Abstract
5–6 July 2018
Oral presentations
Winner, Best Free Communication, BMS Annual Conference 2018
Winner, Best Poster, BMS Annual Conference 2018
NICE referral guidelines for women with postmenopausal bleeding (PMB): Does age really matter?
1Research Fellow, Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, UK; Obstetric and Gynaecology Department, Aswan University, Egypt
2Consultant Gynaecologist and Senior Lecturer, Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, UK
3Consultant Gynaecologist, Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, UK
Introduction
The National Institute of Health Excellence (NICE) guidelines for suspected cancer recognition and referral (NG12, 2017) recommend referring any patient to secondary care for cancer diagnosis if the probability of developing cancer exceeds 3%. Therefore, NICE endorses referring women aged ≥55 years of age with PMB using the “2 weeks wait” suspected cancer pathway to exclude endometrial cancer. Those <55 years of age are thought to be at lower risk, hence NICE recommends considering the suspected cancer pathway according to the clinical judgment of family doctor. The aim of this study is to quantify the prevalence of endometrial atypical hyperplasia and cancer in women with PMB stratified according to age.
Methods
Prospective consecutive data of 1995 women attending the PMB clinic were collected between 1 January 2011 and 31 January 2015 in Sandwell and West Birmingham Hospitals Trust, UK. Women were categorized according to age into: group 1 (<55 years) and group 2 (≥55 years). All women with PMB were routinely seen within two weeks of referrals. The project was approved by the Clinical Effectiveness Department of the Trust.
Results
The number of women in group 1 was 684 (34.3%) and in group 2 was 1311 (65.7%). The prevalence of endometrial atypical hyperplasia and cancer in group 1 and group 2 was 15 (2.2%) and 158 (12%), respectively (p < 0.001). Out of the 15 cases in group 1, 7 has atypical hyperplasia and 8 had cancer. Comparing to group 1, the odds ratio (95% CI) of women in group 2 to develop atypical hyperplasia and cancer was 6.1 (3.6–11.6).
Conclusion
The prevalence of endometrial atypical hyperplasia and cancer in women with PMB aged <55 years was 2.2% which is less the 3% positive predictive value used by NICE to recommend “2 weeks wait” referral. Nonetheless, if NICE guidelines were to be implemented in this cohort, 15 cases would potentially have had unnecessary delayed diagnosis. Women <55 years of age with PMB remain at low but clinically significant risk, and should be referred to secondary care using the “2 weeks wait” suspected cancer pathway.
More menopause education is needed for healthcare professionals in primary care
1Regional Director PCWHF, UK
2Chair PCWHF, UK
Introduction
There are many healthcare professionals (HCPs) who have had inadequate menopause training and are still unaware of the NICE guidance on diagnosis and management of the menopause. The aims of this study were to understand the level of education and training among health care professionals (HCP) regarding the menopause, and to determine knowledge regarding treatment.
Methods
HCPs who are members of Primary Care Women’s Health Forum (PCWHF) were invited to complete a questionnaire developed by the authors. All replies were pooled anonymously.
Results
A total 87 HCPs participated, 70% were general practitioners (GPs) and 16% primary care nurses. The vast majority (92%) thought that the menopause should be managed at primary care level. Only 40% had attended formal menopause training. Responders were more confident in treating healthy women with hormone replacement therapy (HRT) (88%) rather than younger menopausal women of <45 years (66%). Most responders (83%) believed that HRT reduces the risk of osteoporosis, but the risk of breast cancer (BC) was more controversial. A fifth of HCPs (20%) thought that any type of HRT increases the risk of BC, while 16% thought there is an increased risk in any aged woman. Around half, 46%, incorrectly thought that taking oestrogen only HRT increases the risk. The vast majority, 70%, had either offered or given antidepressants to menopausal women with symptoms of low mood. A fifth of those responded (19%) incorrectly thought that raised blood pressure is a contra-indication to taking HRT.
Conclusion
This survey demonstrates a gap in management of the menopause at primary care level, even in HCPs with an interest in Women’s Health, with low levels of confidence in managing young women and inappropriate antidepressant prescribing. There is a desperate and urgent need for more evidence-based menopause care to occur in the UK and worldwide. Many healthcare professionals have had very little training and education about the perimenopause and menopause and this needs to change. Menopause care needs to be mainly delivered in primary care.
Outcomes of endometrial assessment in women with unscheduled bleeding on hormone replacement therapy
1Clinical Research Fellow, Early Pregnancy and Gynaecology Unit, King's College Hospital, London, UK
2Lead Gynaecology Nurse, King's College Hospital, UK
3Specialist Trainee (ST1) in Obstetrics and Gynaecology, King's College Hospital, UK
4Consultant Obstetrician and Gynaecologist, King's College Hospital, London, UK
5Consultant Gynaecologist, King's College Hospital, London, UK
6Consultant Gynaecologist, Subspecialist in Reproductive Medicine and Surgery, King's College Hospital, London, UK
Introduction
Most women who present with unscheduled bleeding on hormone replacement therapy (HRT) have a normal endometrium, with low risk of endometrial cancer. No current consensus exists as to the management of women who experience unscheduled bleeding on HRT.
Methods
Retrospective analysis of a consecutive case series of 498 patients with unscheduled bleeding (230 patients on sequential and 268 patients on continuous combined therapy) was identified from our clinical database. The clinical protocol was to investigate women with an endometrial thickness ≥ 5 mm, with evidence of an endometrial polyp or inadequate visualisation of the endometrium. The histopathological diagnoses were normal endometrium, endometrial polyp, endometrial hyperplasia without atypia, atypical hyperplasia/ cancer and insufficient sample.
Results
Mean age was 54 years old ± 8 years SD (range 34–85 years). Normal appearance of endometrium on scan was seen in 142/230 (62%) patients on sequential therapy, median thickness of 3.8 mm ± 1.9 mm STD (range 1–10.6 mm) versus 112/268 (42%) patients on continuous combined therapy (normal endometrium <5 mm), endometrial median thickness of 3 mm ± 0.9 mm STD (range 0.8–4.9 mm) (p < 0.01, 95% CI 1.5 to 3.1). A thick appearance of the endometrium in the sequential therapy group, median of 7.8 mm ± 4.9 mm SD (range 4–29.5 mm) was seen in 60/230 (26%) patients versus 116/268 (43%) patients in continuous combined group (thick endometrium ≥5 mm) 6.8 mm ± 2.8 mm STD (range 2.7–24.1 mm) (p < 0.01, 95% CI 0.3–0.7). Endometrial polyps were suspected in 28/230 (12%) versus 40/268 (15%) patients respectively (p = 0.3, 95% CI 0.3–0.6). Following outpatient endometrial biopsy in 36/230 (16%) patients versus 59/268 (22%) and hysteroscopy in 46/230 (20%) versus 93/268 (35%) results showed 56/230 (25%) versus 84/268 (31%) normal endometrial tissue; 19/230 (8%) versus 47/268 (18%) benign endometrial polyps; 2/230 (1%) versus 17/268 (6%) insufficient sample; 1/230(0.4%) versus 1/268 (0.4%) endometrial hyperplasia without atypia; 4/230 (2%) versus 3/268 (0.5%) atypical hyperplasia/endometrial cancer in the sequential and continuous combined therapy groups respectively.
Conclusion
Women with unscheduled bleeding on HRT both on sequential and continuous combined regimens can be reassured that the risk of pathology is low.
Premature ovarian insufficiency – How confident are general practitioners diagnosing and managing premature ovarian insufficiency?
1UKCP Accr/ Snr MBACP Specialist Counsellor POI; London N.W. University Healthcare NHS Trust, London, UK
2Consultant Obstetrician and Gynaecologist, BSc, FRCS, FRCOG London N.W. University Healthcare NHS Trust, London, UK
3RN M Clin Sci; London N.W. University Healthcare NHS Trust, London, UK
4London N.W. University Healthcare NHS Trust, London, UK
5London N.W. University Healthcare NHS Trust, London, UK
6London N.W. University Healthcare NHS Trust, London, UK
Introduction
A young menopause clinic for women with premature ovarian insufficiency (POI) has run in a busy general district hospital since 2004. Young women consistently comment on a delay in recognising and diagnosing POI (1) and concomitant psychological distress (2). General practitioners are often unsure of management of climacteric symptoms at the average age (3), and find POI additionally challenging (4), often because this presents less frequently.
Aim
To ascertain the degree of knowledge and confidence amongst GPs in the diagnosis and management of POI, and if there is a need for further education what the most acceptable form of delivery might be.
Method
An electronic survey elicited 52 fully completed responses out of 55.
Results
Eighty-one percent of respondents were female; 52% qualified less than nine years ago; 20% had no relevant education on POI; 41% reported ‘a little as part of continuing professional development’; 33%: ‘some as a student’; 85% expressed interest in further education; 49% preferred a half study day; 30% learning online. Most were aware of the definition but 10% confused it with early menopause or had no knowledge; 73% either thought it rarer than it is or didn’t know prevalence; 81% would use FSH blood tests for diagnosis; 63% knew this should be done twice, six weeks apart; 75% answered that young women should be on HRT until the average age of menopause (5). Confidence was scored between 0 and 91 where 0 is no confidence and 100 is totally confident; 33% of responders clustered between 50 and 70 (average level of confidence: 37). 94% were aware this is a long-term condition, with risks to bone health though only 55% thought heart health could be affected. Long-term prescribing is an issue: 48% indicated that six monthly prescribing, but 7% would only prescribe monthly or two monthly; 79% would prescribe HRT but almost universally, androgen replacement was not considered and one respondent offered an SSRI.
Conclusion
Understanding and recognition of POI by GPs are limited. Long-term prescribing and androgen therapy pose challenges – the need for education and training is paramount.
References
Speaking the taboo – How women manage the impact of their menopause in a UK workplace
1University of Leicester, UK
2University of Bristol, England, UK
3The Open University, England, UK
4newsonhealth.co.uk
5talkingmenopause.com
6Carol Brown & Lesley Byrne (West Midlands Police)
Introduction
Menopause symptoms are known to affect work but work to affects menopause symptoms (Brewis et al. 2016). HR professionals are not well equipped for the coming menopause tsunami (Atkinson et al. 2015).
Objective
To assess the attitudes and actions of women in managing their menopause at work, and understand why women do or do not disclose menopause symptoms at work.
Methods
A survey of 335 mid-life women in a UK regional police service captured physical (n = 38) and psychological symptoms (n = 21) developed from qualitative research and applied K-means clustering to identify menopause sub-groups. The survey measured the impact of symptoms on work functionality, absence, and career progression alongside the psychosocial work environment and used ANOVA, t-tests and Chi-square as well as qualitative data to explain non-disclosure and impact of symptoms.
Results
Menopause symptoms had a negative impact on work for 82.1%. Where menopause impacted work, 21.5% of women had taken time off, usually as sick leave; 33.5% had considered leaving/reduced hours; 55.3% of women report coping with symptoms in work but 26.2% felt incapable of performing their roles. Menopause remains hidden in this workplace so symptoms are managed privately by women. Only 28% had disclosed symptoms to line managers. Four distinct menopause sub-groups were defined using varying symptom profiles. Analysis confirms there is more confident self and GP diagnosis for physical symptoms but, where there are more psychological symptoms, women more readily acknowledge the impact on work incapability and work dysfunctionality. Women with a greater range of psychological symptoms were more likely to take time off work or consider leaving or reduced hours. Women with lower numbers of psychological or physical symptoms were most resistant to disclosure at work. Reasons for non-disclosure are also reported from qualitative data.
Conclusions
Menopause literacy and visibility at work are important for greater acceptance and use of workplace initiatives to support women with menopause symptoms. Physical symptoms are more readily recognised, so greater attention to psychological symptoms is needed to tackle workplace menopause taboo.
Prevalence of hyperplasia and cancer in benign-looking endometrial polyps in women with postmenopausal bleeding
1University of Birmingham, Birmingham, UK; Obstetrics and Gynaecology Department, Aswan University, Aswan, Egypt; Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
2University of Birmingham, Birmingham, UK
3Obstetrics and Gynaecology department, Aswan University, Aswan, Egypt
4Obstetrics and Gynaecology department, Aswan University, Aswan, Egypt
5University of Birmingham, Birmingham, UK; Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
Introduction
The malignant potential of endometrial polyps in women with PMB has not been adequately addressed in the literature, and there is no consensus regarding the best management approach. This systematic review and meta-analysis was conducted to quantify the prevalence of hyperplasia and cancer to help inform clinical practice as whether benign-looking endometrial polyps ought to be removed when first diagnosed or expectant management could also be offered.
Methods
We searched the published literature using strategies developed by a medical librarian using a combination of standardized terms and key words and were implemented in PubMed, EMBASE and clinicaltrials.gov. Search was limited to primary research published in English and reporting endometrial polyps in women with PMB till December 2017. The standard of meta-analysis of observational studies in epidemiology (MOOSE) was followed. The prevalence was estimated with a random effect model using the method of DerSimonian and Laird. Exact CI was calculated for the individual studies. Heterogeneity was assessed using the I2 statistic and calculation of 95% prediction intervals for the response proportion in a new study. The possibility of small study effects was assessed by asymmetry of funnel plots and the potential impact quantified using Duval and Tweedie non-parametric “trim and fill” method.
Results
The number of retrieved studies was 4025. After removing the duplicates and performing the title and abstract filtering, 37 manuscripts were identified. We excluded 17 papers for not reporting PMB women as a separate group, and 12 for mixing tamoxifen users with none users. The remaining eight studies were included in the analysis. The pooled estimate of prevalence and 95% CI were 8.5% (6.2%, 10.8%). Adjustment for small study effects leads to a lower estimate of 7.3% (4.7%, 9.9%). An I2 statistic of 59% is suggestive of likely moderate heterogeneity. This may be clinically relevant as the between-study standard deviation was 2.4%, and a 95% prediction interval suggests that the prevalence in a new study might lie between (1.9%, 15.2%).
Conclusion
The high prevalence of hyperplasia and cancer in benign-looking endometrial polyps in women presenting with PMB justifies removal at first presentation rather than adopting expectant management
Posters Poster 1
Trends in bone mineral density following cancer treatment
1University College London Medical School, London, UK
2Honorary Clinical Professor, UCL EGA Institute for Women’s Health, University College London Hospitals, London, UK
3Consultant Obstetrician & Gynaecologist, UCL EGA Institute for Women’s Health, University College London Hospitals, London, UK
Background
The number of young cancer survivors is increasing and these patients require long-term health surveillance.1 The late effects clinic in the reproductive medicine unit (RMU) at UCLH provide a unique service for women who have experienced fertility and endocrine complications after cancer treatment. Although the decline in bone mineral density (BMD) after natural menopause is well documented, there is little on BMD in women diagnosed with primary ovarian failure due to cancer treatment.1
Materials and methods
This was a retrospective study that examined approx. 1050 electronic patient records available on the RMU database.
Inclusion criteria
1. Previous cancer treatment. 2. Diagnosis of primary ovarian failure 3. ≥ 2 serial DEXA lumbar and hip BMD measurements. BMD was measured by dual-energy X-ray absorptiometry (DEXA). Total hip and total lumbar measurements were plotted using Graphpad Prism Software with respect to age. BMD reference data were retrieved from the NHANES III dataset.
2. Full HRT history and serial BMD measurements were available for a subset of patients and this was plotted
Results
A total of 108 patient records were retrieved that matched inclusion criteria nos. 1 and 2; 77 patient records included ≥2 DEXA BMD measurements; 41 patient records included full HRT history as well as ≥2 serial BMD measurements.
Conclusion
At presentation the majority of patients had sub-optimal BMD. The trend in BMD was stable over time. In particular, patients on HRT maintained BMD.
Discussion
In this large cohort of cancer survivors, our study has demonstrated a reduction in BMD at presentation; this reduction is multifactorial, but the main causes are ovarian failure, chemotherapy and steroid use. We were able to follow BMD over time and establish that HRT is associated with stable BMD. The main limitation of the study was its retrospective nature. In particular, there were further BMD DEXA measurements for patients fulfilling inclusion criteria Points 1 and 2 that were inaccessible. This topic would benefit from prospective cohort studies. However, we are not aware of any such studies to date.
Poster 2
Audit to investigate if women with premature ovarian insufficiency who had egg donor treatment received appropriate advice about their hormonal therapy and ongoing care
1GP with Special Interest in Sexual and Reproductive Health, Bath Fertility Centre, England, UK
2Consultant Gynaecologist with Special Interest in Menopause Care, Poole Hospital, England, UK
3Consultant Gynaecologist with Special Interest in Reproductive Medicine, Royal United Hospital Bath and Bath Fertility Centre, UK
Introduction
Women with premature ovarian insufficiency (POI) have increased risk of osteoporosis, cardiovascular morbidity, diminished sexual wellbeing and anxiety and depression. Advice from NICE Guidelines NG23 states women should be offered hormonal treatment with hormone replacement therapy (HRT) or combined hormonal contraception (CHC) until at least the average age of the natural menopause (51) and given an explanation about the importance of treatment. We set out to investigate whether women with a diagnosis of POI who were seen in a fertility clinic setting for donor egg treatment were being provided with appropriate advice about their hormonal therapy and ongoing care.
Method
Standards from the NICE guidelines NG23 1.6.6 to 1.6.9 were applied regarding offering HRT or CHC until aged 51, consideration of contraindications to treatment, explanation to women about the importance of treatment. A total 83 sets of notes were audited from patients who had received egg donor treatment at Bath Fertility Centre between 2005 and 2016. Inclusion criteria were applied including age under 40, FSH >13, previous diagnosis of POI, history typical of menopause.
Results
A total of 25 patients met the inclusion criteria; 0/25 (0%) met the full standards of advice as per NICE guidance; 0/25 (0%) had documented evidence of contraindications to HRT; 8/25 (32%) were on hormonal treatment already; 7/25 (28%) had some documentation of advice about the need for HRT. Content of advice was mixed.
Conclusion
Some patients with a diagnosis of POI who had received egg donor treatment were not taking HRT or COC and did not have evidence of contraindications which would prevent use. Patients did not have documented evidence of receiving the full level of appropriate advice and information about their ongoing hormonal needs. Difficulties with the audit were noted. Advice may have been given verbally or documented at a historic appointment. They may have stopped their HRT or CHC for the short term prior to their fertility treatment.
Recommendations
This audit has highlighted the need for staff education in the fertility clinic about the importance of treatment of POI. Recommendations for service improvement include amending our treatment proforma to address ongoing hormonal needs and the need for ongoing care by a specialist with interest in menopause.
Poster 3
Development of an integrated health and wellbeing programme for menopausal women
1MMS FFSRM FRCOG, Consultant Gynaecologist, Poundbury Clinic King Edward VII Hospital London & Dorchester, UK
2MFFP FRCOG MSc, Consultant Sexual and Reproductive Healthcare, NHS Ayrshire & Arran, UK
3MBChB DRCOG, Specialty Doctor Sexual and Reproductive Healthcare, NHS Ayrshire & Arran, UK
4RGN, Health & Wellbeing Coordinator, Great Steward of Scotland Dumfries House Trust, Ayrshire, UK
5Health & Wellbeing Coordinator, Great Steward of Scotland Dumfries House Trust, Ayrshire, UK
Introduction
In East Ayrshire, a partnership service for women presenting frequently to primary care with menopausal symptoms was set up between the Great Steward of Scotland’s Dumfries House Trust and the Health and Social Care Partnership.
Methods
Individuals referred by local GPs attended six, 3-h small group sessions. The programme provided a holistic approach to creating wellbeing in the menopause transition. Assessment was made at the beginning and end of each programme using the Health and Wellbeing Wheel (HWW), Warwick Edinburgh Mental Health and Wellbeing Scale (WEMWEBS) and qualitative information gathered from online questionnaires. Sessions provided a forum to learn about and discuss menopausal symptoms, HRT and other therapies, with an emphasis on managing menopause through a healthy lifestyle. Therapists provided introductory sessions on complementary treatments, with participants introduced to boxercise, yoga and Tai Chi.
Results
Eighty-six women attended the course over 20 months. The HWW is a way for participants to track their overall health and wellbeing, over eight health domains – using a score of 0–6. Completed at the beginning and end of the programme, results show an increase across all domains, with an average individual increase of 1.2 points per domain. WEMWEBS is a 14 item scale with 5 response categories, summed to provide a single score rating between 14 and 70. Pre programme scores averaged 20/70 with post programme scores increasing to 48/50, with an average individual cumulative increase of 13 points. Online questionnaires demonstrated 84% of women reported feeling better informed and 65% reported a gain in self symptom management; 57% reported benefit from education around nutrition and exercise.
Conclusion
The women attending benefited from learning in a non-clinical environment, and experienced a holistic approach to menopause transition. Women reported feeling more confident, and informed to make decisions about their menopause. Lifestyle advice for menopause and future health was delivered in a way which encouraged women to try.
Poster 4
Premature ovarian insufficiency support group
1Specialist Counsellor, Chelsea & Westminster Hospital NHS Trust, London, UK
2Clinical Nurse Specialist, Chelsea & Westminster Hospital NHS Trust, London, UK
3Consultant Gynaecologist, Chelsea & Westminster Hospital NHS Trust, London, UK
Introduction
Premature ovarian insufficiency affects 1–10% of the female population under the age of 40. It has a significant effect upon women who were often hoping to have children at some point in their lives. There is little support around the country and a monthly support group was start at Chelsea and Westminster Hospital in 2016 facilitated by the clinical nurse specialist and specialist counsellor. The groups ran over four months with two terms per year. Each meeting followed a topic with invited speakers. The aim of the audit was to understand the impact of a psycho-educational support group focused on POI in a tertiary setting.
Methods
A retrospective audited of attendance was taken from the feedback forms. Information was collected at the end of each session along a 5-point Likert Scale (very useful to not at all useful). Additionally, feedback in the form of comments regarding topics covered and any gaps in coverage was also collected.
Results
In aggregate, 79% rated the meeting as very useful and 3% as neutral. None were rated any lower. Comments included ‘shared experience, helpful information, reassurance, comfortable environment’; excellent explanation of the condition and treatments’; ‘Speaking openly and actually laughing’. Identified difficulties in the group were the inclusion of partners where none attended in spite of an open invitation. Other areas of difficulty expressed were: involving families, if women became pregnant and the usefulness for those women with iatrogenic cause, not wanting children or who already have children.
Conclusion
While there was consensus among participants that generally the group was supportive, certain areas were more sensitive and remained unresolved. However, a co-facilitated live support group appears to be a welcome and effective intervention for at least a proportion of women who previously reported distress at a lack of information and support pertinent to them. Going forward, the next phase aims for a more structured approach to include discussion and handouts of some of the more ‘difficult’ topics, with the aim of providing a sense of greater empowerment to all the women attending.
Poster 5
Hormone replacement therapy and endometrium – A comparative study at a London-based university hospital
1Consultant Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
2Brett- Foundation Year 2 Junior Doctor, Whipps Cross University Hospital NHS Trust, London, UK
Introduction
Post-menopausal bleeding, bloating, pain or an abnormality identified on a scan – such as a lesion or a thickened endometrium are common gynaecological complaints and following clinical review often warrant assessment via hysteroscopy. The risks and benefits of hormone replacement therapy HRT have long been discussed and research continues to determine the effect this has. This looks at comparing the findings in those undergoing hysteroscopy in post-menopausal women on HRT and those not.
Objectives
The aim of this study was to review ultrasound, hysteroscopy and histopathology findings in a sample of postmenopausal women receiving HRT compared to postmenopausal women not on HRT at the Whipps Cross University Hospital.
Methods
This was a retrospective observational study of postmenopausal women on HRT undergoing outpatient hysteroscopy for either postmenopausal vaginal bleeding or abnormal ultrasound suggestive of endometrial pathology. Their findings were compared to postmenopausal women not on HRT.
Time period
2 May 2017–1 May 2018.
Results
Our outpatient hysteroscopy clinic had 765 patients undergoing outpatient hysteroscopy during the time period. Out of these women, 282 were menopausal (36.86%). Of the menopausal group, 47 (16.67%) were on HRT at the time or within the last one year. In the HRT group, 89.36% presented with postmenopausal unscheduled bleeding on HRT, 8.51% were co-incidentally diagnosed with abnormal thickened endometrium on ultrasound performed for other symptoms – such as bloating, pain, vaginal discharge; 2.31% presented for other reasons. In the control group of post-menopausal women not on HRT group – 73.61% presented with post-menopausal bleeding 22.98% had co-incidental scan findings on ultrasound performed for symptoms such as bloating and pain and 5% were for other reasons. Ultrasound scans in women on HRT were more likely to be diagnosed with thickened endometrium than in postmenopausal women not on HRT. Ultrasound scans in women on HRT showed 88.63% had an endometrial thickness of >4, and 2.27% <4, 0 were described as suspicious, 4.55% could not comment on ET due fibroid or polyps and 4.55% could not comment due to IUD. In the control non HRT group, 80.26% showed an endometrial thickness of >4, 8.15% were <4. 4.72% could not describe thickness due to fibroids or polyps and 4.29% due to IUDs. 2.58% were described as suspicious. Hysteroscopy findings in the HRT group showed atrophic endometrium in 51.06%, suspicious in 0%, polyps in 23.40%, IUD – nil other findings in 2.13%, unable to visualize endometrium in 2.13%, fibroid in 2.13%, normal in 10.64%. In the non HRT group, hysteroscopy findings described atrophic in 32.34%, suspicious in 5.53%, polyp in 34.47%, IUD – nil other findings in 0.85%, unable to visualize endometrium in 10.64%, fibroid in 5.11%, normal in 5.11% and pus in 0.43%. Histopathology endometrial samples were obtained in 65.96% in the HRT group. Out of the samples sent, 0% showed malignancy, 48.4% reported benign, 12.9% showed hyperplasia or proliferation, 35.5% were insufficient, 3.2% described hormonal effect on tissue. In the non HRT group – samples were obtained in 66.39%. Of these, 8.9% were reported as cancer, 58.3% as benign, 10.3% as hyperplasia or proliferation, 15.4% as insufficient, 6.4% hormonal effects and 0.6% as endometritis.
Conclusion
Post-menopausal vaginal bleeding was the most common presentation in both groups. Ultrasound scans showed a higher percentage of thickened endometrium in the HRT group compared with those not on HRT. More research is needed to see if the cut off for endometrial thickness on ultrasound to be increased from <5 in women on HRT. Hysteroscopy findings showed that a higher percentage of HRT group had endometrium described as atrophic, and demonstrated less pathology compared with the non HRT group. In women with postmenopausal vaginal bleeding, endometrial cancer was more prevalent in the non HRT users compared to the balanced HRT users.
Poster 6
Health professional survey on managing symptoms of menopause in women living with HIV – Is guidance needed?
1Specialist Registrar, Poole Menopause Centre, Poole Hospital NHS Trust, England, UK
2Consultant, Sexual Health, Salisbury Hospital NHS Trust, England, UK
3Consultant Obstetrician & Gynaecologist, Poole Menopause Centre, Poole Hospital NHS Trust, England, UK
Introduction
In acknowledgement of the fact that more than half the people with HIV will soon be over the age of 50, managing menopausal symptoms in this cohort of women is becoming more relevant. HIV is an independent risk factor for early death, cardiovascular disease and decreased bone mineral density as is the menopause making these women at higher risk than the non HIV population. From recent studies, we know that menopausal symptoms are managed poorly in this group of women, partly due to the symptoms being attributed to the HIV but also because clinicians are reluctant to prescribe HRT alongside ART. These women are often managed by GPs and by genitourinary physicians who may lack confidence in prescribing hormone replacement therapy and motoring their associated chronic health care issues. In response to the above, we feel a guideline to help streamline the care of these women could improve the management of their symptoms and improve their long-term health. Prior to developing this, we sent out a survey to local health care professionals to assess their confidence around managing these women.
Method
We sent out a six question survey to local healthcare professionals who may come in contact with this group of women.
Results
We received 20 questionnaire responses; 40% GP; 10% menopause specialist; 10% GP with interest in menopause; 5% menopause specialist nurse; 35% gynaecologists; 60% of respondents didn’t know that women with HIV tend to experience the menopause earlier. On average the respondents gave a score of 3.9 out of 10 for how confident the felt about managing these women. Respondents were even less confident in prescribing HRT to these women and gave a score of 3.2 out of 10. 95% of respondents stated they would find a guideline useful.
Conclusion
In line with a recently published questionnaire from the PRIME study, health care professionals report a lack of confidence in managing menopause in women living with HIV. The healthcare professionals who took part feel that some practical, evidence-based guidance would be helpful to improve the management of these women.
Recommendation
In view of the above findings, our next step will develop a practical, evidence-based guidance for use in primary care and specialist GU clinics.
Poster 7
An innovative approach to pelvic organ prolapse: Experience of site specific repair at a regional Australian Centre
1Registrar, Ballarat Health Services, Victoria, Australia
2FRANZCOG Trainee, Ballarat Health Services, Ballarat, Australia
3Obstetrician/Gynaecologist, Obstetrics Gynaecology, Ballarat, Australia
Introduction
While the aetiology of pelvic organ prolapse is multifactorial with certain risk factors such as age, parity and BMI1–3 identified, the pathophysiology remains poorly understood. Traditionally pelvic organ prolapse was thought to be due to attenuated or lax pelvic connective tissue which resulted in colporrhaphy (surgical procedure to reinforce the fascial layer between the rectum and vagina/bladder and vagina) being the preferred treatment option. However, Richardson et al. and Baden/Walker have identified that detachment of the fascial supports of the vagina from their origin and / or breaks in such fascia are responsible for pelvic organ herniation.1 Hence, the development of site-specific vaginal repairs where the objective of the surgery is to re-attach the fascial supports and repair the breaks in the fascia in order to correct prolapse.1–3
Objective
This study aims to show that site specific technique is a valuable and highly successful method of prolapse repair which provides superior results to those quoted for traditional colporrhaphy in the literature.
Methods
A retrospective study was undertaken examining all patients from a private practice in a regional setting who have had site specific vaginal repair performed over a 10-year period (2007–2016). These procedures were carried out by one gynaecologist with a special interest in pelvic organ repair. The type of repair was decided by the specialist and was dictated by presenting symptoms and examination findings. Patient files and operation notes were examined with demographics, BW scale, pre-operative symptoms and type of procedure performed recorded. The outcomes analysed were rate of prolapse recurrence, resolution of symptoms, and success rate (which was defined as resolution of symptoms with no recurrence of prolapse for > 1 yr). Complete success was defined as complete resolution of symptoms, vaginal examination findings near normal, as well as patient satisfaction (interpreted from the notes) at the 12-month mark. A total 511 patients were identified to have had a site specific vaginal repair performed in the specified time frame. Rates of success and complications for colporrhaphy were obtained from IUGA resources
Results
The success rate of site specific repair was 94% (482 clients) at one year with 77% having complete success and 16% partial success. Rate of prolapse recurrence was lower than those seen from traditional repair, while resolution of symptoms and success rates was higher. Complications from surgery were low overall.
References
Poster 8
The Hampshire Menopause Café: A social franchise concept to support and empower women in the community
1Speciality Doctor, Emergency Department, Southampton University Hospital Trust, Southampton, UK
2Portfolio GP, Mid Hampshire Healthcare Trust, UK
Introduction
“A Menopause Café is a group-directed discussion of menopause with no specific agenda, objectives or themes and with no intention of leading people to any conclusion.”1 During these community-based meetings, people are invited to join conversations about the menopause and share their stories. We organised and hosted the first ever community Menopause Café in England, on 20 January 2018 in Petersfield. This was followed by a second Menopause Café on 21 April 2018.
Background
Having heard about the concept of Menopause Cafés through Twitter, the authors, who met during a residential Menopause Skills course (British Menopause Society), decided to help increase awareness of the impact of the menopause on those experiencing it in their area and to organise and host their own evidenced based Menopause Café. The idea of the community Menopause Café was initially developed by Rachel Weiss from Perth, Scotland and this first event took place in June 2017 in Perth.
Methods
The Hampshire Menopause Cafés were advertised on Eventbrite, with publicity care of local: radio,2 television3 and press.4 Refreshments were provided by the authors. Participants were free to sit where they wanted, around small tables. Menopause bingo initiated proceedings, there was a mixture of whole room and individual table discussion, with the authors circulating to facilitate this and answer questions. Feedback, including a questionnaire was requested at the end, to enable the authors to shape future events.
Results
The Hampshire Menopause Cafés have been very well received, with universally positive feedback, were over-subscribed both times, 63 women in total attended and seem to be fulfilling a real need within the community.
Conclusions
Holding a Menopause Café in Petersfield every three to four months would seem to meet demand. Reaching other parts of Hampshire within different locations might also be beneficial. The challenge being to find the time to do this. One participant is looking to organise their own Café, which is encouraging.
References
Poster 9
A national survey assessing the clinical practice of members of the British Menopause Society on the management of patients with unscheduled bleeding on hormone replacement therapy
1MRCOG, Clinical Research Fellow in Early Pregnancy and Acute Gynaecology, King’s College Hospital, London, UK
2Honorary Director of Conferences, RCOG, London, UK
3MD FRCOG, Consultant Gynaecologist, Subspecialist in Reproductive Medicine and Surgery, King's College Hospital, London, UK
Introduction
The aim of this study was to explore current practice in the management of women who experience unscheduled bleeding on hormone replacement therapy (HRT) amongst members of the British Menopause Society (BMS).
Methods
A cross-sectional questionnaire survey was distributed in March 2018 and completed by May 2018.
Results
A total of 90/172 (52%) of clinicians would investigate patients who have unscheduled bleeding within 3–6 months of starting sequential HRT (seq-HRT) versus 80/172 (46%) for continuous combined HRT (com-HRT) (p = 0.28, OR 1.3, 95%CI 0.83–1.93); 49/172 (28%) versus 53/172 (31%) would investigate unscheduled bleeding continuing beyond 6 months (p = 0.4, OR 0.90, 95%CI 0.60–1.42), while 16/172 (10%) versus 24/172 (14%) would investigate within 3 months (p = 0.18, OR 0.63 95%CI 0.32–1.23). For seq-HRT, 93/172 (54%) would continue HRT and refer versus 112/172 (65%) for com-HRT (p = 0.03, OR 0.63 95%CI 0.4–1.0); 19/172 (12%) would stop seq-HRT and refer versus 23/172 (13%) with com-HRT (p = 0.5, 95% CI 0.42–1.5); 44/172 (26%) would change the progesterone preparation in women with unscheduled bleeding on seq-HRT. For unscheduled bleeding with com-HRT, 11/172 (6%) would change to sequential HRT and 8/172 (5%) to Mirena IUS. The Mirena IUS is the progesterone of choice for 78/172 (45%) of clinicians, oral micronised progesterone for 45/172 (26%), oral Provera/Norethisterone/Dydrogesterone for 17/172 (10%) and transdermal progestogens for 14/172 (8%). Assessment is requested as urgent by 84/170 (49%) clinicians, routine by 46/170 (27%) and two-week-wait/cancer referral by 40/170 (24%). Endometrial biopsy was taken when endometrial thickness > 5 mm by 111/171 (65%) for unscheduled bleeding with seq-HRT versus 117/169 (70%) in com-HRT (p = 0.3, OR 0.82 95%CI 0.5–1.3).
Conclusions
There is a homogenous approach in the practise amongst BMS members to managing women with unscheduled bleeding on HRT. Further research is needed to determine the optimal assessment pathways for women with unscheduled bleeding on HRT.
Poster 10
To develop hand held notes for women with premature ovarian insufficiency
1MBBS Year 4 Medical student, King's College London, London, UK
2MBBS Year 4 Medical student, King's College London, London, UK
3MBBS Year 4 Medical student, King's College London, London, UK
4MBBS Year 4 Medical student, King's College London, London, UK
5MBChB DFFP MD MRCOG, Senior Lecturer, Honorary Consultant Gynaecologist, King's College London, London, UK
6MA PhD MRCOG, Consultant Gynaecologist, King's College London, London, UK
7RGN BA Hons Msc, Consultant Nurse, King's College London, London, UK
Background/introduction
Women with POI see many healthcare professionals leading to multiple sets of notes, many of which are either inaccessible or misplaced. Introducing handheld notes would streamline care and increase overall POI patient satisfaction.
Aim(s)/objectives
Develop handheld notes that will: collate patient’s medical information; allow for autonomy of care; avoid unnecessary investigations and assist health care professionals in understanding the patient’s journey.
Methods
We designed handheld notes based on Guy's and St Thomas (GSTT) guidelines, patient and healthcare providers’ feedback; 10 women, seen in the POI clinic at Guy’s Hospital, were invited to a focus group and asked to fill out 2 surveys. Each survey contained 16 questions; 1–13 measured patient satisfaction with and without handheld notes (maximum score of 65). Questions 14–16 asked about ease of using the notes.
Results
In a three-factor model of clinical experience (patient understanding; doctor’s knowledge of the patient’s journey; ease of service use), we found an improvement in patient satisfaction was enough to improve the global satisfaction score from 2.8 (without notes) to 3.6 (with notes). A t-test showed significant improvement with a 95% confidence interval. The questions that showed a significant improvement were related to patient understanding.
Discussion/conclusion
Overall, handheld notes have shown initial promise by improving patient perception of POI management, ease of bringing to appointments and overall patient satisfaction. Limitations include: small sample size and limited time resulting in one data collection. This is an ongoing project with an aim to collate longitudinal evidence with a larger sample size and additional feedback from healthcare professionals.
Poster 11
“Over the decades”: Current and previous patient satisfaction surveys
1ST7 Obstetrics & Gynaecology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
2Consultant Gynaecologist, Northwick Park Hospital, London North West University Healthcare NHS Trust; Imperial College, London, UK
3SRN, Imperial College, London, UK
Introduction
We conducted a survey of 150 patients in a large district general hospital with wide ethnic variation and socio-economic disparity. The aim was to assess current attitudes to service provision following recent changes in clinic structure and to evaluate change in perception over the past 20 years.
Method
A total of 150 women who attended either general menopause, premature ovarian insufficiency or breast cancer clinics were given questionnaires which were anonymous, administered independently on arrival by the receptionist. They were completed after consultation with a member of the multidisciplinary team (MDT). Twelve questions included key ones regarding personnel and service structure. The last 80 questionnaires included questions on attitude to the MDT and allowed comparison to previous surveys.
Results
Age ranged from late teens to >75 years. 1 in 5 patients were > 55 years old; 19.3% were Asian / Asian-British and 8.7% were Black; 32% were first time attendees and 6.7% attended for three to four years; 85.3% of women felt they had received sufficient information to understand the purpose of the service; 77.4% rated the clinic as “high”/“very high” quality; 76.7% felt the service met their needs “extremely”/”very well”; 81.3% found the clinic responsive to concerns; 75% felt “completely” involved in decision making; 80% of women indicated they would recommend this service to a friend or colleague. Over 95% were happy with the consultation; 1 in 5 saw the Senior Nurse Specialist, 13.8% the Consultant Pharmacist and 12.5% the Associate GP Specialist rather than a Gynaecologist. Comments from the free text section indicated concerns regarding waiting times and poor communication. In 2000, 25% of women were unaware of the Consultant Pharmacist’s role, approximately 90% saw a doctor, only 14% saw the Nurse Specialist; 88% rated the clinic as “good”/”excellent”.
Conclusion
This is a busy clinic seeing complex cases. We have maintained a good level of service. However, recent Trust changes have reduced the perception of quality. From inception, it has always been an MDT clinic. Previous surveys showed patients were keen to see the consultant, now all team members are equally appreciated.
Poster 12
NHS prescribing of new drugs – A time consuming but necessary process for formulary inclusion!
1Women's Services, London North West University NHS Healthcare Trust & Imperial College, London, UK
2Women's Services, London North West University NHS Healthcare Trust & Imperial College, London, UK
London
Introduction
DuaviveR, licensed December 2014, was recently launched in the UK. The indication for treatment are postmenopausal women with risk benefit evaluation supporting HRT use, but where due to progestogen sensitivity, DuaviveR (combines conjugated equine oestrogens with a selective oestrogen receptor modulator) maybe an alternative preferred option. NHS prescribing is restricted for newly licensed products. In line with evidence-based prescribing and medicines optimisation, new drugs have to go through a rigorous review process before inclusion within trust formularies. We report on this process for the geographical locality served by our NHS University Trust.
Methods
The three stage application process required support from consultant colleagues, sign off from Directorate leads, approval by Trust Drugs and Therapeutics Committee (DTC), and the Area Prescribing Committee.
Results
Service leads completed the relevant DTC forms, supported by both Directorate Clinical Director and Lead Consultant for Gynaecology. Minor queries from Formulary Pharmacy team were addressed, who commented that inclusion of the NHS Evidence-Based DuaviveR (August 2016) Summary strengthened the submission. Service leads then attended a DTC meeting for discussion and questions from a multi-disciplinary panel. Even with DTC approval, a new drug cannot be included within Trust formulary, until second round review by the Area Prescribing Committee (APC). This second stage is crucial for ensuring seamless patient care, engendering partnership working with primary care and prescribing agreement of the new drug. Interestingly the one modification requested by the APC panel (included GP representatives, prescribing advisors and secondary care professionals) was a charted algorithm for menopause management. DuaviveR has been approved for third-line prescribing, with specialist clinic supervision and first prescription, review appointment at three months, to be then followed by primary care prescribing.
Conclusion
This three stage process supports robust evaluation for prescribing of new UK licensed drugs, but is time consuming and needs specialist pharmacist input. The NHS Evidence Summary and Menopause Management Algorithm were decisive aspects for Formulary inclusion. The DuaviveR formulary submission process has highlighted a need for teaching and training in menopause management.
Poster 13
Omega 3 polyunsaturated fatty acids and the menopause
1Medical Director, Haipharm Ltd, London, UK
2BSc (Hons) MBChB (Hons) MRCP FRCGP, GPwSI Menopause, Spire Parkway Hospital, W Midlands, London, UK
Introduction
Omega-3 polyunsaturated fatty acids (PUFAs) are essential fatty acids that must be obtained from dietary sources, primarily oily fish. Omega 3 PUFA has many health benefits such as reducing the risk of congestive heart failure, coronary heart disease, ischemic stroke, and sudden cardiac death1 as well as having anti-inflammatory activities. The objective of this study was to assess the data and recommendations related to omega 3 in the menopause.
Methods
A thorough review of available literature on omega 3 PUFAs and menopause was conducted, with a special emphasis on international and national guidelines. The major outcomes were symptoms control of the menopause including vasomotor, mood and osteoporosis, and adverse event such as risks of cardiovascular (CV) events, and breast cancer (BC).
Results
Very few small and varied studies assessed the effect of omega 3 PUVA on menopause symptoms of hot flashes and mood changes as well as quality of life and revealed mostly positive effects. A systematic review of 10 RCTs with a diet rich in omega 3 – PUFAs or supplements versus placebo, showed that it appears omega 3 – PUFAs might be beneficial for osteoporosis when co-administered with calcium. We identified a single national guideline recommending omega 3 during the menopause (Spain),2 while international guidelines (IMS and EMAS) and national guidelines such as the USA (ACE), UK (NICE) do not address this topic.
Conclusions
Omega 3 PUFAs have wide range health benefits affecting many conditions prevalent in menopause women and emerging data of reducing vasomotor menopausal symptoms and osteoporosis, without increasing risk of cancer. It is appropriate for national and international menopausal guideline to include omega 3 as part of menopausal management.
References
Poster 14
Controversies and challenges in the management of postmenopausal hirsutism: A systematic review of the literature
14th Year Medical Student, Leicester Medical School, University of Leicester, Leicester, UK
2Consultant Gynaecologist, Subspecialist Reproductive Medicine, Honorary Senior Lecturer, University Hospitals of Leicester NHS Trust, Leicester, UK
Introduction
Hirsutism is a distressing condition and more so in the menopause, however it has not received much attention in clinical practice. There are several case reports on management of postmenopausal hirsutism but there is a lack of clear and concise guidance on management of this complex clinical dilemma. Women are often referred to several different specialties before receiving treatment resulting in control of their symptoms. This study has systematically examined the literature and explored the challenges in the management and outcomes of women with postmenopausal hirsutism.
Methods
The electronic database search included Medline (1946 to May 2018), Embase (1980 to May 2018) and Cochrane library. Key MESH and Boolean terms were used for the search. Data extraction and collection were performed based on the eligibility criteria by two authors independently. Included studies were case reports/series where the main presenting symptom was postmenopausal hirsutism.
Results
A total of 157 case reports were included (n = 179 women) in the study. In 92.2% (n = 165 women) hyperandrogenism was reported secondary to ovarian pathology, and the majority were managed with surgical intervention; 3.4% (n = 6 women) were secondary to adrenal pathology; and 4.8% (n = 8women) were iatrogenic or idiopathic. Interestingly, 42.4% (n = 70) of ovarian pathology was not picked up on imaging; 9.5% (n = 17/179 women) were treated for incidental adrenal findings noted on imaging with no response and subsequently diagnosed with ovarian pathology. These women were eventually treated with ovarian surgery and had resolution of symptoms with normalisation of blood results.
Conclusion
Postmenopausal hirsutism presents a difficult dilemma with major concern about underlying adrenal pathology. Women are often referred to varying specialities with management being dependent upon individual experience and preferences. There is a general trend for conservative management; however, this review has highlighted ovarian pathology as a source of excess androgen, which often requires surgical intervention. Women should be counselled about the management options on presentation to decrease the psychological impact of a drawn-out diagnosis and allow them to make informed decisions.
Poster 15
Management of women with premature ovarian insufficiency: A multi-disciplinary review of practice
1Subspecialty Trainee in Reproductive Medicine and Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
2Senior Registrar in Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
3Consultant Endocrinologist, Leeds Teaching Hospitals NHS Trust, Leeds, UK
4Associate Specialist, Leeds Teaching Hospitals NHS Trust, Leeds, UK
5Consultant Gynaecologist and Subspecialist in Reproductive Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Introduction
Premature ovarian insufficiency (POI) is associated with numerous aetiologies and may therefore present before or after menarche. Women may complain of various symptoms and consequently be seen in a range of clinical settings. The management of POI is multifactorial and may potentially vary depending on the awareness and expertise of the clinicians within each specialty/subspecialty. In 2015, the European Society for Human Reproduction and Embryology (ESHRE) published guidelines on the management of POI. These state that women should have the following investigations: chromosomal analysis; screening for Fragile-X pre-mutation, thyroid peroxidase (TPO) and 21-hydroxylase antibodies; and measurement of bone mineral density (BMD). Treatment should incorporate: lifestyle advice; oestrogen replacement; contraception and/or fertility options; bone protection; and psychological support.
Aims
To assess compliance with the ESHRE guidelines at the Leeds Teaching Hospitals NHS Trust (LTHT) and determine whether this varies according to clinical setting of presentation.
Methods
A retrospective review of all females with POI diagnosed between 1 July 2016 and 30 June 2017 in one of the following clinics: reproductive medicine; menopause; general gynaecology; general endocrinology; paediatric endocrinology; and oncology follow-up. We reviewed whether the necessary investigations had been performed and what treatments had been discussed.
Results
We identified 103 women, who were distributed fairly evenly between the different clinics. Overall, 40.6% had a karyotype. Screening for the Fragile-X pre-mutation, TPO and 21-hydroxylase antibodies occurred in 7.4%, 11.1% and 13.6%, respectively. Only 35.9% had their BMD measured. There was significant variation in the performance of a karyotype (p < 0.001) and TPO antibodies (p < 0.01) between the different settings. Overall, lifestyle advice was offered to 30.1%. Oestrogen replacement, contraception, fertility and bone protection were discussed with 76.0%, 38.4%, 59.0% and 75.0%, respectively. Psychological support was offered to 25.2%. There was significant variation for all apart from contraception.
Conclusion
Management of women with POI at the LTHT is not compliant with the ESHRE guidelines and requires improvement. Furthermore, there is significant variation in practice amongst the different specialties/subspecialties. We suspect similar results will occur elsewhere. We have proposed remedial action and will reassess following implementation.