31st Annual Scientific Conference Chesford Grange,Kenilworth

Menopause moments: a workplace wellbeing initiative

“The judges felt the presentation was clear, covered an important subject and showed how support can be provided to colleagues with menopausal symptoms working in a busy NHS hospital.”

Hormonal replacement therapy in menopausal women in the UK: a descriptive study

“Impressive presentation, clear data, sound methodology and a large sample size, which is useful information for clinical practice”

ANutr, MSc Nutritional Medicine

Background: There has been much attention within the last year on the topic of menopause – support for women in the workplace, reduction in prescription costs and reduced availability of Hormone Replacement Therapy (HRT). For some women HRT is not possible, available, or their preference is a more natural approach. Some studies have shown that omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA) are used by women for menopause symptom management, yet we know little of its mode of action or efficacy.

Objective: To understand the role of omega-3 fatty acids in the management of menopausal symptoms; hot flushes, depression and insomnia.

Methods: A search of PubMed, Science Direct and Web of Science was conducted to identify RCTs, systematic reviews and cross-sectional studies involving menopausal women, omega-3 fatty acids and either vasomotor symptoms (VMS), depression or insomnia. Eligible papers were quality assessed using the Jadad scale and the Newcastle Ottawa Scale. Two meta-analyses were conducted, one using RCTs to measure the effect of omega-3 fatty acid on VMS severity and the second using cross-sectional studies to identify association between dietary omega-3 fatty acids and depression.

Results: Four RCTs were pooled and identified SMD -0.61 (CI-1.50, 0.29) with high heterogeneity (I2 95%) and a non-statistically significant effect (p = 0.18) of omega-3 fatty acid in reduction of VMS severity. The meta-analysis included a subset to distinguish high from medium dose intervention, and the RCTs with similar medium dose intervention had SMD -0.87 95% (CI-1.84, 0.09) and p = 0.08. Meta-analysis of the association between omega-3 fatty acids and depression identified a 40% reduction in depressive symptoms odds ratio 0.60 95% CI (0.40, 0.90) (p = 0.01) in women consuming omega-3 fatty acids in the highest quartile.

Conclusions: Women with omega-3 fatty acids consumption in the highest quartile were associated with a lower rate of depressive symptoms. Larger studies with a consistent measurement scale are required to reduce heterogeneity and assist with conclusions on the effect of omega-3 fatty acids on VMS severity. More studies are also required to make conclusions regarding the relationship between omega-3 fatty acids and insomnia.

¹ST7, Belfast Health & Social Care Trust

²Associate Specialist, Belfast Health & Social Care Trust

³Consultant Gynaecologist, Belfast Health & Social Care Trust

Objective: With increased media attention and awareness of menopausal symptoms more women are requesting HRT. There is a significant rise in new referrals to already overburdened specialist menopause clinics. British Menopause Society envisages that all healthcare professionals should have knowledge of menopause. This new regional service provides a platform to aid this.¹

An audit and satisfaction survey was performed in 2019 to assess the acceptability of written advice to GPs as an alternative to clinic appointments for selected patients referred to a regional HRT clinic. This progressed to the implementation of a live advice response system via the clinical communications gateway (CCG). The advice request and response are integrated into the patient’s electronic care record.

Methods: A review of 50 consecutive electronic advice requests over a 5-day period was completed in March 2022. The source and reasons for advice were reviewed. Patient demographics including age and referring trust were considered. Primary outcome measure was subsequent referral or clinic review.

Results: Themes of advice request were identified, commonly, persistent symptoms despite HRT treatment, breast cancer risk and bleeding on HRT. The average age of referral was 53. Only 2 patients required subsequent clinic review. There were 47 new referrals and 3 advice requests regarding existing patients. 60% of patients referred were already on HRT. 100% of advice requests in this sample came from general practitioners, although requests are also sent by advanced nurse practitioners and practice pharmacists.

Conclusions: Patients requesting help with menopausal symptoms are largely managed within primary care. A live advice system helps both patients and healthcare practitioners without long waits for clinic review. Within the NHS, resources are limited, and this system reduces the number of patients requiring clinic appointments and the wait time for those who require a consultation. Additionally, it provides learning opportunities for general practitioners and aids in fostering relationships between primary and secondary care to enhance patient experience. The CCG also allows an opportunity to attach learning pathways and guidelines relevant to the clinical query.

Reference

1. Vision for menopause care in UK. BMS. https://thebms.org.uk/wp-content/uploads/2021/08/BMS-Vision-MAY2021-01C.pdf

Agile Life Sciences

Objective: Menopause is a long-term hormone deficiency which will affect 52% of the population. Over 80% of menopausal women suffer from atrophy – which causes vaginal dryness, itching and pain during sex. Current diagnostic tools include invasive blood hormone tests that cannot accurately determine the menopause phase, due to the normal fluctuations in hormone levels. Agile Life Sciences aim to develop a vaginal microbiome test from a non-invasive urine sample that can be utilised by menopause clinicians to identify the menopause phase of women and monitor the progress of treatment plans.

Methods: Vaginal swabs and urine samples were collected from pre, peri and post-menopausal women. DNA was extracted from samples and prepared for next generation sequencing (NGS) using The One 16S NGS Kit for Illumina from YouSeq. Samples were sequenced on the iSeq 100 device and analysed using a bespoke reference library designed by Agile Life Sciences for vaginal microbiome as an update to the STIRRUPS reference library.

Results: No significant differences were found between sequencing results for vaginal swabs and urine samples. Urine samples are less invasive than swabs and are more inclusive for those unable to perform self-swabbing. The vaginal microbiomes for each participant were analysed and scored using Vaginal Community State Types (CST) and assigned a menopausal phase (Pre/Peri/Post). After scoring, the results were compared to the self-reported menopausal phases of the participants and 86% of predictions were correct. The remaining incorrect predictions were due to HRT treatment, which would be included in the analysis along with age when the service is launched.

Conclusion: Agile Life Sciences have developed a vaginal microbiome test from a non–invasive urine sample that enables and empowers clinicians to map an individual’s menopause journey and provide reliable and accurate feedback on menopause treatment plans. Using a bespoke metagenomic database to map the vaginal microbiome to species level, a snapshot of vaginal health and menopausal status can be produced, which can be used by menopause clinicians to monitor treatment plans and patient progress.

¹Population Health Sciences, University of Bristol, UK

²Birmingham Women’s & Children’s NHS Foundation Trust, UK

³Director Menopause Services Peppy Health, formerly NWLH NHS Trust, UK

⁴King’s College Hospital, London, UK

⁵President, The British Association of Day Surgery, UK

Objective: To investigate the experience of remote outpatient menopause service delivery by clinicians and patients during the COVID-19 pandemic.

Methods: Two different surveys were used to explore the experiences of patients and clinicians separately. Patients attending menopause clinics in the UK were directed to an online patient experience survey which included questions on demographics and on their experience of their most recent appointment. A clinician survey was shared to members of the British Menopause Society (BMS) via email and was also made available on the BMS website homepage. It contained questions on their clinic’s characteristics and their experience of delivering remote menopause consultations. Surveys were available for completion between 01/12/2020 and 10/02/2021.

Results: Of 180 patients who completed the patient survey, 52% felt remote consultations were the same or better than face-to-face consultations, and 90% of patients felt a choice between remote and face-to-face consultations should be offered. Patients overall were satisfied with the convenience, duration and feeling of involvement in decisions about their care, though numerous problems were highlighted with appointment administration (e.g. scheduling cancellation and waiting times) of 76 clinicians who completed the clinician survey, 68% conducted remote consultations via telephone, with the remainder using a combination of telephone and video. Most found remote patient consultations either no different, or a bit worse than face-to face consultations but found that they offered more flexibility. In some cases, significant rescheduling was necessary to accommodate for the clinical needs of the consultation (e.g. clinical examination and patient language/hearing difficulties).

Conclusion: A ‘one-size-fits-all’ approach to managing the delivery of menopause care is not supported by patients or clinicians. There must be a robust process in place, with sufficient administrative and information technology support, to avoid problems with appointment scheduling and associated communications. Lessons learned from the pandemic can help to provide holistic menopause care and a national consensus on standard of care would improve menopause service delivery.

¹Consultant Obstetrician and Gynaecologist, Queen Elizabeth Hospital, Lewisham & Greenwich NHS Trust

²GP Vocational Training Scheme – Bexley

³Consultant Obstetrician and Gynaecologist, University Hospital Lewisham, Lewisham & Greenwich NHS Trust

⁴Consultant Obstetrician and Gynaecologist, University Hospital Lewisham, Lewisham & Greenwich NHS Trust Consultant Obstetrician and Gynaecologist, University Hospital Lewisham, Lewisham & Greenwich NHS Trust

⁵Specialist Doctor, University Hospital Lewisham, Lewisham & Greenwich NHS Trust

⁶Associate Director – Staff Wellbeing and Medical, Lewisham & Greenwich NHS Trust

Objective: Development of an inclusive staff wellbeing initiative designed to offer multilayer menopause support to employees of a London acute and community NHS Trust with nearly 7000 employees.

Methods: Using a holistic approach rather than focussing on medicalisation, we developed a programme named ‘Menopause Moments’. There are three ways that employees can interact with the programme, designed to increase access. All sessions are open to those working in community, hospital and affiliated roles. A monthly theme is set by the webinar – streamed live with question-and-answer sessions with an expert presenter and recorded for those unable to attend on the day. Topics have included physical symptoms, menopause for managers, the role of non-prescription treatments and impacts on sexual health and relationships. Webinars are supported by drop-in peer support sessions aimed at reducing stigma by discussing issues in an informal manner. For those seeking individual clinical advice, self-referral to an interested gynaecologist is available. Data is collected by validated patient reported outcome measures to provide assessment of the impact menopause and associated symptoms are having in a workplace environment and the efficacy of this innovative intervention.

Results: The programme has been funded on a 12-month trial basis and is in the third month of delivery. Attendance at webinars and drop-ins provides evidence of the appetite for staff to engage in menopause support in this way. Clinic demand has quickly outstripped available appointments. By presenting this model, it is hoped that other NHS Trusts or forward-looking employers might be able to implement similar support structures for staff.

Conclusion: As NHS services recover from the after-effects of the COVID pandemic, employee well-being within the health sector has never been a higher priority. Menopause symptoms can last 10 years, and the impact is not limited to those of female gender. However, by recognising that over three quarters of NHS staff is female, and seventy-five percent of those going through menopause will experience symptoms, it is increasingly being recognised that supporting colleagues with menopause related issues is not only compassionate but makes organisational sense and equips NHS Trusts for the next stage of the recovery programme. Development of this programme from an employee wellbeing perspective has provided a comprehensive and holistic approach to supporting employees with menopause. It is hoped that after the trial, we will be able to embed this programme into the permanent support provided for staff-wellbeing.

¹Honorary Clinical Lecturer in Medicine, UCL

²Science 4 performance

Objective: The objective was to develop a practical and clinically relevant way of assessing female hormone health using artificial intelligence techniques, to distinguish between subclinical hypothalamic and ovarian causes of menstrual disruption and quantify the degree of reduced ovarian responsiveness typical of perimenopause.

Methods: Bayesian inference was used to estimate hormone variation curves for follicle stimulating hormone, luteinising hormone, oestradiol and progesterone to explain the results from blood samples that would be taken around days 14 and 21 of the menstrual cycle. These hormone curves were compared to healthy, ovulating women of matched cycle length. An innovative, quantitative measure of ovarian responsiveness was devised, as this declines during perimenopause. An expert system was developed to generate a personal report explaining the results in the context of reported well-being metrics known to be associated with hormonal fluctuations. This methodology was tested on a range of virtual results representing ovulating women, women with subclinical hypothalamic anovulatory issues and perimenopausal women with reduced ovarian responsiveness.

Results: The model provided an effective way to chart the variation of female hormones over the menstrual cycle and to explain the results to women who may be experiencing menstrual disruption. It was possible to distinguish between hypothalamic and ovarian dysfunction. In the case of perimenopausal women, the ovarian responsiveness score provided an indication of the progression towards menopause.

Conclusion: Artificial intelligence techniques are being applied across a range of medical fields to personalise delivery of healthcare. This research took up the challenge of modelling one of the most complex systems in the body. A personalised approach to female health, specifically female hormones around perimenopause is a gap that needs filling. This research provides a practical clinical tool that can help clinicians and empower women to make informed choices about their personal female hormone health.

References

1. ‘Machine learning for individualised medicine’ Mihaela van der Schaar, Annual Report of the Chief Medical Officer. 2018, Chapter 10. Health 2040 – Better Health Within Reach. Accessed 2021.

2. Van de Schoot R, Depaoli S, King R et al. Bayesian statistics and modelling. Nat Rev Methods Primers 2021;1:1. https://doi.org/10.1038/s43586-020-00001-2

¹GPST3, Cookham Medical Centre, Cookham, Berkshire

²GP, Cookham Medical Centre, Cookham, Berkshire

Objective: It is well-documented that oral anti-hormonal medication like Tamoxifen, Anastrozole, Exemestane and Letrozole which are used for stopping growth or recurrence of breast cancer can induce ‘menopausal-type symptoms’ through their adverse-effects. These can include breast tenderness, hot flushes, night sweats, insomnia, memory change, palpitations, headaches, incontinence and vaginal itching. It can particularly be troublesome to those women who are pre-menopausal or already have menopausal symptoms, when initiating such medication. Many women may silently succumb to overlooking or even accept having these ‘menopausal-type symptoms’. Our aim was to audit a cohort of such women registered at Cookham Medical Centre (CMC) and to subsequently raise awareness of these ‘menopausal-type’ adverse-effects by sending out questionnaires with the aim to produce a patient information leaflet (PIL) for our practice website pertaining to self-help measures and when to seek medical expertise from General Practitioner or Oncology team.

Methods: A primary search was run on EMIS software for CMC registered patients who were female and currently on either Tamoxifen, Exemestane, Anastrozole or Letrozole. Exclusion criteria included inactive records, discontinued treatment, or those patients with total mastectomy. This resulted in 32 patients between the age of 46 and 95 old. The distribution of patients per treatment were as follows: Tamoxifen (n = 6), Letrozole (n = 9), Anastrozole (n = 12) and Exemestane (n = 5). A survey was then produced using a template extrapolated from the North American Menopause Society and were sent as AccuRX text messages, email or via post.

Results: There were 25 patients who responded out of 32 (response rate 78%). Most ‘menopausal-type’ adverse-effects were classified as having a mild–moderate effect on women’s activities of daily living. 75% of women alone mentioned that Tamoxifen caused moderate – severe insomnia with all women associating their hot flushes to this medication.

Conclusion: verall, Tamoxifen was linked with the most category of ‘menopausal-type’ adverse-effects, whilst vaginal dryness and incontinence issues seemed to be strongly linked with Exemestane in our cohort. Both Letrozole and Exemestane seemed to be well tolerated from their adverse-effects. Recognised limitations include low population numbers and no subjective split between severity of symptoms between pre- and post-menopausal women.

¹GP, Leeds NHS Menopause Service, Meanwood Medical Centre, Leeds

²GP, Poole Menopause Centre, University Hospitals, Dorset

³Queen Charlottes & Chelsea and Westminster Hospitals, Professor of Practice, Imperial College London, President Elect, International Menopause Society, Director, International Centre for Hormone Health

⁴Consultant Gynaecologist, University Hospitals Dorset, Poole

Objective: To explore the potential for a set of eligibility guidelines that follow a similar structure and appearance to the UKMEC for contraception. To enable non-specialists to feel confident in safely prescribing HRT, and to aid selection of the most appropriate first line treatment.

Methods: We undertook a literature review and summarised the evidence and guidance on six areas that are frequently considered barriers to prescribing. These include cardiovascular disease and stroke, migraine, venous thromboembolism, breast cancer and personal risk factors. We have then produced a set of eligibility tables for each domain

Results: Our literature search confirmed the importance of distinguishing between different types and routes of administration when considering the suitability of HRT. Considerable amounts of evidence are based on older synthetic types of HRT, which whilst they still have a role in management, carry different risks to the now more accepted use of body identical types. It also highlighted the increased nuances of prescribing in comparison to contraception, increasing the complexity of forming guidelines, with the need for consideration to be given to an individual’s own perception of risks and benefits.

There are also areas with evidence to support appropriate but off label prescribing, such as the use of transdermal oestrogens in thrombophilias.

Conclusion: The demand for HRT prescribing has risen in recent years and there is a need for this to be managed effectively, for most patients in primary care. Our hope is that the production of this type of guidance will enable the non-specialist to be confident in safe and evidence-based prescribing. The guidelines are also designed to demonstrate to prescribers which complex patients should be referred onto menopause specialists. We propose to discuss this with the British Menopause Society to help develop and promote these guidelines further.

¹MSc, identifyHer Ltd, Ireland

²PhD, IdentifyHer Ltd, Ireland

Objective: Diagnosing perimenopause can be challenging as there are no objective ways to detect and track symptom profiles. Instead, clinicians spend a lot of time validating the self-perceived and self-reported symptoms from women during consultations. The purpose of this proof-of-concept case study is to demonstrate that a wearable biosensor patch can detect the frequency of night sweats under free-living conditions.

Methods: A 42-year-old woman experiencing night sweats intermittently for the previous 8 months wore a non-invasive biosensor patch under the breast on the left-hand side of the torso for 17 nights. The participant provided written informed consent and was not taking any medication for symptom management. When night sweats were experienced, the participant logged the event and time. Time series data processing techniques and statistical feature extraction was performed on the sensor output prior to algorithm training. Data fusion methods allowed the labelling of the senor output prior to model training. Data balancing and normalisation was also performed prior to model training. We used five machine learning classification models and a 10-crossfold validation to train each classification model. The accuracy (F1-score), precision, recall and receiver operating characteristic (ROC) curves were used to measure and visualise the model performance.

Results: A total of 17 nights of vital sign data was collected and the participant recorded 1–4 events per night. Of the 5 machine learning classification models used to train for the detection of night sweats, 60% obtained an accuracy score higher than 90% and the best performing model obtained an accuracy score of 99% (precision 0.98, recall 0.99).

Conclusion: In this proof-of-concept case study, we have demonstrated the objective detection of night sweats using a wearable biosensor patch. The next stage is to run clinical studies on a larger scale to validate the detection of night sweats using the biosensor and to develop algorithms to detect other menopausal symptoms starting with hot flushes, anxiety and sleep quality.

¹GPVTS St2, Haxby Group Practice, Hull

²Consultant Sexual and Reproductive Health, Conifer House, Hull

Objective: Identify areas to support and enhance primary care management and ensure secondary care services are used efficiently MethodsNew referrals to the Specialist Menopause clinic Hull between 1/6/21 and 1/7/21 in the electronic patient records were analysed, to identify if primary referral indication met referral criteria

Results: 22 (30%) referrals met referral criteria for secondary menopause services. Criteria: Past history of thrombosis (4) Migraine (2), premature menopause (2), cardiovascular disease (2), history of endometrial, ovarian or breast cancer (5), difficulty stopping hormone replacement therapy (HRT) (1) and testosterone replacement (6). Fifty-one (70%) referrals did not meet the current referral criteria. These non-criteria referrals are categorized into six referral categories based on the primary indication for referral. Symptom management (18), expert advice/up to date risks discussions/patient request (15), comorbidities (5), age concern (5), family history breast cancer (7) and mental health (1). 41 % of non-criteria patients had trialled HRT or were on HRT at time of referral. At the first clinic appointment, 86% of patient had a prescription for HRT issued. Symptom management was indicated as the most common reason for non-criteria referrals (35%), followed by the need for expert/up to date advice and patient requesting to be referred (29%). The commonest symptoms described were vasomotor and psychological symptoms

Conclusion: Number of referrals influence waiting time for all patients including patients that require specialist expertise prior to pharmacological management. Whilst many of the referrals can be managed in primary care, there appears to be an increasing trend for women to seek Specialist input into their care (29%). This suggests a lack of confidence in primary care for management of common menopausal symptoms. Recommendations include development of an interim service, led by primary care clinicians with appropriate training triaging referrals; dedicated menopause care clinicians with appropriate training in primary care networks; extending menopause care to a multidisciplinary team approach where complex referrals can be discussed and managed appropriately between primary and secondary care, with patients having access to trained professionals who can assist in their menopause management and support.

¹(DCRT. MSc radiotherapy and oncology), Consultant Radiographer. Centre head Maggie's Cambridge. Trustee of the pelvic radiation disease association. Consultant adviser for PERCI Health.

²KIrkby & Masham Surgery, CHCP, BMS, BSSM Committee Member, ESSM, IMS, PCWHF, FSRH Menopause Training Working Group Member, COSRT Associate Member, Contemporary Institute of Clinical Sexology Faculty Member, Ripon Trauma Centre Director, Peppy Health.

³Pembridge Villas Surgery, RCGP, BMS, BSSM, ESSM

Background: Menopause within the western society is associated with many challenges. So how much more challenging are the symptoms and consequences to manage as a sequel to cancer? Such women may also be facing issues around fertility, living with uncertainty and other treatment related side-effects all of which can impact on their quality of life (QoL) (Department of Health, 2012). Evidence suggests that worry and anxiety can have a negative impact on reported experiences of hot flushes/night sweats further reducing QOL and increasing anxiety and depression (Hunter, 2013).

Sexual dysfunction is present in 50–65% of cancer survivors yet women are less likely than men to have sexual consequences addressed (Schover, 2019).

Objective: To demonstrate the qualitative impact of collaboration between primary care and Maggie’s Cambridge following delivery of a menopause workshop.

Methods: 76 women attended one of eight, 2-hour workshops delivered over a period of 18 months. The workshop was facilitated by Maggie’s and supported by GP’s trained in menopause management and sexology.

A retrospective survey was undertaken to collate qualitative themes.

Results: Themes presented

Lack of information prior to treatment

Impact on QOL, physical symptoms, knowledge and psychological well-being

Benefits of shared experience within a group

Impact of access to experts trained in sexology/menopause

Legitimising menopause support in the background of a cancer diagnosis

¹ST6 Registrar in Obstetrics and Gynaecology, London

²SHO in Obstetrics and Gynaecology, London ³Medical Support Worker in Obstetrics and Gynaecology, London ⁴Consultant in Obstetrics and Gynaecology, London

Objectives: To assess if patients undergoing surgical menopause are informed pre-operatively about the hormonal consequences of surgery and the role of Hormone Replacement Therapy (HRT). A secondary aim was to ascertain the understanding and confidence that Obstetrics and Gynaecology (O&G) trainees have towards the management of surgical menopause.

Methods: A retrospective study was performed including all pre-menopausal patients who underwent a bilateral oophorectomy between January 2020 and January 2022 at a single hospital. A survey was also sent to O&G trainees in North Central and East London via their trainees’ newsletter.

Results: A total of 45 pre-menopausal women underwent a surgical menopause. Of these, 87% of women underwent a hysterectomy in addition to a bilateral oophorectomy. 20% of women undergoing a surgical menopause were below the age of 45. The most common reason for the procedure was fibroids or heavy menstrual bleeding, accounting for 47% of procedures. Other reasons included pelvic pain/endometriosis (16%), uterine cancer (13%), endometrial hyperplasia (11%), ovarian suppression for breast cancer treatment (9%), ovarian cysts (2%) and persistent cervical dyskaryosis (2%). There was no documented pre-operative discussion regarding the menopausal implications or management options of a surgical menopause in 49% of patients. The survey was completed by a total of 53 O&G trainees, of which 87% were registrars, and 13% were SHOs. 57% of respondents felt confident discussing the implications of a surgical menopause on cardiovascular and bone health with patients. 42% of respondents felt confident discussing hormonal and non-hormonal management options, and only 25% felt confident recommending suitable HRT regimes.

Conclusions: The results of our audit are in keeping with published studies (1,2) which showed that only 5.6–30% of patients undergoing surgical menopause were given advice on hormonal consequences or HRT pre-operatively. Our survey highlights a lack of confidence around the management of surgical menopause, and the need to improve the training provided to healthcare professionals.

References

1. Richardson A et al. Hormone replacement therapy in pre-menopausal women undergoing bilateral salpingo-oophorectomy for benign disease. Post Reprod Health. 20172.

2. Elson J et al. Review of menopause advice given to patients undergoing bilateral oophorectomy, Post Reprod Health. 2021.

Locum GP, Blackmore Vale Medical Practice, North Dorset

Background: The NICE guidelines from 2015 on the diagnosis and management of menopause state that HRT should be considered first line to alleviate low mood that arises as a result of the menopause. Recent studies, anecdotal evidence and high-profile media reports suggest that this is not happening.

Objective: The objective of this small study was to assess whether women of peri-menopausal and menopausal age presenting with new psychological symptoms in a GP setting are being asked about other menopausal symptoms; this is an important step required to identify whether or not the symptoms are a result of the menopause. The study also looked at what factors may influence the likelihood of this discussion.

Method: Case notes were reviewed for women aged between 44 and 57, registered at a rural North Dorset General Practice who had been issued a new antidepressant prescription between March 2019 and March 2021, to ascertain whether menopausal symptoms had been discussed in addition to their mental health symptoms. The influence of medical and social factors was assessed using the Chi Squared test.

Results: Of the 53 patients included in the study, 42% had a documented discussion of menopausal symptoms, in addition to low mood and anxiety. There was no difference in the likelihood of a documented discussion about menopause between patients with no medical issues and those with one or more medical issues (33% v 46%, p = 0.39). However, there was an association between social complexity and documentation of such a discussion; there was documented discussion in 57% those with no social issues versus only 11% patients with complex social issues (p = 0.001).

¹UCL School of Pharmacy, Department of Pharmacy Practice and Policy and Imam Abdulrahman Bin Faisal University, College of Clinical Pharmacy, Department of Pharmacy Practice

²UCL School of Pharmacy, Department of Pharmacy Practice and Policy

Background: Despite reports that overall HRT prescriptions have doubled in the last five years, there has been no recent study on population based prescribing rates of HRT. We therefore aimed to describe changes in the prescribing of HRT medicines in a cohort of UK menopausal women from 2010 until 2021.

Methods: Primary care data of women 50 years and older and/or with a record of menopause between January 2010 and November 2021 were extracted from the IQVIA Medical Research Database. The number of menopausal women who received their first prescription for HRT (prescribing incidence) was calculated for each year of the study using person-years at risk (PYAR) as denominator. The average annual percentage change in prescribing throughout the study period was assessed using linear regression. Incidence rates were stratified by route of administration, type of HRT and age group. The prescribing prevalence per 100 women was calculated annually using the mid-year menopausal population estimates as denominator.

Results: The rate of women who were prescribed HRT medicines for the first time increased from 5.01 in 2010 to 18.16 per 1000 PYAR in 2021, corresponding to an average increase of 13.6% per year. This increase was driven by new prescriptions of fixed combinations of oestrogen and progesterone (from 3.33 2010 to 12.23 2021 per 1000 PYAR; an increase of 17.6% per year) and oestrogens only (2.53 2010 to 10.64 2021 per 1000 PYAR; an increase of 16.7% per year). The incidence rate of transdermal formulations of HRT increased from 1.48 in 2010 to 14.55 per 1000 PYAR in 2021, corresponding to an average annual increase of 31.5%. New prescriptions of HRT to women aged 50–59 years increased from 19.17 in 2010 to 54.11 per 1000 PYAR in 2021, an average annual increase of 11.7%. The prescribing prevalence of HRT medicines increased from 7.81 to 8.16 per 100 women in 2010 and 2021, respectively.

Conclusions: Our study shows a steady increase in the number of women receiving their first prescription for HRT during the study period. The increase in new prescribing suggests regained acceptance of HRT medicines, particularly non-oral and combined fixed formulations.

¹GP, Capelfield Surgery, Claygate

²Consultant Gynaecologist, Guys & St Thomas' NHS Trust, London

³Nurse Consultant in Gynaecology, Guys & St Thomas' NHS Trust, London

⁴Consultant Gynaecologist, Guys & St Thomas' NHS Trust, London

Objective: The objective is to evaluate the difference between women aged 40 to 44 years old and 45 years old presenting in a General Practice regarding:– what perimenopausal symptoms women are presenting with – what investigations are being performed, the cost and outcome of investigations– what management are women being offered

Method: Clinical notes were reviewed for all females who had a GP telephone consultation between 6 June and 6 September 2021 at the Capelfield Surgery detailing any perimenopausal symptoms as listed on the National Institute for Health and Care Excellence Clinical Knowledge Summary (NICE CKS) guidance. When a menopausal symptom was identified, further data was collated including age of patient, presenting symptom(s), investigations performed, cost and outcome of investigation, referrals made and management offered.

Results: Of the total 119 patients, 28 patients were identified to have a perimenopausal symptom as detailed by NICE CKS. The 28 patients compromised 20 patients aged 40–44 years old and 8 patients aged 45 years old.

Overall the 40 to 44 years old age group:

– present less frequently (0.22 v 0.29)

– report fewer symptoms (1.35 v 3.25)

– undergo more investigations (3.25 v 1.88) – are referred to specialities more (0.30 v 0.25)

– are less likely to receive a medical certificate (0.05 v 0.25)

– are more likely to be treated with non-hormonal medication (0.65 v 0.13) and less likely to receive a hormone prescription (0.2 v 0.5)

– undergo more investigative tests (3.25 v 1.88) than the 45-year-old patients.

Conclusion: There was no suggestion from the data that 40–44-year-old women are currently managed the same as women with premature ovarian insufficiency as advised by the British Menopause Society. There was no documentation of lifestyle advice, requests for bone density scans or discussion around osteoporosis.

This study highlights the need for clearer guidance of perimenopause in this cohort of women, suggesting that 40–44-year-old are missing out on the opportunity to receive lifestyle advice and treatment to optimise their physical and mental health through reduction of cardiovascular disease, prevention of osteoporosis and improvement of cognitive function.

¹GP and menopause specialist, Newson Health Menopause Society

²GP and menopause specialist, Newson Health Research & Education

³Policy, Insight and Public Affairs Manager, Fawcett Society

⁴Producer, FInestripe Productions

⁵MBBS, PhD, Newson Health Research & Education and EGA Institute for Women’s Health, University College London

Objective: Whilst most women experience some symptoms related to their menopause, many do not receive the advice and care they need. But just how wide is this gap in health provision?

Methods: We analysed the results of a large-scale panel survey carried out on behalf of the Fawcett Society of women aged 45-55 with current menopausal symptoms. The survey was conducted online between 26 January and 4 February 2022 and included 4014 female respondents. Data was weighted to be representative of UK women aged 45–55 by age and region.

Results: In a population of women experiencing symptoms of the menopause or perimenopause, a mere 14% were currently taking HRT, and only 7% said they had taken HRT in the past but stopped. Of those who had never taken HRT (79%), two-thirds had experienced five or more symptoms related to the menopause (66%).

Over half of the study population who were taking HRT (54%) agreed with the statement that the treatment ‘had given them their life back’, and over a third of women taking HRT (36%) and who were currently working said that it had helped them being more productive at work. Only 18% reported that HRT had not helped resolve their symptoms, and just 2% said that they planned to stop HRT because of the side effects.

Conclusion: The first step in improving access to menopause care is an accurate understanding the scope of the current shortfalls in care. This survey adds to previous evidence showing that most women in the UK with severe menopausal symptoms do not receive the care they need. Further work is needed to explore how we can attempt to close this gap.

¹GP and menopause specialist, Newson Health Menopause Society

²GP and menopause specialist, Newson Health Research & Education

³Policy, Insight and Public Affairs Manager

⁴Producer, Finestripe Productions

⁵MMS, PhD, Newson Health Research & Education and EGA Institute for Women’s Health, University College London

Objective: Effective menopause care depends on women and health professionals being able to recognise whether the symptoms a woman experiences are related to the menopause or not. Our objective in this study was to explore what the most common menopause symptoms are in a representative sample of women in the UK.

Methods: We analysed the results of a large-scale panel survey carried out on behalf of the Fawcett Society of women aged 45-55 with current menopausal symptoms. The survey was conducted online between 26 January and 4 February 2022 and included 4,014 female respondents. Data was weighted to be representative of UK women aged 45–55 by age and region.

Results: The most common symptom (84%) reported was exhaustion and difficulty sleeping, followed by poor memory and concentration and difficulty focussing on a task (colloquially referred to as ‘brain fog’) (73%), and only then hot flushes or night sweats (70%). Mood-related changes (69%), joint pain or stiffness (69%) and low libido (54%) were subsequently the most common symptoms.

We found that almost half of the women surveyed (44%) reported that they had experienced a significant negative impact on their work due to the menopause, including reduced motivation and confidence, as well as the whole spectrum of physical symptoms of the menopause and perimenopause. Almost half of the women surveyed (44%) had experienced three or more symptoms related to the menopause. Genitourinary symptoms, often a cause for tertiary referral, were experienced by 39% of the participants.

Conclusion: To improve care and individualise treatment, there is an urgent need to reconfigure how the menopause is perceived, in a way that more accurately reflects the symptoms that women experience. Further work could sample the views of prescribing clinicians and specialists involved in menopause care.

¹BSc, FRCOG, MFSRH, Professor of Practice, Imperial College London, UK

²MD, PhD, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS, ³University of Pavia, Pavia, Italy

⁴MD, PhD, Palacios Institute of Women's Health, Madrid, Spain

⁵MD, PhD, 3rd Chair and Department of Gynecology, Medical University of Lublin, Poland

⁶MSc, Heroux Consulting, The Hague, Netherlands

⁷MD, Theramex, London, United Kingdom

Funding sources

Theramex HQ UK Ltd

Objective: To compare the risk of venous thromboembolism (VTE) and treatment persistence in postmenopausal women treated with the new combined body-identical oral product 1 mg 17β- estradiol/100 mg micronised progesterone (E2/P4) versus conjugated equine estrogens/medroxyprogesterone acetate (CEE/MPA).

Methods: Women aged ≥40 y treated with E2/P4 or CEE/MPA were selected from a large US claims database (04/2018 – 06/2021). E2/P4 and CEE/MPA were prescribed by the treating physician in the real-world practice and observed through pharmacy dispensing records. VTE risk and treatment persistence were assessed from the first prescription fill of E2/P4 or CEE/MPA (index date) until treatment switch or end of clinical activity records using inverse probability of treatment (IPT)-weighted Kaplan–Meier plots and IPT-weighted regression models to account for confounding factors. Treatment discontinuation (treatment persistence outcome) was assumed to occur on the last day supply before a treatment gap of >90 days or treatment switch. To account for the differential days’ supply associated with prescription fills for E2/P4 and CEE/MPA, treatment persistence was assessed in the subset of women with 30 days’ supply prescription fills.

Results: The study sample included 6526 women treated with E2/P4 and 29,535 treated with CEE/MPA (mean follow-up: 1.2 and 1.4 y post-index, respectively). At baseline, women initiated on E2/P2 were younger (mean age: 54 vs 56 for CEE/MPA), had less cardiovascular disease (34 vs 44%), less hypercholesterolaemia (24 vs 31%) and higher prior utilization of other oral hormonal therapies (oestrogen/estradiol-based: 20 vs 12%; progesterone/progestogen only: 18 vs 5%; all reported for the unweighted cohorts). In the IPT-weighted analyses, the VTE incidence per 10,000 women years was 37 for E2/P4 and 53 for CEE/MPA (incidence rate ratio 0.70, 95% confidence interval [CI]: 0.53–0.92, p < 0.05); the hazard ratio for the time to first VTE was 0.70 (95% CI 0.53–0.92, p < 0.05).

Conclusions: This study results demonstrate that the VTE risk may be lower among women initiated on E2/P4 compared to CEE/MPA.

¹Oxford Hormone Clinic, Oxford

²Nuffield Manor Hospital, Oxford

“Older Women Fall and fracture their thin bones -when their thin Muscles let them down.”

Objective and Method: A constructive and critical review of the recently published ‘UK clinical guideline for prevention and treatment of Osteoporosis’ by NOGG, an imposing paper outlining current guidelines to treat and prevent osteoporosis.

Results: 1. The limited information on HRT emanates from older controversial studies using Conjugated Equine Oestrogen and medroxyprogesterone acetate with known adverse risk profiles. No reference to using modern transdermal oestradiol and progesterone, or oestrogen only HRT is made. Newer studies using transdermal oestrogen clearly show no increased clotting risk, a reduction in osteoporosis and dementia, a reduced cardiovascular risk by 50% and no adverse risk when started >10 years after menopause. The small risk (smaller than lifestyle factors) of breast cancer in combined HRT with synthetic progestogen is further reduced if micronized progesterone is used instead. These well-established conclusions from several studies are not included.

2. Cost benefit analysis would be useful as treatments listed are expensive, h and often Toxic. Transdermal oestrogen is cheap, well tolerated, no monitoring needed, can be used as prevention and treatment, has very few, harmless side effects and has lifelong health benefits.

3. Sarcopenia is not mentioned or the importance of muscle mass to prevent fractures and disability. Sarcopenia features in the 2015 NICE guidelines of Osteoporosis treatment.

4. Low oestrogen/testosterone, important risk factors, are not mentioned.

5. References are not up to date, no reference to 2015 NICE guidelines or any BMS reference. The only reference is to a study in 2002 and a re-evaluation of that study in 2012.

Conclusion: This influential study is not balanced and does not represent current osteoporosis management by underplaying the well-established role that estrogen has in preventing osteoporosis and sarcopenia as well as helping older women avoid the most common cause of disability. We suggest the Guideline be amended; with involvement and advice from menopause specialists; and reference to studies on modern HRT with economic benefit/risk analysis.

¹Consultant in Obstetrics and Gynaecology, St George's University Hospital NHS Foundation Trust, London

²Health Psychologist, St George's University Hospital NHS Foundation Trust

³Health and Wellbeing Advisor, St George's University Hospital NHS Foundation Trust

⁴Staff Psychotherapist, St George's University Hospital NHS Foundation Trust

Objective: Many women experiencing the menopausal transition period have symptoms that make their working life more challenging. Staff working at an inner-London NHS Hospital Trust were invited to a focus group to share their experiences of the menopause within the workplace and to better understand how support structures could be developed to help with their wellbeing whilst at work. The focus group found that there was a need for a facilitated learning environment to learn more about the menopause, how to manage symptoms and better support the psychological and physiological needs of people experiencing the menopause.

Method: As a result, a 4-week closed psychoeducational group was designed that involved the Trust’s Health and Wellbeing Team, the Staff Counselling Team and the Trust’s Lead for the Menopause Service (Consultant in Obstetrics and Gynaecology). This 4-week programme was evidence based and delivered health promotion information to staff on nutrition and exercise, mental health, sleep and HRT management. This programme was delivered as a pilot to see if it would have a positive impact.

Results: 11 staff members participated in the pilot programme. Confidence in managing menopausal symptoms and understanding the menopause increased 36% from pre to post intervention. 76% of participants were either ‘very’ or ‘extremely likely’ to implement the tools from the programme in their everyday lives. 75% were ‘very’ or ‘extremely likely’ to recommend the programme to a colleague. One staff member reported ‘I got so much useful information on resources, organisations, healthy living and many more topics. Met participants who shared valuable information’.

Conclusion: Implementing the designed intervention was shown to have preliminary benefits on the confidence of those who took part, including in discussing and managing the menopause. In addition, the results indicated that over ¾ of participants who took part will take the skills they have learnt and implement them into their lives to improve their general wellbeing. Repeating the pilot to improve the validity of this intervention is required. This programme is now being repeated each calendar quarter.

¹2nd year UG medical student, King's College London (KCL)

²Consultant Gynaecologist, Guys and St Thomas’ NHS trust (GSTT)

³2nd year UG medical student KCL

⁴Consultant Nurse Specialist GSTT

⁵Staff Health and Wellbeing Manager, Occupational Health GSTT

⁶Consultant Gynaecologist GSTT

Many women aged between 45 and 65 struggle with managing their menopausal symptoms and this negatively impacts their ability to work. Access to menopause advice was difficult for women before the pandemic and is becoming increasingly more with overloaded GP services, long waiting lists for NHS menopause clinics and a national shortage of menopause specialists. To try to address this, Professor Rymer, Dr Bruce and Ms Holloway, who run the NHS menopause clinic at Guys and St Thomas’ NHS trust (GSTT), rolled out a pilot staff menopause clinic in liaison with GSTT Occupational Health to try to help support these women and it was part of the GSTT staff health and wellbeing offer and was supported by the GSTT charity.

Objective: To offer support, advice and educate NHS staff members at GSTT with menopausal symptoms to improve their health and wellbeing and support them to continue working within the NHS.

Methods: Over 3 months, 54 NHS staff were offered 15-minute telephone consultations to discuss their menopausal symptoms and provide management advice. Following the appointment, the staff members were asked to complete an anonymous survey to provide feedback about their experience. The pilot menopause clinic was advertised through various mediums including the trust website, staff bulletin, email, local newsletters and via managers.

Results: Data obtained from the clinics shows there were an 89% attendance rate and 73% survey response rate. 100% of the participants reported that their questions were answered by the clinicians, were given a clear management plan and said they would use the service again. On a scale of 0–10, participants rated an average of 8.6 in terms of how useful they found the clinics and an average of 8.9 on recommending these clinics to other staff members. ConclusionData obtained from the clinics were very promising and clearly indicates the high demand and benefit for such staff clinics. The next step for this pilot is to conduct a follow up questionnaire to see the long-term impacts this clinic has had. In addition, funding is to be sought to provide this service on an ongoing basis.

BSc MRCOG DFSRH, Consultant in Obstetrics and Gynaecology, Salisbury Hospital Foundation Trust

Objective: Analysis of referral patterns to a new NHS Menopause service in a DGH.

Method: Clinic was opened Sept 2018. This data is from analysis of referrals seen from June 2018 to Aug 2019. Data collection was prospective, and category of problem was assigned by AH. Analysis was using Excel.

Results: There were 139 referrals seen in this time. 44 were for menopausal symptoms, 28 were for ineffective HRT, 20 were for POI, 13 were for PMS, 4 for other endocrine issues, for example, secondary amenorrhoea and 30 were for sexual issues. n = 139106 were referrals from the GP = 76% Of these 87 were from GPs within the usual catchment area for this trust, 19 were external to the usual catchment area served by the trust. There were 20 internal referrals from other gynaecologists within the department, plus 6 Internal referrals from other consultants within the Trust = 20/139 = 14% There were 7 External referrals from other hospitals, of which 6 were from gynaecologists. In total there were 33 = 24% Tertiary referrals.

Discussion: There was discussion whether this service would have adequate referral input. This initial data analysis shows a variety of referral avenues and types of patient being served, which reflects the skillset of the provider. The referrals have increased dramatically over the last four years and are now 1/3 of the total gynaecology referrals for this department.

Conclusion: Specialist services can be set up in a way that they can serve both a local and regional population as both a secondary service level provider and a tertiary sub-specialist referral service. This aligns with our Trust values of providing good local general care, with some niche specialist services.

¹GP and menopause specialist, Newson Health Menopause Society

²GP and menopause specialist, Newson Health Research & Education

³Policy, Insight and Public Affairs Manager, Fawcett Society

⁴Producer, Finestripe Productions

⁵MBBS, PhD, Newson Health Research & Education and EGA Institute for Women’s Health, University College London

Objective: It is well known that the menopause can be disruptive and detrimental to a woman’s quality of life. However, the extent to which the menopause impacts wellbeing at work has not been clearly mapped out.

Methods: We analysed the results of a large-scale panel survey carried out on behalf of the Fawcett Society of women aged 45-55 with current menopausal symptoms. The survey was conducted online between 26 January and 4 February 2022 and included 4,014 female respondents. Data was weighted to be representative of UK women aged 45–55 by age and region.

Results: We found that almost half of the women surveyed (44%) reported that their menopausal symptoms had caused significant negative impact on their work. Common symptoms included reduced motivation and confidence, as well as the whole spectrum of physical symptoms associated with the menopause and perimenopause.

Additionally, we found evidence of workplaces being resistant to change: only 14% of respondents said their employer had put in place a menopause support network and only 9% said their employer had a menopause absence policy. Many women felt unable to get adequate leave to recover from their symptoms and had to use other reasons than then menopause to apply for sick leave.

The impact on work and professional progression was equally profound. Of those surveyed, 28% had either reduced their hours or altered their working pattern to being part-time and 10% had left their work due their workplace being unable to accommodate their needs. This equates to a workforce attrition of over 330,000 women between the ages of 45–55 years.

Conclusion: These results suggest that the UK has a long way to go for women to feel supported at work, and for employers to be able to ensure that their staff are given a work environment able to adapt to their needs.

¹Consultant in Sexual & Reproductive Health, Liverpool Women's Hospital, Liverpool

²Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool

Funding sources

The research was supported by an unrestricted educational grant of £5K provided by Theramex

Objective: To determine the best method to diagnose urogenital atrophy

Methods: A prospective observational feasibility study to examine the acceptability and concordance of different methods of assessment including: 1. A validated symptom questionnaire, DIVA (symptoms include vaginal dryness, itching, burning and dyspareunia) 2. Clinical examination using a modified vaginal speculum allowed scoring of tissue changes based on colour, elasticity, pH and architectural changes (prototype in development in collaboration with Robinson Healthcare Ltd). A score <7 = mild, 7–14 = moderate and > 14 severe urogenital atrophy. 3. Vaginal smear to determine the vaginal maturation index MI (ratio of superficial to parabasal cells, calculated using the formula 0.2 x % parabasal cells + 0.6 x % intermediate cells +1.0 x % superficial cells). The higher the MI, the healthier the tissue quality. MI is currently a US Food and Drug Administration (FDA) requirement in clinical trials of new drugs. 4. Analysis of vaginal secretions using NMR spectroscopy 5. Analysis of the vaginal microbiome Of the 60 women recruited, 40 were post-menopausal and 20 pre-menopausal, with ages ranging from 22 to 78 in a normal distribution, mean age 50.4 (SD 13.251). Body mass index ranged from 18.7 to 46.

Results: 1. MI was compared with the impact of symptoms on sexual desire. A weak linear correlation was noted (R2 0.066). 2. The score for the speculum examination correlated strongly with increasing age (R2 = 0.511). This compared with a very weak correlation between age and MI (R2 = 0.016) 3. The correlation between MI and the score for clinical examination using the adapted speculum was inversely related (R2 0.036).

Conclusion: The modified vaginal speculum appears to be a more reliable method of assessment for urogenital atrophy and will be accessible to primary care.

¹Agile Life Sciences

²Consultant in Sexual & Reproductive Health, Liverpool Women's Hospital

Funding sources

Dr Paula Briggs was awarded an unrestricted educational grant from Theramex of £5000.

Objective: Oestrogen deficiency as a result of the menopause can lead to deterioration of urogenital tissue and increased susceptibility to injury. Symptoms include vaginal dryness, itching and pain during intercourse. Current diagnosis of atrophy is based on visual examination and symptom assessment, and there is a need for objective evidence for both diagnosis and ongoing monitoring of treatment success. Agile Life Sciences have developed a bespoke metagenomic database to map the vaginal microbiome to species level, which will be used to determine whether tampon sample collection devices can be used to identify atrophy.

Methods: Urogenital samples were collected by use of tampon from participants attending Liverpool Women’s Hospital gynaecological outpatients’ clinic. The samples were collected by using a sterile tampon and after 20 minutes use, the outer sleeve was removed and soaked in PBS prior to centrifugation to collect the cell pellet. DNA was extracted from samples using magnetic beads and prepared for next generation sequencing (NGS) using The One 16S NGS Kit for Illumina from YouSeq. Samples were sequenced on the iSeq 100 device and analysed using a bespoke reference library designed by Agile Life Sciences for vaginal microbiome testing.

Results: The vaginal microbiomes for each participant were analysed and scored using Vaginal Community State Types (CST). After scoring, the results were compared to the reported symptoms to determine whether vaginal microbiome could predict atrophy. Atrophy was predicted by a decrease in Lactobacilli species, particularly L. crispatus, and an increase in diversity. The CST groups 4A and 4B were most prevalent in participants suffering from symptoms of atrophy.

Conclusion: The metagenomic barcoding protocols developed by ALS can be used on DNA extracted from tampons to identify atrophy. A UK study in 2010 revealed that 95% of participants preferred a self-collected menstrual tampon to a clinician-collected lower vaginal swab due to avoidance of embarrassment and convenience (Int J STD AIDS. 2010 Apr;21(4):279-82. doi: 10.1258/ijsa.2009.009277). Depending on the additional analyses required, urine samples may also be suitable for diagnosis of atrophy as urine samples are less invasive and more inclusive for those unable to use the tampon sample collective device.