Women's health toolkit

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Date: Thursday, 18 August 2022, 3:21 AM

Description

This Women’s Health Hub is categorised into sections best representing the needs of women at different stages of their lives.

Introduction

Women make up 51%1 of the population, 47% of the workforce2 and women related concerns account for an estimated one in four consultations in primary care.

A woman’s life-course from menarche, through her reproductive years to menopause and beyond is a normal process but is different for each woman requiring holistic individual assessment, management and support:

  • Many women suffer from menstrual related issues; pre-menstrual symptoms, heavy and/or painful menstruation, which impact on their ability to concentrate or function at home and work.
  • At any point three quarters of women of reproductive age are wanting to prevent a pregnancy with 45% of pregnancies being unplanned3 and one in seven couples having conception delay4.
  • Being menopausal is inevitable with 80% of women experiencing symptoms and over 40% saying these were worse than expected5.

This Women’s Health Hub is categorized into sections best representing the needs of women at different stages of their lives, while recognising that there is much overlap. The three sections are reproductive health, menstrual wellbeing, menopause and beyond. Each section includes resources for healthcare professionals, women and commissioners to help optimize the care provided and to support women to make choices about self-care and management.

This project is a result of joint working between the RCGP, Faculty of Sexual and Reproductive Health, the Royal College of Obstetricians and Gynaecologists (RCOG), the British Menopause Society, the Royal College of Nursing, Public Health England, and Endometriosis UK. The project has been supported by Medtronic and further joint working has developed the women’s health library where many other resources and reference documents can be found.

Reproductive Health

Women's Reproductive Organs

Key Facts

The World Health Organisation (WHO)1 defines reproductive health as a “state of physical, mental, and social well-being in all matters relating to the reproductive system. It addresses the reproductive processes, functions and system at all stages of life and implies that people are able to have a satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so”.

For the majority of women in their reproductive years, contraception and preconception care are important aspects of their daily lives that require individualised support.

At any point an estimated 78%2 of women aged 16-44 are sexually active and either wanting to prevent or to achieve an unassisted pregnancy

Of these:

  • 12% are using no contraception
  • 45% need ongoing contraception according to need
  • 20% need preconception and postnatal care.

A planned pregnancy is likely to be a healthier one, as unplanned pregnancies represent a missed opportunity to optimise pre-pregnancy health. Currently, 45% of pregnancies and one third of births in England are unplanned or associated with feelings of ambivalence3.

Although pregnancies continuing to term mostly lead to positive outcomes, some unplanned pregnancies can have adverse health impacts for mother, baby and children into later in life.

General practice remains the preferred place for women to access their contraception3.

References

  1. WHO Pacific Regional Office. Reproductive Health
  2. PHE: Health matters: reproductive health and pregnancy planning
  3. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3); Wellings K et al. The Lancet. 2013: 382; 1807-16.
  4. PHE: What do women say? Reproductive health is a public health issue

General

Most women of reproductive age are at any point either wanting to become pregnant or to prevent pregnancy. Contraception and pregnancy planning care should be integrated to enable optimization of health and wellbeing of the woman and her family for when the decision is made to try for a pregnancy.

There are many opportunities in primary care to offer preconception advise including appointments for contraception, cervical screening, management of long-term conditions and medication review.

Public Health England (PHE) have produced a series of resources for professionals working with women and men that may have children in the future focusing on reproductive choice and ensuring that pregnancy, if desired, occurs at the right time and when health is optimised. Effective contraception and planning for pregnancy mean that women and men stay healthy throughout life and take steps to improve the health of the baby.

Resources:

  1. What do women say? Reproductive health is a public health issue
  2. Health matters: reproductive health and pregnancy planning: A resource focusing on reproductive choice and ensuring that pregnancy, if desired, occurs at the right time and when health is optimised.

Resources for Training and Appraisal

The majority of contraception is provided from primary care. There are many resources available for training in counselling and provision of contraception including the resources listed below.

A 60 minute RCGP contraception e-learning course has been produced to upskill professionals so that they can provide accurate information about the contraceptive options available to women. The course is useful for those providing contraception at a basic level in primary care; including contraceptive choices counselling, emergency contraception, risk/benefit assessment and information about sexual health screening.

This course was developed in partnership with Public Health England and The Faculty of Sexual and Reproductive Healthcare (FSRH)

This free two-hour contraceptive counselling online course designed to support healthcare professionals to develop:

  • Key concepts in contraceptive counselling
  • Key skills for effective contraceptive counselling
  • Understanding good and bad consultations
  • Action planning to improve contraceptive consultations

The comprehensive curriculum for Sexual and reproductive healthcare e-learning (e-SRH) was developed to reflect the level of knowledge and competence required by a doctor or nurse delivering non-specialist sexual and reproductive healthcare in a community setting. The learning is also useful as theoretical training towards FSRH qualifications.

It includes:

  • Contraception
  • Sexually transmitted infections
  • Early pregnancy assessment and referral
  • Recognising psychosexual problems
  • The law relating to confidentiality, sexual activity and young people

The Faculty of Sexual and Reproductive Healthcare offers additional training, either as a Diploma in Sexual and Reproductive Healthcare (DFSRH) or as Letters of Competence in Intrauterine insertion and Sub-dermal insertion and removal techniques.

Guidelines and Pathways

NICE Long-acting Reversible Contraception (CG30, Oct 2005, updated 2019)

This guideline covers long-acting reversible contraception (LARC). It aims to reduce the number of unintended pregnancies by improving the information provided to women about contraceptive choices and increasing the use of the more effective ‘fit and forget’ LARC methods.

LARC methods of contraception are defined in this guideline as contraceptive methods that require administration less than once per cycle or month. Included in the category of LARC are:

  • copper intrauterine devices
  • progestogen-only intrauterine systems
  • progestogen-only injectable contraceptives
  • progestogen-only subdermal implants

The NICE CG30 guideline includes pathways for improving contraception counselling and LARC provision:

The Faculty of Sexual and Reproductive Health's current clinical guidance lists a number of resources to help improve the safety and use of different methods of contraception in a range of clinical scenarios. These resources are produced by the FSRH Clinical Effectiveness Unit and are free to access by all.

Including:

The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) offers guidance on contraceptive safety. The evidence-based recommendations allow a safety assessment for use of a contraceptive method by women with particular medical conditions or personal characteristics. This is an essential resource for use by any clinician providing contraception consultations. The summary document can be downloaded onto the clinical system for easy reference.

Other guidance includes evidence-based information for contraceptive use that are:

Method specific:

  • Intra-uterine contraception
  • Progestogen-only implant
  • Combined Hormonal Contraception
  • Progestogen-only pills
  • Progestogen-only injectable

For specific consultations:

  • Emergency contraception
  • Quick starting contraception

For specific populations:

  • Contraception for women aged over 40
  • Contraception after pregnancy
  • Overweight, obesity and contraception
  • Contraceptive choices for young people

Top tips and useful resources

Contraceptive CHOICE project round up: what we did and what we learned

The US Contraceptive CHOICE Project was a prospective cohort study of 9,256 women in the St. Louis area. The project provided no-cost reversible contraception to participants for 2-3 years with the goal of increasing uptake of long-acting reversible contraception and decreasing unintended pregnancy in the area.

Results from this project found that when barriers to contraception (cost, access and knowledge) were removed women choose the most effective and user-independent methods, method satisfaction and continuation rates were higher and unintended pregnancy and abortion rates were reduced.

Primary Care Women’s Health Forum: 10 top tips for intrauterine contraception

Useful evidence-based tips to improve counselling and increase awareness of the advantages of intrauterine methods of contraception.

Guidelines in Practice: Top Tips: sexual and reproductive health

Excellent top tips summary on providing sexual and reproductive health in general practice, including recommendations on:

  • Screening patients for sexually transmitted infections and HIV
  • Contraception methods and recommendations
  • Providing care for different communities including people who identify as LGBT.

Commissioning

Commissioning fragmentation in England as a result of the 2012 Health and Social Care Act alongside difficulties with accessing training in the UK has resulted in fewer trained primary care clinicians providing Long Acting Reversible Contraceptives.

Resources:

  1. The Faculty of Sexual and Reproductive Health's report 'Opportunities to embed sexual and reproductive healthcare services into new models of care. A practical guide for commissioner and service providers', sets out case studies demonstrating the potential for new models of care to embed SRH services.
  2. The Health and Social Care Committee: Sexual Health Inquiry report has results and recommendations from the Government Select Committee Inquiry into sexual health.
  3. Public Health England's Making it work. A guide to whole system commissioning for sexual health, reproductive health and HIV contains recommendations for local government, clinical commissioning groups (CCGs) and NHS England. The guide focuses on establishing seamless, integrated care pathways through taking a whole system approach, and describes how this can be made to work in practice.
  4. The RCGP's report, Sexual and Reproductive Health; Time to Act' is a response to funding and training cuts and reduction in provision of LARC in primary care. The report includes comments from GPs about the impact of the cuts in their local areas.The RCGP recommendations include the requirement for oversight of the fragmented commissioning system in England and improved funding and training for LARC provision in primary care.
  5. The Sexual and Reproductive Health Profiles have been developed by Public Health England to support local authorities, public health leads and other interested parties to monitor the sexual and reproductive health of their population and the contribution of local public health related systems.

Interactive maps, charts and tables provide a snapshot and trends across a range of topics including teenage pregnancy, abortions, contraception, HIV, sexually transmitted infections and sexual offences. Wider influences on sexual health such as alcohol use, and other topics particularly relating to teenage conceptions such as education and deprivation level, are also included.

Patient resources

  1. Brook, the national charity offers clinical sexual health services and education and wellbeing services for young people including, resources for young people and clinicians.
  2. The Contraception Choices website providing information to help weigh up the pros and cons of the different methods available. Includes an easy to use tool to determine how effective each method is at preventing pregnancy plus access to NHS Choices YouTube video explaining each method.
  3. The NHS UK: Your contraception Guide provides information about contraception aiming to answer questions about different contraception choices and about the method they are using if there are concerns.
  4. The Sexwise website provides information about all contraceptive methods plus an option to compare methods allowing the user to determine which method is right for them.

Menstrual Wellbeing Toolkit

A list of words pertaining to menstruation - decorative only

Menstrual related problems affect a significant proportion of the 25% of UK population who are female of reproductive age, from menarche to menopause, affecting their physical, psychological and social well-being.

The opportunity for early management of ‘period problems’ is often delayed because of the associated stigma and myths leaving women unsupported and in some cases at risk of developing long-term consequences of untreated disease.

This Menstrual Wellbeing toolkit is an ‘easy to use’, logical, evidence based resource for GPs and other primary care clinicians when diagnosing, supporting and managing the concerns of women with problems caused by menstrual dysfunction.

Key facts about Menstrual dysfunction

  1. Dysfunction of the menstrual cycle causes physical, social and psychological impact, compromising education, work, social and family life.1,2,3
  2. There are many myths and stigma about periods meaning many women and girls are too embarrassed to discuss their problems. Empowering women of all ages to raise their concerns openly, including any problems related to sex, improves the short and long-term outcomes.
  3. Not all menstrual dysfunction causes bleeding problems. Taking a careful history or using a symptom diary can be helpful in determining a cyclical pattern of associated bowel or urinary or mood problems.
  4. One in five women of reproductive age suffer with heavy menstrual bleeding (HMB), causing one in 20 women aged 30-49 to contact their GP each year.1
  5. One in 10 women of reproductive age suffer with endometriosis4, affecting 1.5 million women - the same number diagnosed with diabetes5 – costing the health and social care economy an estimated £8.2 billion/year.
  6. Early management of endometriosis is important to reduce the long-term consequences of untreated disease: subfertility, ectopic pregnancy and chronic pelvic pain.2
  7. Premature ovarian insufficiency (POI), defined as menopause aged less than 40, affects 1 in 100 women. Management with replacement hormone therapy reduces the long-term consequences of POI: cardiovascular disease, osteoporosis and cognitive impairment.3
  8. The psychological impact of menstrual disorders is underestimated; a recent survey of women with heavy menstrual bleeding found that of 1000 surveyed6:

4% experienced anxiety

67% suffered with depression.

  1. Endometrial cancer is the commonest gynaecological malignancy in the UK with increasing incidence - exacerbated by obesity - with nearly 9000 new cases diagnosed in 20157.
  2. Recently published NICE guidance provide evidence based recommendations on the management of menstrual dysfunction, much of which can be managed in primary care with specialist referral for diagnosis and treatment when indicated or chosen.1,2,3

References:

  1. Heavy menstrual bleeding: assessment and management. NICE Guideline (NG88). NICE, March 2018 (updated November 2018)
  2. NICE. Endometriosis: diagnosis and management. NICE Guideline (NG 73). NICE, September 2017
  3. NICE. Menopause: diagnosis and management. NICE Guideline (NG23). NICE, November 2015, updated December 2019. 
  4. Rogers PA, D'Hooghe TM, Fazleabas A, et al. Priorities for endometriosis research: recommendations from an international consensus workshop. Reprod Sci 2009;16(4):335-46
  5. Diabetes UK: Diabetes prevalence 2020
  6. Wear White Again, Hologic survey 2017
  7. Uterine Cancer Statistics.

Top tips for managing heavy menstrual bleeding in primary care

  1. Heavy menstrual bleeding is common; one in five women experience heavy periods with one in 20 women aged 30-49 presenting to primary care each year.
  2. HMB affects a woman’s physical, psychological and social health and wellbeing.
  3. The history of the problem and any co-morbidities determine if examination and investigations are required.
  4. HMB occurring in women with obesity or any condition causing unopposed oestrogen excess requires investigation to exclude endometrial hyperplasia and cancer, rates of which are rising in the UK.
  5. Treat without further need to examine or investigate if there are no additional symptoms and low risk for endometrial pathology.
  6. Basic laboratory investigations include:
  • FBC for all
  • Testing for coagulation disorders only if HMB since menarche or personal/FH of coagulation disorder
  • Consider sexual health screen
  • Cytology if due
  • No indication for testing thyroid function, hormone levels or ferritin without the presence of additional symptoms.
  1. Recommended investigations for women with HMB:

Pelvic ultrasound scan (trans-vaginal preferably) for possible larger fibroids or adenomyosis:

  • Enlarged uterus/ pelvic mass/ pelvic pressure symptoms
  • Dysmenorrhea

Hysteroscopy for possible endometrial pathology (hyperplasia/polyps/submucosal fibroids). Persistent irregular and/or intermenstrual bleeding:

  • Infrequent heavy bleeding plus obesity or PCOS
  • Late menopause (over 55)
  • Use of tamoxifen
  • FH Breast/bowel/ovary cancer
  • Abnormal ultrasound scan findings
  • If previous treatment unsuccessful
  1. Treat with tranexamic acid +/- analgesia at first visit, including while waiting for further investigations or referral.
  2. Future treatments depend on investigation findings, imminent fertility requirements, risk assessment and informed patient choice:

Hormonal:

i. Levonorgestrel intra-uterine system

ii. Combined hormonal contraception

iii. Long-cycle or continuous progestogens

Non-hormonal:

i. Tranexamic acid (1.5g three or four times daily)

ii. Plus/or NSAID of choice

Surgery referral:

i. Fibroid resection or embolization

ii. Endometrial ablation

iii. Hysterectomy

  1. Following endometrial ablation women require reliable contraception and combined HRT preparations for menopausal symptoms even if amenorrhoeic.

Top tips for managing endometriosis in primary care

Adapted from Top Tips developed by Primary Care Women's Health Forum.

  1. Endometriosis is common, affecting approximately 10% of women of reproductive age. There are as many women with endometriosis as there are with either diabetes, asthma or back pain. The average time to diagnosis is 7.5 years.
  2. Endometriosis usually causes cyclical problems. Using a 3 month menstrual diary found on line or as an app is a good diagnostic tool. This can also be used to determine the pattern of urinary and bowel symptoms.
  3. Endometriosis affects a woman’s physical, psychological and social health and wellbeing.
  4. NICE recommend that an abdominal +/- pelvic and speculum examination is performed. Sexual health screening should also be considered.
  5. An Ultrasound Scan, preferably transvaginally if acceptable, is recommended to exclude endometriomas or adenomyosis. BUT a normal result does not exclude endometriosis or adenomyosis.
  6. Simple analgesia or combined hormonal contraception or desogestrel should be commenced at the first visit. An understanding of imminent fertility requirements assists treatment choices.
  7. On review the use of continuous hormonal treatment (any hormonal contraception) should be commenced to control symptoms if the diagnosis of endometriosis is likely. Signposting to patient information for support i.e. Endometriosis UK is recommended.
  8. Referral to secondary care should be considered if symptoms change, continue, recur or if there are symptoms of bowel or urinary tract involvement or for patient choice.
  9. Early prevention of ovulatory bleeding will reduce the longer-term complications of endometriosis such as reduced fertility and chronic pelvic pain. These issues require management as appropriate with early referral to fertility services for women with endometriosis if conception is delayed.
  10. For women with endometriosis who have required surgical treatment with pelvic clearance (hysterectomy and BSO) use consider use of continuous HRT or tibolone for 12 months before considering changing to oestrogen only HRT.

Top tips for managing menopause in primary care

Adapted from Primary Care Women’s Health Forum top tips, with permission

  1. The diagnosis of menopause in women aged over 45 is clinical and based on symptoms. It does not usually require confirmation with an Follicle-stimulating hormone (FSH) level.
  2. Remember that contraception is needed until infertility can be assumed. The use of intra-uterine progestogen offers endometrial protection and contraception. Refer to FSRH CEU Guideline Contraception for women over 40 for further information.
  3. Consider menopause as a possible cause of amenorrhoea in women under 45 who are not using hormonal contraception once pregnancy is excluded.
  4. Recommend Hormone Replacement Therapy (HRT) routinely to women who are menopausal aged under 45, even if they are asymptomatic, to reduce the consequences of long-term hypo-oestrogenism such as osteoporosis and cardiovascular disease.
  5. Provide and signpost women to reliable patient information, for example, menopause matters and manage my menopause, to allow informed and shared decision making between the woman and her healthcare professional.
  6. Prescribing is not difficult and decision-making guides are available. Refer to Primary Care Women's Health guidance on management and prescribing HRT in primary care.
  7. HRT is much safer than you think. NICE Clinical Guidance (2015); Diagnosis and Management provides the evidence and reassurance for use.
  8. Support the woman to initiate HRT and continue with a review after three months. Once stable review annually to reassess the risk/benefits of ongoing HRT use for her. There is no arbitrary limit to length of use.
  9. The benefits of HRT outweigh the risks for most women who start treatment aged under 60. Women with any cardiovascular or thrombotic risk factors who are eligible for HRT would benefit from a transdermal preparation.
  10. Low dose vaginal oestrogens are safe to use for as long as required in most women. Some women will require the use of vaginal oestrogen in addition to their systemic HRT to control their genito-urinary problems.

Clinical resources for training and appraisal

The RCGP Women's Health Library

The RCGP Women’s Health Library has been developed in conjunction with The Royal College of Obstetricians and Gynaecologists (RCOG) and The Faculty of Sexual and Reproductive Healthcare (FSRH) to provide educational resources and guidelines on women’s health that are relevant to GPs and other primary healthcare professionals. These resources will be helpful for those who wish to develop a more specialised interest in women's health.

NICE Guidelines and pathways

NICE Guideline (NG88) Heavy Menstrual Bleeding: assessment and management. March 2018, updated 2021

The Guideline covers the assessment and management of women with heavy menstrual bleeding. It aims to help healthcare professionals appropriately investigate the causes of the heavy periods that are affecting a woman’s quality of life and to offer information and access to treatments allowing the woman to choose the right treatment for her dependent on her priorities and preferences.

The NICE NG88 guideline includes a pathway for improving the assessment and management of heavy menstrual bleeding.

NICE Guideline (NG73): Endometriosis: diagnosis and management. September 2017.

This Guideline covers the diagnosis and management of endometriosis. It aims to raise awareness of the symptoms with an ambition to reduce the short and long-term consequences of untreated endometriosis. It also provides advice on the treatment options available.

The NICE NG88 guideline includes a pathway for improving the diagnosis and management of endometriosis

UK Guidance

The RCOG Green Top Guideline: Long-term consequences of Polycystic Ovary Syndrome

Polycystic Ovary Syndrome is one of the commonest endocrine disorders of women of reproductive age. It is often complicated by chronic anovulatory infertility and hyperandrogenism, with the clinical manifestations of oligomenorrhoea, hirsutism and acne. Many women with the condition are obese and have long-term consequences of impaired glucose tolerance, type 2 diabetes and adverse cardiovascular risk profile. Women with obesity and chronic anovulation are also at risk of endometrial hyperplasia and cancer.

This guideline provides information, based on clinical evidence, on the advice required for women about the long-term health consequences of what is fundamentally an endocrine disorder.

RCOG Green Top Guideline: Management of endometrial hyperplasia

Endometrial cancer is the most common gynaecological malignancy in the Western world and endometrial hyperplasia is its precursor. The most common presentation of endometrial hyperplasia is abnormal uterine bleeding including heavy menstrual bleeding, intermenstrual bleeding, irregular bleeding, unscheduled bleeding on hormone replacement therapy and postmenopausal bleeding.

The 'RCOG Green Top Guideline: Management of endometrial hyperplasia' provides recommendations regarding the management of endometrial hyperplasia.

FSRH CEU Clinical Guidance: Problematic Bleeding with hormonal contraception

Management of women presenting with problematic bleeding while using hormonal contraception is a frequent challenge. It may result from the contraceptive method or from other causes. This guidance provides evidence-based recommendations and good practice points for health professionals on the management of problematic bleeding in women using hormonal contraception currently available in the UK.

RCOG Green Top Guideline: Premenstrual Syndrome, Management (Green-top Guideline No. 48)

Premenstrual syndrome (PMS) affects an estimated 4 in ten women with 5-8% of these women suffering with severe symptoms. Women may be affected by a range of psychological symptoms including depression, anxiety, irritability, lack of confidence and mood swings and also by physical symptoms including bloating and mastalgia.

The aim of this guideline is to review the diagnosis, classification and management of PMS.

European Guidance

Management of women with endometriosis. Guideline of the European Society of Human Reproduction and Embryology

This guideline offers best practice advice on the care of women with suspected and proven endometriosis. The guideline includes recommendations on the diagnostic approach for endometriosis, including which symptoms suggest the diagnosis, use of diagnostic medical technologies and of clinical examination. Treatments for endometriosis, as medical treatment, non-pharmacological treatment and surgery, are discussed for both relief of painful symptoms and for infertility due to endometriosis.

Information is also included for the management of patients in whom endometriosis is found incidentally (without pain or infertility), for primary prevention of endometriosis, for the treatment of menopausal symptoms in patients with a history of endometriosis and for women with questions about the possible association of endometriosis and malignancy.

Management of women with premature ovarian insufficiency. Guideline of the European Society of Human Reproduction and Embryology

This guideline offers best practice advice on the care of women with premature ovarian insufficiency (POI), both primary and secondary. The recommendations are for women younger than 40 years (which includes Turner Syndrome patients) and those who are older with disease onset before 40.

The guideline includes recommendations on the initial assessment and management of women with POI, including with hormonal treatment. POI has consequences for health apart from gynaecological issues, including fertility and contraception, bone health, cardiovascular issues, psychosexual function, psychological function, and neurological function and recommendations about the management are also included.

International evidence-based guideline for the assessment and management of polycystic ovary syndrome (PCOS)

This international evidence-based guideline aims to provide health professionals, consumers and policy makers with transparent evidence-based guidance on timely diagnosis, accurate assessment and optimal treatment of PCOS, to reduce variation in care, optimise prevention of complications and improve health outcomes.

Quality Standards

NICE Quality standards help you improve the quality of care provided or commissioned. Relevant NICE Quality Standards:

Additional resources

RCGP Endometriosis elearning

This free-to-access 30 minute course uses the recommendations of the NICE guideline on endometriosis to follow a case study typically seen in primary care. The case illustrates common issues with diagnosis, when to investigate, when and how to manage in primary care and when to refer.

An educational grant was received from Endometriosis UK to produce this course.

RCGP Heavy Menstrual Bleeding elearning

This free-to-access 30 minute course applies the recommendations of the NICE guideline on HMB using case studies commonly seen in primary care. The cases illustrate common issues with diagnosis, when to investigate, when and how to manage in primary care and when to refer.

An educational grant was received from Endometriosis UK to produce this course.

NICE Clinical Knowledge Summaries (CKS)

Providing primary care practitioners with a readily accessible summary of the current evidence base and practical guidance on best practice:

Guidelines in Practice:

This 'Heavy menstrual bleeding: new treatments offer more options' article discusses the updated NICE recommendations for the diagnosis and treatment of heavy menstrual bleeding including:

  • Advances in techniques, medication and equipment for the management of HMB
  • When a physical examination and/or further investigation is required
  • Benefits of out-patient hysteroscopy vs ultrasound scanning when investigating HMB.

Other Resources:

Information and support for patients and carers

Period problems are very common and may affect physical, social and psychological health and well-being. Many women experience one or a number of concerns including; heavy periods, painful periods, infrequent periods, no periods or irregular bleeding.

Many women do not feel confident discussing the period problems they have because they do not realise that what they are experiencing is not normal and they may feel embarrassed to discuss concerns. NHS Choices has an excellent overview of periods and the conditions that can cause the problems women experience.

In addition to the resources listed below there is much useful information to be found on women’s health concerns on the website patient.info.

Menstrual diaries/period trackers are useful and can be found on line or as an app. Useful examples of free-to-download apps:

Further information and resources

Endometriosis

Endometriosis is a condition where tissue similar to the lining of the womb starts to grow in other places, such as in the pelvis, ovaries and fallopian tubes.

Women with endometriosis suffer from a range of concerns but the main symptoms are painful periods, painful sex and infertility.

Further information about endometriosis and the care provided can be found from the resources listed below:

Heavy Menstrual Bleeding (heavy periods)

Heavy periods are common and can have a significant effect on a woman’s quality of life and ability to function at work or socially. There is not always an underlying cause for the heavy periods but sometimes it is due to problems such as fibroids or endometriosis.

Further information about heavy periods and the care provided can be found in the resources listed below:

Fibroids

Fibroids are benign (non-cancerous) growths made up of musclefibres within the wall of the womb. They are very common and many women are unaware that they have fibroids as they often do not cause any symptoms.

In women who do have symptoms they may cause a range and severity of symptoms including heavy periods, pelvic pressure symptoms including the need to pass urine frequently, pain during sex.

Further information about fibroids can be found in the resources listed below:

Polycystic Ovarian Syndrome (PCOS).

Polycystic ovary syndrome is a common endocrine condition which may cause a variety of concerns including irregular periods, symptoms of having high levels of androgens, including acne and facial hair, and subfertility. The condition may also affect long-term health such as developing type 2 diabetes and high cholesterol later in life.

Further information about PCOS can be found in the resources listed below:

Pre-Menstrual Syndrome/Dysphoric Disorder. (PMS/PMDD)

Pre-menstrual syndrome is the name for the physical and emotional symptoms that some women experience in the two weeks before a period. The symptoms usually start to resolve once the period starts.

The syndrome affects women in different ways with variable severity and can alter from month to month.

Symptoms include mood swings, anxiety, tiredness, bloating, constipation, headaches which can affect the ability to function at work or socially.

Some women experience more severe symptoms, having a significant impact on life and this is known as pre-menstrual dysphoric disorder.

Further information about PMS/PMDD can be found in the resources listed below:

Premature Ovarian Insufficiency (POI)

The average age of the menopause in the UK occurs between age 47 and 53. Early menopause happens when a woman’s periods stop before the age of 45. This can happen naturally, or as a side effect of some treatments.

Premature ovarian insufficiency is classified as menopause occurring before the age of 40. Spontaneous POI affects about 1% of women but there are increasing numbers of women experiencing iatrogenic POI caused by surgery or cancer treatments.

The investigations and treatment recommendations are different to those for women experiencing a ‘normal’ menopause.

Further information about POI and the management options can be found in the resources listed below:

Support organisations

  • Endometriosis UK is a support organization with a vision to improve the lives of people affected by endometriosis and work towards a future where it has the least possible impact on those living with the condition
  • Fibroid Network is a UK based, patient led volunteer, support group, serving as a focal point for women’s fibroid and health issues with the aim to improve women with fibroids, healthcare and health education in the United Kingdom and internationally
  • National Association for Pre-menstrual Syndrome supports individual PMS sufferers and promote a greater awareness of PMS and of its treatment
  • Vicious Cycle is a patient-led project, passionate about raising awareness of Premenstrual Dysphoric Disorder, and improving the standards of care for those living with the condition
  • The Daisy Network is dedicated to providing support to women with Premature Ovarian Insufficiency (POI), also known as Premature Menopause
  • Verity – PCOS is a self-help group with a goal to improve the lives of women with polycystic ovary syndrome (PCOS).

Background information for commissioners

Menstrual related problems affect a significant proportion of the 25% of the UK population who are female of reproductive age between puberty and menopause, affecting their physical, psychological and social well-being. If unmanaged some of these conditions can cause lifelong problems including metabolic disease or chronic pelvic pain.

In the UK an estimated:

  • One in five women of reproductive age suffer with heavy menstrual bleeding (HMB) 1
  • One in 20 women aged 30-49 contact their GP with HMB each year.1
  • One in 10 women of reproductive age in the UK suffer with endometriosis,2 affecting 1.5 million women - the same number diagnosed with diabetes3.
  • Endometriosis costs the health and social care economy an estimated £8.2 billion/year4.

There is an under-recognition of the problems that women with menstrual dysfunction face with many women not realising their periods are not ‘normal’, a direct result of lack of education about menstrual health. This under-recognition and the ‘taboos’ surrounding the subject mean that many women are compromised, as they are not empowered to request support to help them attend school, college or work for several days and months a year.

The psychological impact is also underestimated and a recent survey of women with heavy menstrual bleeding5 found that of 1000 surveyed:

  • 74% experienced anxiety
  • 67% suffered with depression.

There are opportunities to reduce the health and social impact resulting from menstrual-related problems, whilst improving patient choice and experience, in primary care and out-of hospital settings by applying recommendations from recently updated NICE guidance 1 and improved access to diagnostic and minimal intervention technologies.

Resources:

The 'All Party Parliamentary Group on Women’s Health Report; informed choice? Giving women control of their healthcare' report from the All Party Parliamentary Group on Women’s Health (WHAPPG) in the UK highlights insufficient care and concern for women with endometriosis and fibroids.

Their survey of over 2600 women (with endometriosis and fibroids) found:

  • 42% of women said that they were not treated with dignity and respect
  • 62% of women were not satisfied with the information that they received about treatment options for endometriosis and fibroids
  • Nearly 50% of women with endometriosis and fibroids were not told about the short term or long term complications from the treatment options provided to them.

The recommendations from the report are wide-ranging, including improving awareness and reducing stigma of menstrual concerns by improving education at secondary school as well as for healthcare professionals, by improving information resources on the conditions and management options and by endorsing best practice pathways and care provided consistently following NICE recommendations.

Annual Report of the CMO 2014 – The health of the 51%:women

The report, developed with the support of expert academic and clinician input, examines women’s health in England and makes a range of recommendations for improvement.

The report identifies several missed opportunities for intervention in women’s health, and brings attention to ‘embarrassment’ as a needless barrier to health.

The main themes include:

  • obesity and its impact on women’s health, including reproductive health
  • women’s health in later life (menopause)
  • women’s health in later life (pelvic floor dysfunction and incontinence)

Menstrual Health Coalition report. Heavy Menstrual Bleeding – Breaking Silence and Stigma

Many women struggle to manage their menstrual health for a number of reasons. The Menstrual Health Coalition conducted an inquiry to explore this in further detail. The recommendations from the inquiry have been published in the 'Menstrual Health Coalition report. Their suggestions were:

  • Improve awareness and education to inform women about what is normal and abnormal menstruation and remove stigma encouraging more women to seek help and ensure that those who are approached are able and qualified to provide help.
  • Adequate, easily accessible and evidence-based information should be available for women and clinicians. The information should be comprehensive, including input from Royal Colleges and patient voices, as well as NHS and PHE resources.
  • Access to services should be prioritised and systems linked up to ensure that women can access the help that they need in a timely manner.

Plan UK report

The 'Break the Barriers: Girls’ Experiences of Menstruation in the UK' report reveals a culture of stigma and silence have turned periods into a hidden public health issue – putting girls' physical, sexual and mental health at risk. The report demands action through a menstrual manifesto to end the challenges girls face and break down the taboos that continue to make them feel ashamed of their bodies when they have their period.

RCOG: Heavy Menstrual Bleeding Audit final report.

A national audit to assess patient outcomes and experiences of care for women with heavy menstrual bleeding in England and Wales.

The Royal College of Obstetricians and Gynaecologists undertook a first audit and a repeat audit after four years to describe the provision of services for HMB in hospitals in England and Wales and patient-reported outcomes in an outpatient setting.

The conclusions of this work include:

  • The existing referral pathways between primary and secondary care should be reviewed with nearly one-third of women reported that they had not received any treatment for their HMB in primary care.
  • There were differences to care provided to different ethnic and socio-economic groups and there is a requirement to address this to improve how the individual needs of women are being met.
  • Information for patients should be improved with women being informed adequately about the treatment options available.
  • Hospital services should compare themselves with peers to reduce variation in protocol, organisation and treatments offered.

NICE recommendations – putting this guideline into practice

NICE Guideline (NG88) Heavy Menstrual Bleeding: assessment and management. March 2018 (updated November 2018)

The guideline for assessment and management of heavy menstrual bleeding was updated in March 2018 with further amendments in 2021. It aims to help healthcare professionals investigate the cause of heavy periods that affect a woman’s quality of life and to offer the right treatments, taking into account the woman’s priorities and preferences.

Tools and resources have been produced to help put the guideline into practice noting specific issues including:

  • facilities and staffing for hysteroscopy services in community settings.
  • Providing hysteroscopy in line with best practice guidelines.

NICE Guideline (NG73): Endometriosis: diagnosis and management. September 2017

The guideline for diagnosis and management of endometriosis was published in September 2017. This aims to raise awareness of the symptoms of endometriosis, and to provide clear advice on what action to take when women with signs and symptoms first present in healthcare settings and of treatment options available.

Recommendations include that the community, gynaecology and specialist endometriosis centres should work together to provide coordinated care to provide prompt diagnosis and treatment of endometriosis to improve quality of life and reduce adverse consequences of untreated disease.

Commissioned service requirements

Specialist endometriosis centres

NHS England specialist commissioners have published the specification for the service for treating endometriosis with a recommendation to commission services from centres that meet the British Society of Gynaecological Endoscopy (BSGE) Accreditation criteria. The ambition is to deliver treatment by multidisciplinary teams working in specialist centres who have sufficient workload to maintain skills and audit their performance.

List of specialist endometriosis centres found online.

RCOG Advice for Heavy Menstrual Bleeding (HMB) services and commissioners.

The lessons learnt from the RCOG Heavy Menstrual Bleeding audit have informed a recommendation for commissioners and providers of HMB services. The purpose of this advice, endorsed by the Royal College of General Practitioners (RCGP), is to ensure that effective and patient focused clinical care can be delivered nationally in primary and secondary care.

References:

  1. NICE. Heavy menstrual bleeding: assessment and management. NICE Guideline 88. NICE, March 2018 (updated November 2018). www.nice.org.uk/ng88
  2. Rogers PA, D'Hooghe TM, Fazleabas A, et al. Priorities for endometriosis research: recommendations from an international consensus workshop. Reprod Sci 2009;16(4):335-46
  3. Diabetes UK: Diabetes prevalence 2012. (April 2012). Diabetes affects around 2.9 million people, of which slightly less than half of this are women.
  4. Simoens S, Dunselman G, Dirksen C, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod 2012;27(5):1292-9
  5. Wear White Again, Hologic survey 2017

Menstrual wellbeing podcasts

Endometriosis: managing its impact.

RCGP Menstrual Well-being Spotlight Project Clinical Champion Dr Anne Connolly talks to Jody Stewart, a patient diagnosed with endometriosis who is also a member of the project steering group, about her experiences of suffering with painful periods, diagnosis, treatment and support from Endometriosis-UK.

Heavy Menstrual Bleeding

RCGP Menstrual Well-being Spotlight Project Clinical Champion Dr Anne Connolly talks to Jillian Neckar, a patient who suffered with heavy menstrual bleeding, about her experiences at school and in the workplace, her management and her treatment choices.

Endometriosis: Diagnosis and management

Dr Sally Higginbottom interviews RCGP Clinical Champion for Women’s Health, Dr Anne Connolly, on the diagnosis and management of women suffering with endometriosis, based on the recommendations of the NICE guideline.

Managing pelvic pain

Dr Thomas Round interviews Dr Louise Newson on the management of women presenting with chronic pelvic pain, based on the RCOG guideline, explaining the important aspects of history taking, examination, investigation and management.

This toolkit has been developed in partnership between the RCGP and Endometriosis UK.

Please send any feedback or suggestions to clinicalquality@rcgp.org.uk

Menopause and beyond

Menopause word cloud

Key facts

There is much confusion about management of the menopause and although it is an inevitable occurrence for women many continue to suffer in silence. An estimated 40% of women reported that the symptoms were worse than they had anticipated1 with 45% reporting that menopause symptoms had a negative impact on their work2.

Premature ovarian insufficiency is classified as menopause in women aged less than 40. The risk of cardiovascular disease, osteoporosis and dementia is increased in this cohort of women and HRT is recommended as ‘replacement’ therapy as well as for symptom control3.

Female urinary incontinence becomes increasingly problematic in women postmenopausally and as they age, caused by pelvic floor muscle weakness and/or detrusor muscle over activity. The recently updated NICE guidance4 clearly outlines management and includes a section on management of pelvic floor prolapse for the first time.

Ovarian cancer has low survival rates because the vague symptoms result in late presentation. Earlier diagnosis and a low threshold for considering testing are required to make significant difference to the poor outcomes5.

Vulval disorders become more problematic as women age and require examination and early treatment to reduce the long-term consequences of scarring and malignant transformation.

References:

  1. British Menopause Society, National Survey
  2. European Society of Human Reproduction and Embryology Guideline on the management of premature ovarian insufficiency. Published date: December 2015.
  3. NICE guideline: Urinary incontinence and pelvic organ prolapse in women: management (NG 123) Updated June 2019.
  4. NICE guideline. Ovarian cancer: recognition and initial management (CG122) Published 2011

Resources for training and appraisal

Training resources

  1. The International Menopause Society Professional Activity for Refresher Training, (IMPART) is an online training course aimed at both primary care practitioners and hospital specialists. IMPART comprehensively provides practitioner training in managing both acute menopausal symptoms and the long term consequences of the changes that occur at menopause. It provides guidance in midlife preventative health care, including when and what basic health checks should be performed to prevent and detect bone loss and osteoporosis, cardiovascular disease, gynaecological cancers, and impaired mental health.
  2. RCGP e-learning. Bloating and other symptoms: Could it be ovarian cancer? A 30 minute e-learning module developed in conjunction with Target Ovarian Cancer aiming to increase knowledge and confidence in deciding when to assess women with bloating and other abdominal symptoms for ovarian cancer. This session covers the presentation and diagnosis of ovarian cancer in primary care through the use of case studies.

Top tips for menopause management in primary care

Adapted from Primary Care Women’s Health Forum top tips, with permission

  1. The diagnosis of menopause in women aged > 45 is clinical and based on symptoms. It does not usually require confirmation with an FSH level.
  2. Remember that contraception is needed until infertility can be assumed. The use of intra-uterine progestogen offers endometrial protection and contraception. Refer FSRH CEU Guideline Contraception for women over 40 for further information.
  3. Consider menopause as a possible cause of amenorrhoea in women < 45 who are not using hormonal contraception once pregnancy is excluded.
  4. Recommend Hormone Replacement Therapy (HRT) routinely to women who are menopausal aged < 45, even if they are asymptomatic, to reduce the consequences of long-term hypo-oestrogenism such as osteoporosis and cardiovascular disease.
  5. Provide/signpost women to reliable patient information (i.e.menopause matters and manage my menopause) to allow informed and shared decision making between the woman and her healthcare professional.
  6. Prescribing is not difficult and decision-making guides are available. Read the Easy HRT prescribing guide on management and prescription of HRT in primary care, Primary Women's Health Forum.
  7. HRT is much safer than you think. NICE Clinical Guidance (2015); Diagnosis and Management provides the evidence and reassurance for use.
  8. Support the woman to initiate HRT and continue with a review after three months. Once stable review annually to reassess the risk/benefits of ongoing HRT use for her. There is no arbitrary limit to length of use.
  9. The benefits of HRT outweigh the risks for most women who start treatment aged < 60. Women with any cardiovascular or thrombotic risk factors who are eligible for HRT would benefit from a transdermal preparation.
  10. Low dose vaginal oestrogens are safe to use for as long as required in most women. Some women will require the use of vaginal oestrogen in addition to their systemic HRT to control their genito-urinary problems.

Top tips and useful resources

  • The British Menopause Society has developed a number of tools to help clarify some common myths and misconceptions of menopause. These are useful for women and healthcare professionals, improving understanding of menopause, including summarising the NICE guideline and providing guidance on HRT
  • The British Menopause Society also has a series of short videos explaining common issues with menopause management including:
    • HRT
    • Premature ovarian insufficiency
    • HRT and bleeding
    • HRT and breast cancer
    • Migraine and headache

Guidelines and Pathways

  • NICE Menopause: diagnosis and management. (NG23, November 2015, updated 2019). This guideline covers the diagnosis and management of menopause, including in women who have premature ovarian insufficiency. The guideline aims to improve the consistency of support and information provided to women in menopause. The guideline was amended in December 2019, following the MHRA safety alert on hormone replacement therapy (HRT) and the risk of breast cancer, to include the MHRA’s advice on risks and benefits.
  • The NICE NG23 guideline includes a pathway for improving diagnosis and management of menopause.
  • The British Menopause Society website hosts a series of consensus statements which address key disorders and controversial topics in post-reproductive health. These statements are developed from evidence review and informal consensus to support healthcare professionals to provide quality post-reproductive healthcare including:
    • Hormone Replacement Therapy
    • Non-hormonal based treatments for menopausal symptoms
    • Premature ovarian insufficiency
    • Bioidentical HRT
    • Urogenital atrophy

Commissioning

  • Conservative Management of Prolapse – competency framework for primary care. The Primary Care Women’s Health Forum competency framework for conservative management of prolapse recognises that some clinicians will both fit and check pessaries while others will provide follow up care. The principles of this competency framework apply to both levels of care with differing expectations of practical competencies.

Patient and carer resources

  1. Patient information leaflets
  2. Podcasts
  3. Explanation of medical terms
  1. Surgery for stress urinary incontinence
  2. Surgery for uterine prolapse
  3. Surgery for vaginal vault prolapse
  • The Primary Care Women's Health Forum (PCWHF) 'Rock my menopause' campaign to reduce the stigma around menopause by making people more menopause aware. Includes resources for patients, families and health care professionals on symptoms, self-help, HRT, menopause and mental health.
  • The Daisy Network, a charity for women diagnosed with premature ovarian insufficiency (premature menopause) sharing information to support women and their extended networks to understand the concern and treatment options available.
  • Bladder and Bowel UK, a charity supporting people with bladder and bowel problems. Urinary incontinence is a common concern particularly for women following childbirth and as they age. Bladder and bowel UK have developed resources to help with self-care and information to support sufferers to understand their concerns and treatment options available.
  • The Eve Appeal, a UK national charity raising awareness and funding research into the five gynaecological cancers – womb, ovarian, cervical, vulval and vaginal.
  • Target Ovarian Cancer, an ovarian cancer charity working to improve earlier diagnosis and provide support for women with ovarian cancer.

Women's health and COVID 19

Since the start of the COVID-19 pandemic we have changed the way of working in general practice by continuing to deliver high quality care through initial remote consultation and triage aiming to reduce infection spread by unnecessary face to face contact. In women’s health there are opportunities to deliver quality care remotely provided there is a good understanding of the menstrual cycle, individualised holistic risk assessment and to support patient expectations. There are also many excellent on-line resources available which can empower patients with a better understanding of their concerns and management choices (self-care and medical interventions).

This section of the Women’s Health toolkit contains resources to help provide care during the COVID-19 pandemic, including when this can be offered remotely, including tips about applying recommendations to practice.

Guidance on:

  • Maternity
  • Reproductive health
  • Menstrual wellbeing
  • Menopause and beyond
  • Patient information

Maternity

Coronavirus (COVID-19) infection in pregnancy published by RCOG and RCM.

This updated document aims to provide guidance to healthcare professionals who care for pregnant women during the COVID-19 pandemic.

The advice is not intended to replace existing clinical guidance but to use available evidence, good practice and expert consensus opinion to:

  • Reduce the transmission of SARS-CoV-2 to pregnant women
  • Provide safe, personalised and woman-centred care during pregnancy, birth and early postnatal period, during the COVID-19 pandemic
  • Provide safe, personalised and woman-centred care to pregnant and postnatal women with suspected/confirmed COVID-19

Supporting pregnant women using maternity services during the coronavirus pandemic: Actions for NHS providers.

In December 2020 guidance was published by NHSE to support women using maternity services during the coronavirus pandemic. This includes advice for maternity units to permit pregnant women in England to have one person beside them at all stages of the maternity journey and to be able to attend appointments (ante-natal, intra-partum and postnatal), as long as the support partner is not showing any COVID-19 symptoms.

The Royal College of Psychiatrists advice on perinatal mental health during the COVID-19 pandemic

The recommendations identify the need to support pregnant women who may experience increased anxiety because of concerns about:

  • COVID-19 infection
  • impact of social isolation and reduced support from usual family and friends’ networks
  • financial worries
  • changes to usual face to face antenatal care

This is particularly important for those experiencing domestic violence or with safeguarding concerns.

The document includes information and signposts to a number of support services for women affected by:

  • postpartum psychosis
  • bipolar disorder
  • perinatal OCD
  • eating disorders
  • depression and other perinatal mental illnesses
  • perinatal anxiety

COVID-19 vaccination and pregnancy

Gov.UK have published COVID-19 vaccination: a guide for women of childbearing age, pregnant, planning a pregnancy or breastfeeding.

Questions have been raised about COVID-19 vaccines in pregnancy, women who may become pregnant within the following 3 months and when breast feeding. Updated advice published by MHRA on 30 December 2020 recommended that both the Pfizer / BioNTech and Oxford University / AstraZeneca vaccines may be considered for use in pregnancy when the potential benefits outweigh any potential risks for the mother and baby. Women should discuss the benefits and risks of having the vaccine with their healthcare professional and reach a joint decision based on individual circumstances. Women who are breastfeeding can also be given the vaccine.

Reproductive health

Faculty of Sexual and Reproductive Health Clinical Effectiveness Unit (FSRH CEU) recommendation on extended use of etonogestrel implant and 52mgs levonorgestrel-releasing intrauterine system during COVID restrictions.

The available evidence suggests that the risk of pregnancy in the 4th year of use of an etonogestrel implant and the 6th year of use of a 52mgs levonorgestrel-releasing intrauterine system (LNG-IUS) is likely to be very low. FSRH CEU suggest that in the current circumstances replacement of both devices can be delayed for up to a year although users should be made aware that the contraceptive efficacy cannot be guaranteed. Progestogen-only contraceptive pills can be taken in addition or use of condoms is an alternative option while waiting for the change of their contraceptive device.

When using Mirena for endometrial protection as part of HRT the LNG-IUS must be changed after 5 years or alternatively the HRT can be altered to a combined preparation.

The lower dose LNG-IUS devices require changing at their expiry time or additional contraception added as there is no evidence to support their extended use.

Managing contraceptive provision during coronavirus pandemic.

Primary Care Women’s Health Forum (PCWHF) resource ‘How to manage contraceptive provision without face to face consultations’.

The resource is written by expert clinicians at the PCWHF and includes advice on:

  • Combined hormonal contraception
  • Progestogen only pill
  • Women due for a change of IUD/IUS/implant
  • Contraceptive injections
  • Emergency contraception

Protocol for LARC fittings in primary care during COVID-19 restrictions

Since March 2020 there has been a reduction in LARC activity in specialist SRH services and primary care. To support clinicians to safely deliver services where possible the PCWHF resource explains how to minimise the risk of transmission of COVID-19 while providing LARC procedures.

PCS COVID-19 Community Contraception Guide

A contraception guide flowchart for local use or adaptation. It covers oral contraception, repeat or new starter and long acting reversible contraception: Depo DMPA, implant, copper IUD and IUS.

Guidelines in Practice article: Top Tips: contraception and COVID-19

Written by a practicing GP with an interest in sexual and reproductive health this article offers practical information on:

  • The impact of the COVID-19 pandemic on access to contraception
  • How to maintain the provision of contraception despite the reduction in face-to-face consultations
  • The efficacy and practicality of long-active reversible contraceptive methods, particularly during the pandemic

Webinar: Managing contraception in primary care remotely during COVID times and beyond

Case based presentation applying latest recommendations on providing contraception choices counselling using on line resources and remote consultation where appropriate, including management of any concerns aiming to improve contraceptive compliance and uptake of long-acting reversible contraception.

Menstrual wellbeing

Joint RCOG, BGSE, BGCS guidance for the management of abnormal uterine bleeding in the evolving Coronavirus (COVID-19) pandemic

A consensus statement providing a framework for the management of women presenting with abnormal uterine bleeding including:

  • Heavy menstrual bleeding
  • Intermenstrual bleeding
  • Postmenopausal bleeding
  • Post-coital bleeding

How to manage women presenting with abnormal uterine bleeding in primary care without face to face contact during COVID-19

Advice published by PCWHF produced by clinical expert consensus and adapted for use in primary care from recommendations published by RCGO/BSGE/BGCS/BMS. The guidance includes advice on managing women presenting to primary care with:

  • Heavy menstrual bleeding
  • Intermenstrual bleeding
  • Postmenopausal bleeding (occurring in women not using HRT)
  • Post-coital bleeding
  • Unscheduled bleeding on HRT

Guidelines in Practice article: Abnormal uterine bleeding: management in COVID-19 and beyond

Written by a GP with an interest in women’s health this article explains:

  • Types of abnormal uterine bleeding
  • When women with AUB need to be seen, examined and investigated and when management can be remote
  • How guidance on the management of AUB in the COVID-19 pandemic may provide future learning opportunities

Webinar: NICEr for women: managing bleeding problems in primary care

Case based presentation applying latest evidence and guidance to the management of women presenting to primary care with abnormal uterine bleeding. Including recommendations for when women can be managed remotely and when examination and investigations are required.

Menopause and beyond

Webinar: Managing HRT and contraception remotely during COVID and beyond

Case based presentation applying latest evidence and guidance to the management of women presenting to primary care with menopausal concerns, including when prescribing hormone replacement therapy (HRT). The discussions include tips about when management can be provided remotely and when examination and investigations are required.

The Personalised Care Podcast: Women's Health

In the first episode of The Personalised Care Podcast, brought to you by the Personalised Care Institute, you’ll hear a patient’s powerful description of what it was like to go through the menopause as we discuss the impact of a personalised care approach from healthcare professionals. We explore the importance of sensitive language in consultations and discover why the ‘one size fits all approach can be very damaging. This episode is all about helping healthcare professionals to empower women who seek help with the menopause, and we’ll be discussing the importance of appreciating the individual’s concerns and what matters to them.

How to manage HRT provision without face-to-face consultations during COVID-19 healthcare restrictions

PCWHF guide for primary care practitioners to support HRT provision during the COVID-19 pandemic, endorsed by BMS.

Includes tools for:

  • Initiating HRT by remote consultation
  • Reviewing HRT by remote consultations
  • HRT prescribing
  • Managing side effects and trouble shooting
  • Managing unscheduled vaginal bleeding and HRT
  • Individual assessment of long-term benefits and risks of HRT
  • Use of vaginal treatments

Reflections and recommendations on the COVID-19 pandemic: Should HRT be discontinued?

The board of the Italian Menopause Society has provided advice on the use of hormone therapy during the COVID-19 pandemic including the following recommendations:

  • Hormone therapy and hormonal contraceptives should be continued, unless the woman is severely ill
  • In cases of disease progression to severe symptoms, expert advice should be requested with consideration of the need to treat with heparin
  • Transferring from oral to transdermal oestrogen may be considered, but is not mandatory
  • If starting or restarting therapy it is probably useful to use transdermal instead of oral oestrogens
  • When hormone therapy is discontinued, it should be remembered that withdrawal bleeding may occur

BSUG guidance on management of urogynaecological conditions and vaginal pessary use during the COVID-19 pandemic

The recommendations include the assessment for timing and requirement for face to face review of women with urogynaecological conditions and when remote or delayed management is preferred when balancing the benefits and risks of COVID-19 transmission. Recommendations also include vaginal pessary use for prolapse.

Patient information

RCOG and RCM Coronavirus infection and pregnancy

This resource provides information for pregnant women and their families, including videos and frequently asked questions.

This resource also includes information on:

  • Covid-19 vaccination during pregnancy and breast feeding Women at higher risk of serious illness including from BAME communities
  • Early pregnancy
  • Antenatal care
  • Childbirth choices
  • Postnatal care
  • Occupational health guidance for pregnant women working in public facing roles

Sexwise - Help during COVID-19

Resource providing advice on contraception choices and sexual health including a section on Help during COVID-19. This provides information on how to access sexual health services during the COVID pandemic, including:

  • Where to find the local sexual health services
  • How to access services which appear closed
  • Maintaining good sexual and reproductive health during COVID-19
  • Further specific information sites

Endometriosis - COVID 19 and endometriosis

Endometriosis UK have added a page to their website containing the latest information and resources available on COVID-19 and endometrioisis. The resources include current recommendations on medical treatments and strategies for the management of associated symptoms including:

  • Coronavirus and endometriosis
  • Medical and self-care advice
  • Pelvic exercise programme
  • Webinars on endometrioisis and COVID-19

Jo’s Trust - Coronavirus hub

Jo’s Trust have created guidance to help manage concerns for those due for cervical screening, have cell changes or are affected by cervical cancer. This includes information on:

  • Cervical cancer and coronavirus
  • Changes to screening and colposcopy
  • Blogs to include practical tips, other people’s experiences and support

Target Ovarian cancer - wellbeing during the pandemic

In response to concerns raised about emotional distress caused by coronavirus pandemic Target Ovarian Cancer have produced a page on wellbeing during the pandemic including:

  • Q&A on mental health concerns and anxiety due to COVID-19 Support for women waiting for/undergoing cancer investigations and treatments
  • Signposting to on-line resources to help with mental health concerns

Eve Appeal - cancer and coronavirus

Eve appeal have published a page on their website specifically for people living with gynae cancer, or experiencing any worrying symptoms. This includes information on coronavirus and:

  • Womb cancer
  • Ovarian cancer
  • Vulval cancer
  • Vaginal cancer
  • Cervical screening and colposcopy
  • BRCA testing during COVID-19
  • Reducing your risk.