi: 10.5664/jcsm.8318. Epub 2020 Feb 6. PMID: 32026802; PMCID: PMC7849810. 12. Lum LC. Hyperventilation: the tip and the iceberg. J Psychosom Res. 1975;19(5-6):375-83. doi: 10.1016/00223999(75)90017-3. PMID: 1214233.

THERE IS A MISCONCEPTION THAT A BIGGER BREATH INCREASES OXYGEN DELIVERY TO THE TISSUES

Patient care, patient recovery

WORDS BY EMMA COOPER

The Royal Osteoporosis Society, in collaboration with the University of Bristol, has launched a new toolkit for healthcare professionals, that will help make changes to organisational arrangements and improve the quality of hip fracture care across the UK.

The guidance has been developed following the REDUCE study, carried out by the University of Bristol, and funded by the charity Versus Arthritis, which found out that how well patients recover after a hip fracture varies greatly between NHS hospitals in England and Wales. Significant findings from the study show that the way hospitals deliver patient care is linked to longer term patient recovery. The researchers identified that patients had a lower risk of dying in hospitals where hip fracture staff met regularly to discuss feedback from patients as a team. In addition, in hospitals where staff were able to get at least 90% of hip fracture patients out of bed the day after surgery, patients stayed in hospital on average two days less.

REDUCE study

The REDUCE ( RE ducing unwarranted variation in the D elivery of high-qUality hip fraC ture services in E ngland and Wales) study linked data from multiple national datasets quantifying elements of hip fracture care at both patient – and

hospital – levels using hospital-level metrics, the study quantified each hospital’s organisational capacity to manage fragility fractures across a range of care domains, including the delivery of emergency, surgical, orthogeriatric and rehabilitation services, along with overarching governance structures.

The study then examined which hospital-level organisational factors, and corresponding care domains, predicted patient outcomes post-hip fracture across England and Wales. These findings shaped the content of the toolkit, which focuses on the following:

Clinical governance and multi-disciplinary team working

The REDUCE study showed the importance of routinely reviewing patient feedback, such as Friends and Family Test data, at clinical governance meetings, to improve patient experience and outcomes. Multi-disciplinary team (MDT) working is essential to deliver effective, streamlined care along a complex patient pathway, and ensure optimal patient outcomes. The ‘how to’ tool provides guidance for effective MDT working.

Tools include:

• REDUCE How to guide effective MDT working

• REDUCE Clinical Governance tool

• NHS Friends and Family test tool

• NHFD Adapted 120-day follow-up questionnaires

The Royal Osteoporosis Society has launched a new toolkit to improve the quality of hip fracture care across the UK.

THE STUDY DATA HAS ENABLED US TO MAKE RECOMMENDATIONS THAT WE HAVE USED TO BUILD THIS TOOLKIT FOR HEALTHCARE PROFESSIONALS AND OUR AIM IS THAT IT WILL DRAMATICALLY IMPROVE THE QUALITY OF CARE FOR EVERYONE WHO SUFFERS A HIP FRACTURE

– Jill Griffin, Head of Clinical Engagement at the Royal Osteoporosis Society

Hip fracture pathway checklists

These five checklists are informed by the findings from the REDUCE study. They support evidencebased practice and set targets to optimise care pathways. They are not intended to list all aspects of care, but rather focus on those organisational changes, that if delivered, have been associated with improved patient outcomes in the REDUCE study.

The five checklists map to the inpatient pathway from the emergency department through admission to rehabilitation. They can be downloaded to inform MDT quality improvement work, and achievement against these checklists can be reviewed at Clinical Governance meetings. Tools include:

• REDUCE Emergency department/ admission checklist

• REDUCE Orthogeriatric checklist

• REDUCE Anaesthetic checklist

• REDUCE Orthopaedic checklist

• REDUCE Rehabilitation checklist

MDT roles and structure

The care of older patients with fragility fractures requires expertise from a wide number of different health professionals. The typical multidisciplinary team structure for a hip fracture unit is shown in an organogram. Whilst some of these roles are well recognised, others are specific to fragility fracture care delivery in complex older patients. Role specification tools are provided to guide the writing of job descriptions for these important MDT roles.

Tools include:

• REDUCE Organogram

• REDUCE Role specification

– consultant/specialist

orthogeriatrician essentials

• REDUCE Role specification

– Speciality doctor in orthogeriatrics essentials

REDUCE Role specification – Specialist nurse in orthogeriatrics essentials

• REDUCE Role specification

– Advanced practice physiotherapist essentials

Hip fracture unit service specification and business case development

The roles and responsibilities of these healthcare professionals are outlined in the ‘Hip Fracture service specification’, which includes links to standards from the relevant professional organisations.

The REDUCE Cost Benefit Calculator (the Calculator) has been created to assist NHS organisations in preparing a business case or other documentation leading to

improvements in care for people with hip fractures. The Calculator has been designed to make it easier for clinicians and managers to create a business case for investment to make one or more of 13 evidencebased service improvements, identified by the REDUCE Study to lead to improvements in patient care and greater efficiency in the hospital in which the improvement is implemented. The content of the cost benefit Calculator maps to the model business case, a written tool which provides guidance and example text that you can edit and use to construct a business case for hip fracture service improvement locally.

THE CARE OF OLDER PATIENTS WITH FRAGILITY FRACTURES REQUIRES EXPERTISE FROM A WIDE NUMBER OF DIFFERENT HEALTH PROFESSIONALS

Notably, whilst these tools have been derived based on evidence supporting hip fracture care, they can be adapted to inform non-hip fragility fracture services.

A narrated powerpoint, presented by Prof Celia Gregson, the REDUCE Study Chief Investigator, talks through how to use the cost benefit Calculator.

The Calculator is made available free of charge to those working in NHS organisations. To access the Calculator you will need to register yourself and your hospital and then you will be emailed the calculator for you to use as you wish. Registration is necessary simply to be able to audit use.

Tools include:

• REDUCE Hip fracture service specification

• REDUCE Model business case

• REDUCE Evidence-based service improvement cost benefit calculator

• REDUCE How to use the cost benefit calculator

Hip fracture service quality improvement

The REDUCE study has shown improved patient outcomes when a patient moves within four hours of presentation from the emergency department to a ward specialising in hip fracture care. Outlying patients on wards which lack specialist

hip fracture expertise should be avoided, unless alternative specialist input is needed as a clinical priority (e.g. acute cardiology).

The REDUCE Audit tool for outlying patients focuses attention on The National Hip Fracture Database (NHFD) KPIs (Key Performance Indicators) as well as other outlier metrics. This tool is freely available and able to be modified according to local preferences and needs, including for non-hip fragility fracture service audit.

Tools include:

• REDUCE Audit tool for outlying patients

• NHFD KPIs link

Hip fracture service induction

Inpatient wards are often in part staffed by rotational doctors in training, and rotational allied health professionals, who make up an important part of the MDT. Patient care is improved if members of the MDT understand the complexity of the care pathway in which they are working, and the overall vision for the service.

The REDUCE hip fracture unit handbook template is a tool that can be adapted for use in your local service and disseminated to new clinical staff when they first join your MDT. It provides a structure and generic instructions for the elements needed within a well-functioning hip fracture service. Once adapted to your hospital, it is advisable that the content is reviewed on an annual basis, to keep it up to date. This template can also be adapted for services managing non-hip fragility fracture care.

Tools include:

• REDUCE Hip fracture unit handbook for new clinical staff

Coming soon:

• REDUCE Introduction to hip fracture care presentation.

► Access the free toolkit at www.theros.org.uk/ healthcare-professionals/hip-fractures/reducehip-fracture-service-implementation-toolkit

Why Femtech is flourishing

International IP firm Mewburn Ellis has published an extensive report exploring some of the exciting new technologies that have entered the Femtech market in recent years. The report highlights how the huge range of Femtech treatments, procedures and solutions being developed are providing genuine health benefits to women, from early cancer diagnoses and improved surgical outcomes, to more sustainable period products and options for the remote delivery of healthcare.

AI-based Femtech Healthcare company, Presagen, believes that existing clinical data may hold the answers to many medical challenges. The company’s suite of Life Whisperer IVF products evaluate oocyte quality, embryo genetic quality and embryo viability, informing clinicians which oocytes or embryos are most likely to result in a successful pregnancy and improving the chances of IVF success.

Each evaluation is conducted by applying an AI algorithm, trained on tens of thousands of images, to the image of interest. In contrast to other genetic quality assessments such as PGT-A testing, which can come with the risk of harming the embryo, the Life Whisperer

genetic quality assessment is completely non-invasive.

b-rayZ is an organisation working to reduce the number of missed early stage breast cancers using AI platforms. Two key factors in breast detection are assessed by the b-rayZ platform, the first being breast tissue density. In a normal mammogram, clinicians have to assess the breast tissue density and decide whether to refer the patient for an ultrasound to assist in cancer detection. The b-rayZ platform removes the need for this subjective assessment by classifying, with over 93% accuracy, the breast tissue density in an acquired image. The platform also provides an image quality assessment directly after the mammogram is carried out, allowing for position correction and assuring image quality.

Studies1 have also shown that AI models provide good diagnostic and predictive capacity in detecting endometriosis. Blood-based microRNA biomarkers have been used to create an AI diagnostic algorithm for endometriosis, which was found to be sufficiently robust and reproducible to replace the current endometriosis diagnosis gold standard of laparoscopic surgery. Such an algorithm has the potential to provide a diagnostic method for endometriosis which requires just a blood sample, as opposed to invasive surgery.

Female-centric surgical technology

WORDS BY EMMA COOPER

Femtech companies are working on ways to help rebuild a patient’s breast tissue through soft-tissue reconstruction. One such company, Lattice Medical, is developing its Matisse project, a 3D-printed breast implant made of a hydrogel which is slowly colonised by the patient’s own fat cells. Within a year the implant fully degrades, so no invasive removal surgery is needed. If successful, this technology will provide all the benefits of an implant but without the potential risks associated with leaving behind foreign material in the patient’s body. Femtech innovators are also using new manufacturing techniques to produce personalised pessaries, based on the unique anatomy and lifestyle needs of individual patients. Cosm, for example, uses a combination of ultrasonic imaging, AI, and additive manufacturing to create custom pessaries. These made-to-order gynaecological prosthetics, or gynethotics, increase the likelihood of a good fit, which increases patient compliance and reduces the risk of complications later on.

Remote healthcare

One company harnessing the power of smartphones is Pulsenmore. The PulsenmoreTM system is an ultrasound scanning system for neonatal health and includes a handheld scanner that docks with a user’s smartphone. A companion app on the user’s phone guides them on where to place the scanner and how to move it in order to collect accurate ultrasound data.

REFERENCE

1. www.tinyurl.com/ aiinendometriosis

Obtaining an accurate ultrasound scan is a very difficult and complex process, with sonographers requiring a significant amount of training to get accurate results. The PulsenmoreTM system addresses this issue through the use of a remotely controlled pivoted support attached

A new report examines the recent technologies that have entered the Femtech market and identifies why this is just the start for the sector.

WOMEN’S HEALTH IS A SPACE THAT IS HISTORICALLY UNDER-RESEARCHED AND UNDER-FUNDED.

FOR YEARS, WOMEN’S HEALTH ISSUES HAVE TAKEN A BACK SEAT, WITH A LACK OF RESEARCH LEADING TO A LIMITED UNDERSTANDING OF HOW WOMEN’S BODIES WORK AND A FAILURE TO DEVELOP TREATMENTS, PROCEDURES AND SOLUTIONS AIMED SPECIFICALLY AT WOMEN’S ILLNESSES AND HEALTH NEEDS.

THIS REPORT HIGHLIGHTS THE RANGE OF EXCITING INNOVATIONS CURRENTLY SEEKING TO REDRESS THE GENDER HEALTH GAP. THE COMING YEARS WILL SEE THIS SECTOR CONTINUE TO THRIVE AND WE ARE EXCITED TO BE PART OF IT.

Andrew Mears, Partner and Patent Attorney at Mewburn Ellis

to the ultrasound array of the PulsenmoreTM probe. The support can alter the orientation of the ultrasound array relative to the scanner body held by the user. It can also vary the extent to which the ultrasound array protrudes from the scanner, which alters the pressure of the array against the body. Importantly, the support is controlled remotely through the companion app by a skilled healthcare provider.

The data obtained by the probe is then transmitted to a healthcare professional for analysis. Any extensive image processing, such as image optimisation and filtering, is performed at the clinician’s end to improve processing times and reduce strain on the user’s phone. The scanning system is more convenient for the pregnant user, removing the need for them to travel to a clinic unless absolutely necessary.

The use of smart devices and wearables is not just limited to monitoring and data collection. There have also been developments

in the provision of treatments at home or on the go. EmbrWave has developed a system for combating hot flushes by using a wrist worn device. The device generates thermal pulses on the surface of the wearer’s skin, triggering the body’s natural temperature regulation systems to provide a cooling effect. The device not only benefits women going through the menopause, it can also be used by anyone who has undergone cancer treatment that affects hormone levels and who experience hot flushes as a result.

Breast cancer detection

AI has been applied in breast cancer screening by Mammoscreen®, an application that uses a combination of multiple machine learning algorithms to perform detailed analytics on lesion type and breast density, as well as taking patient history into account to provide a better understanding of mammogram images. It works by reading both 2D and 3D mammogram images to characterise the level of concern for

different areas of the breast. Areas of high concern are flagged to the clinician for detailed assessment, allowing them to focus on these areas, reducing the chances of missed diagnoses.

A spin out from the University of Bristol, Micrima, has developed MARIA®, a radio wave breast cancer detection tool which originally stemmed from technology designed to detect non-ferrous landmines. The technology works by using 60 radio wave frequency antennae across a wide range of frequencies which transmit and then detect and record the returned signals. This then creates a 3D map which allows the practitioner to see the tissue variation much more clearly and therefore detect the difference between typical breast densities and tumours. The patient is able to lie down and insert their breast into the machine which makes it a much more comfortable experience than a traditional mammogram.

► To read the report in full go to www.mewburn.com/news-insights/femtech-agrowth-industry-new-special-report

Prioritising women’s health

Equity in healthcare has always been a critical issue. As women in the UK live longer than men but also spend longer in ill health and disability, it is imperative that system-wide change occurs to improve women’s health and wellbeing support.

To truly embrace equity means to ensure women have access to the differing services and care they require.

PCWHF Chair, Dr Anne Connolly MBE has been striving for healthcare equity her entire career. A champion of supporting underserved communities to access the healthcare they need, Anne says:

“Health equity is one of the big expectations of the Women’s Health Strategy, but I am not sure they are doing enough for the populations that many of us work within. There is also no extra funding and no expectation that other workloads will be reduced to cope with extra demands.

“We have seen recently that women living in the most deprived parts of England are far less likely to be prescribed HRT to help them deal with the symptoms of menopause than those living in the least deprived areas.

“With over 2 million women using HRT, the news that around 400,000 women across England will get better access to menopause support and cheaper prescriptions is a positive step forward to prioritising the health and wellbeing of women, but still not enough.

“This disparity within healthcare is something that we are trying our hardest to combat.”

FROM ABOVE LEFT CLOCKWISE: Dr Caroline Cooper and Dr Anne Connolly MBE; Lesley Wylde and Dr Louise Price; Dr Toni Hazell and Dr Jane Davis; Dr Stephanie Cook and Dr Aamena Salar

The PCWHF wants to hear your opinion. How are you supporting equity in healthcare? Join the discussion in our private Facebook group at www.facebook.com/groups/PCWHF

On International Women’s Day, the PCWHF explored the importance of prioritising women’s health for equity in healthcare.

ON THE BRINK – The reality of LARC services in primary care

An overview of the PCWHF report coming soon, examining the current issues surrounding payments, contracts and training.

WORDS BY LAUREN ALEXANDER

The Primary Care Women’s Health Forum is increasingly concerned about the viability of longacting reversible contraception (LARC) fitting (implant and IUS/ IUD) in primary care and the implications for wider women’s health and contraceptive care in the future if this is not addressed and prioritised.

Based on first-hand evidence from healthcare professionals in primary care, the forthcoming report provides an up-to-date overview of LARC fitting in the UK, comparing where we are in 2023 with the previous study from 2020. As well as providing an overview, the report also gives conclusions and offers recommendations.

The report draws on newly collected quantitative and qualitative data from two surveys conducted in Spring 2023. 1119 healthcare professionals in the United Kingdom

TOP TAKEAWAYS

• 89% felt the fitting fee for IUS/D contraception was inadequate.

• 49% thought there had been no change to the training for new clinicians.

• 43% thought that training had reduced.

• 80% have not developed an IUS/D insertion service to accept referrals from local GP practices.

For non-fitters or never-fitters, 89% were interested in training but:

• 25% cannot access training.

• 24% report there is not enough time to train.

• 23% say there is no practice support.

• 18% say the training is too costly.

responded. It compares results against a survey conducted in 2020 of a total of 650 healthcare professionals across the UK. The 2023 survey called upon fitters both past and present, as well as non-fitters, to gather an understanding of the current environment of LARC fitting.

The PCWHF has used these responses to shape the report and make sure it reflects the voices of healthcare professionals in women’s health.

Funding

Fees for fitting of LARC are still perceived to be inadequate, with respondents flagging this as a major issue, in many cases making the fitting unviable. A substantial proportion of respondents mentioned the service was costing them money and they, in turn, were incurring a loss to deliver. This was in line with 2020 results.

The results of the study in 2020 and again in 2023 reflect the larger problem of limited funding for all indications, limited access to training, and limited training options. However, the demand for this service has remained the same, if not increased, in some areas.

The results also highlight a need for future commissioners and providers to work together at a national and local level to address this issue.

Variation in fees

There remains a huge variation in reimbursement for fitting of LARC for both insertion and removal and this has not changed since 2020. The variation in fees for fitting implants and IUS/D for all indications ranged between £25–£100+ with an average implant fitting between £25 and £75 and the average for an IUS/D procedure being £80.

Training/workforce

Training remains an issue with respondents saying it takes too long and is too expensive. Provision and

access to LARC training continues to decline. Three years on, access to training and the cost of training/ recertifying is still reported as a major issue. A further consideration is GPs changing roles and finding it harder to continue to deliver a service and maintain competency when they are salaried, rather than partners or locums.

Access to services and sustainability

Healthcare professionals have huge concerns about the impact that the loss of LARC services is having and will continue to have on women’s health. This includes waiting lists, and a de-skilled workforce in primary care. Some practices are continuing to perform services at a loss to support their local communities, which is unsustainable in the long-term.

Conclusions and recommendations

The forthcoming report provides a comprehensive and detailed analysis of the current issues surrounding LARC in primary care. Initial recommendations based on the findings from both surveys include:

• A push for a national ‘fair’ fitting fee that covers the cost of running a LARC service that is financially viable for primary care.

• To ensure LARC funding includes fitting for all indications (contraception and gynaecology).

• Tackle inequalities and remove the current postcode lottery of care.

• To address training issues to support workforce and capacity.

• To review models of service and improve a patients’ journey whilst also making savings.

• Advise a community-based model of Women’s Health Hubs in line with the Women’s Health Strategy and explore access and spending the assigned £25 million.

URGENT ACTION IS NEEDED TO ENSURE SUSTAINABILITY AND PREVENT FURTHER LOSS OF SERVICES

Peaches Womb Cancer Trust

DR HELENA

Womb cancer is the most common gynaecological cancer, with 9,700 new cases diagnosed each year in the UK. Unlike other cancers, incidence of womb cancer is rising due to increased life expectancy, reduced hysterectomy rates, and increasing prevalence of obesity. When diagnosed early, the prognosis for early-stage disease is associated with 90% five-year survival, according to the latest Cancer Research UK data. Unfortunately, 1 in 5 are still diagnosed at a later stage of disease with poorer outcomes1

Previously, there was no national charity dedicated solely to support those affected by womb cancer and raise funds for research, leaving a huge unmet need for patients, carers, and healthcare professionals.

In September 2020, Peaches Womb Cancer Trust was launched by a team of enthusiastic researchers, doctors and nurses led by Professor Emma Crosbie, all with an interest in the early detection and treatment of womb cancer. The aim of Peaches is to preserve the health and improve the lives of those with, or at risk of, womb cancer and their families through four main pillars: raising awareness; supporting patients and carers, advocating for womb cancer on a national level, and promoting and funding research.

The charity on a mission to raise awareness of womb cancer symptoms and how primary care can play a pivotal role in identifying cases and supporting patients.

O’FLYNN

Raising awareness

In 2014, the Guardian newspaper published an article with the headline: “Womb cancer: the most common diagnosis you’ve never heard of”, referencing the low public profile associated with womb cancer despite its high prevalence. In most, womb cancer presents early with post-menopausal bleeding (PMB). However, public surveys have consistently shown poor awareness of abnormal vaginal bleeding as a cause for concern amongst patients.

Barriers to presentation with gynaecological symptoms include fear, embarrassment and difficulty accessing healthcare. Additional complexities may be faced in accessing healthcare advice in some minority groups.

Diagnostic difficulties

Current guidelines from the National Institute for Health and Care Excellence (NICE) advocate urgent referral from primary care of patients presenting with PMB and the use of direct access ultrasound in those aged over 55 with vaginal discharge and thrombocytosis or haematuria 2 For those presenting with PMB, only 5–10% will be diagnosed with womb cancer and most cases are caused

by benign pathology 3 . Furthermore, hormone replacement therapy (HRT) prescription rates have markedly increased over the last two years 4 Abnormal bleeding is a common side effect of HRT and will inevitably lead to increased diagnostic difficulties for primary care clinicians.

Although womb cancer rates increase with age, 6.5% of those diagnosed are under 50 years of age1 . Younger patients subsequently diagnosed with womb cancer are less likely to be referred on an urgent pathway and have higher rates of diagnostic delays, likely due to the difficulty in differentiating those who require urgent investigation5

As primary care acts as gatekeeper to specialist referral, it is imperative that GPs are aware of womb cancer symptoms and have direct access to investigations readily available. More research is needed around tests that can be delivered in primary care.

Prevention

A third of womb cancer cases are preventable due to the strong association with obesity 6 . The risk of developing womb cancer almost doubles with lifelong excess weight and for every five extra BMI units, womb cancer risk increases by

REFERENCES

1. CRUK. Uterine cancer statistics | Cancer Research UK [Accessed 23rd February 2023]

2. Excellence NIfHaC. Suspected Cancer: recognition and referral (NICE guideline NG12).

2015. 3. Smith PP, O’Connor S, Gupta J, Clark TJ. Recurrent postmenopausal bleeding: a prospective cohort study. J Minim Invasive Gynecol. 2014;21(5):799-803.

4. Care DfHaS. Hundreds of thousands of women experiencing menopause symptoms to get cheaper HRT –GOV.UK (2023)

5. Zhou Y, Mendonca SC, Abel GA, Hamilton W, Walter FM, Johnson S, et al. Variation in ‘fast-track’ referrals for suspected cancer by patient characteristic and cancer diagnosis: evidence from 670 000 patients with cancers of 35 different sites. Br J Cancer. 2018;118(1):24-31.

6. Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet. 2022;399(10333): 1412-28.

ABNORMAL BLEEDING IS A COMMON SIDE EFFECT OF HRT AND WILL INEVITABLY LEAD TO INCREASED DIAGNOSTIC DIFFICULTIES FOR PRIMARY CARE CLINICIANS

RESEARCH IS NEEDED AROUND TESTS THAT CAN BE DELIVERED IN PRIMARY CARE

88%7. Obesity rates are strongly associated with socioeconomic deprivation and wider health inequalities within the UK.

Lynch syndrome is an inherited condition that has an increased risk of certain cancers, including womb cancer. In those known to have Lynch syndrome, increased surveillance can be offered for womb cancer. Primary care is pivotal in improving health inequalities associated with obesity and deprivation, as well as identifying those at increased risk of womb cancer who may be eligible for genetic testing.

Support

Since it launched, Peaches has supported hundreds of womb cancer patients through online webinars and virtual coffee mornings. At the most recent support webinars, there have been over 100 sign-ups. Many issues faced by those affected by womb cancer can be sensitive and patients often feel isolated and sometimes

even embarrassed. Peaches virtual coffee mornings, facilitated by a Cancer Nurse Specialist, offer a safe space where patients can talk about issues that are concerning them and receive peer-support. Webinars have national reach and have included topics such as genomic medicine advances, management of menopausal symptoms, sexual function, nutrition, and exercise.

Research and advocacy

With support from the charity, Peaches Patient Voices (PPV) was set up in 2021. The group (currently 70 members) have lived experience of womb cancer, either as a patient or a carer and are all interested in being involved in womb cancer research. For researchers, this is a fantastic resource and members of PPV have also benefited. By being able to share their experiences, they have felt less alone. The PPV group and Peaches Womb Cancer Trust have also participated in

advocacy work including a review of NICE guidelines regarding the use of Dostarlimab in advanced or recurrent endometrial cancer.

Peaches has also funded early career researchers to present their work at national conferences and are working towards developing a research strategy.

Peaches Womb Cancer Trust continues to grow but there is still much to be done to give womb cancer a voice. We are looking to expand the support services offered and a national womb cancer awareness campaign is planned for later this year. We also hope to raise funds to facilitate womb cancer research in the coming years.

► Go to www.peachestrust.org

MORE

7. Hazelwood E, Sanderson E, Tan VY, Ruth KS, Frayling TM, Dimou N, et al. Identifying molecular mediators of the relationship between body mass index and endometrial cancer risk: a Mendelian randomization analysis. BMC Med. 2022;20(1):125.

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