33rd Annual Scientific Conference: Chesford Grange,Kenilworth

¹Senior Registrar Obstetrics and Gynaecology, King's College Hospital, London phoebe.howells@nhs.net

²Consultant Reproductive Medicine, King's College Hospital, London

³Senior Registrar, King's College Hospital, London

⁴Consultant Obstetrician and Gynaecologist, Ashford and St Peter's Hospital

⁵Consultant Obstetrician and Gynaecologist, Princess Royal Hospital, London

⁶Consultant Haematologist, King's College Hospital, London

⁷Consultant Obstetrician and Gynaecologist, King's College Hospital, London

Objective: Is there an increased risk of further thrombosis with using HRT containing transdermal oestradiol in women with a personal history of venous thromboembolism (VTE) or arterial thromboembolism (ATE).

Methods: Patients seen in the King’s College Hospital Trust Menopause Clinic, who have a history of thromboembolism are offered transdermal HRT +/- micronised progesterone after consultation with a Haematologist. We undertook analysis over a 5 year period to ensure that they had not had a recurrence of a VTE or ATE.

Results: We found 115 patients used HRT for over a year. These patients had an age range of 29-58 years old (average age of 53 years old). Their BMI’s ranged from 16-43 with 60% having a BMI <30, 21% with a BMI 30-35 and 9% with a BMI >35. 94/115 (81%) had a personal history of a VTE, 19% had suffered from an ATE.

89/115(77%) had been referred to a Haematologist who had agreed that it was safe to use transdermal estrogen preparations. There was no documented evidence of a case where the Haematologist did not agree that it was safe. 20% of patients required life-long anticoagulation. Although thrombophilia testing is not necessary as it is unlikely to alter the management plan, 64% of the patients had documented results with 42% positive for a thrombophilia.

Patients had taken transdermal preparations +/- micronized progesterone or Mirena coil for a range of 1-20 years, with an average duration of 3 years. 11 patients had switched from oral HRT to transdermal HRT after visiting the clinic.

39/115 patients required a higher dose of their estrogen, taking either more than 2 pumps of gel/spray or >50 micrograms in the form of a patch.

Significantly on follow up, none of the patients had had a recurrence of a thromboembolism after starting transdermal estrogen.

Conclusion: This is the first study to show that women with a history of VTE can be prescribed transdermal HRT +/- micronised progesterone safely. This study will enable more clinicians to consider prescribing HRT and higher patient uptake, after individualised risk assessments.

¹GP, Medical Officer, Complex Menopause Clinic, Cork University Maternity Hospital, BMS Menopause Specialist and Trainer, Ireland soffeke@gmail.com

²GP, Killarney, Co Kerry, Ireland

Funding sources: Kerry Travellers Health Community Development Project, Cork, Ireland.

Kerry Community Health Service Executive, Ireland

Background: Travellers, a minority ethnic group, represent 1.2% of the Irish population. They are disadvantaged and marginalised, negatively impacting on their health. Traveller women have 3 times the mortality rate and 11.5 years shorter life expectancy than peers in the general population with higher incidents of Cardiovascular disease, Diabetes, Obesity, Breast cancer and Mental health issues, poor health literacy and documented difficulties accessing health services.

Aim: To identify specific cultural issues in community regarding the menopause transition and to find a health promotion method best suiting their particular needs.

Method: We contacted the Kerry Travellers Health Community Development Project, a partnership project between the HSE and Traveller organisations that act as an interface between mainstream health services and Traveller Community Health Workers trained as local community health peer workers. We made it clear that we wanted to provide menopause information whatever way would have the biggest impact.

Following our meeting, we started with a round table meeting with 15 trusted members of the community. A questionnaire was circulated. Some of the pre-conceived ideas we had, we quickly learned would not work (e.g. using social media videos), due to menopause being a taboo subject. Instead of a traditional “presentation”, we had a range of slides shown in answer to a participant’s specific question.

Results: We produced a simple booklet with discrete cover “women’s health” using simple language and pictures.

We organised a large interactive event for Traveller women across Kerry. Over 50 women attended. The event consisted of round table discussions, using members of the initial workshop to promote the event and act as facilitators at each table. There was an informational presentation followed by a Q&A session. Many expressed that the biggest barrier was they felt ill-equipped to seek help from their GP.

Conclusions: Collaboration with the Kerry Traveller Health Community Development Project was key to the project’s success. We requested suggestions regarding what would benefit them most going forward. They suggested menopause specialists could train a group of existing trusted members of the community to meet with individuals in the community to prepare them for their first menopause consultation with their GP. This project is now in development. We feel it's a model applicable to other vulnerable groups.

¹FRCP, FRCOG, National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, London j.stevenson@imperial.ac.uk

²B Pharm. MB BS FRCOG FRANZCOG, Professor of Obstetrics and Gynaecology, Faculty of Medicine and Health, The University of Sydney, Australia

³MD, University of California, San Francisco, San Francisco, CA; Sutter East Bay Medical Foundation, Berkeley, CA, USA

⁴MD, PhD, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy

⁵MD, PhD, Palacios Institute of Women's Health, Madrid, Spain

⁶BSc FRCOG MFSRH Professor of Practice, Imperial College, London

⁷MD, PhD, 3rd Chair and Dept. of Gynecology, Medical University of Lublin, Poland

⁸MD, Deputy Head Physician, Gynecological Endocrinology and Reproductive Medicine, Dept. of Obstetrics and Gynecology, University Clinic Inselspital Bern, Switzerland

⁹MSc, Heroux Consulting, The Hague, Netherlands

¹⁰MD, Theramex, London

¹¹MD, Theramex, London

Funding sources: The study was funded by Theramex Ltd.

Objective: The Women’s Health Initiative study suggested an increased risk of cardiovascular events among menopausal women treated with conjugated equine estrogens/medroxyprogesterone acetate (CEE/MPA) as compared to placebo. The newer combined body identical oral product 17β-estradiol/micronized progesterone (E2/P4) may have a more favourable safety profile, but the risk of major adverse cardiovascular events (MACE) has never been investigated for E2/P4 versus CEE/MPA in a real-world or interventional setting. This study compared the MACE risk between women treated with E2/P4 or CEE/MPA combinations.

Methods: This was a retrospective longitudinal, non-interventional, observational study using data from US claims database (04/2019 to 06/2021). The study sample included women aged ≥40 years treated with E2/P4 or CEE/MPA who had ≥6 months of observation after treatment start. E2/P4 and CEE/MPA were observed through prescription fills records. MACE events included hospitalizations for acute myocardial infarction, ischemic or haemorrhagic stroke, or heart failure after treatment start, and were captured through diagnosis and procedures codes. MACE risk was compared between E2/P4 and CEE/MPA cohorts using Poisson/negative binomial and Cox proportional hazards regression models. Confounding was controlled via inverse probability of treatment (IPT) weighting.

Results: The study cohorts included 6,520 women initiated on E2/P4 and 29,426 CEE/MPA (mean follow-up: 1.2 and 1.4 years, respectively). At treatment initiation, women initiated on E2/P4 were younger (mean age: 54 vs 56 years for CEE/MPA), had less cardiovascular disease (34 vs 44%), and less hypercholesterolemia (24 vs 31%). All covariates were balanced post-IPT weighting. In the IPT-weighted analyses, MACE events rates were 23.5 vs 85.4 per 10,000 women-years among women treated with E2/P4 and CEE/MPA, respectively (IPT-weighted incidence rate ratio [IRR] 0.28, 95% confidence interval [CI]: 0.17 – 0.45). The risk of MACE was significantly lower for women treated with E2/P4 than those treated with CEE/MPA (IPT-weighted hazard ratio [HR] 0.28, 95% CI: 0.17 – 0.48).

Conclusions: Women treated with E2/P4 had lower risk of MACE than those treated with CEE/MPA. These results are consistent with other studies demonstrating that HRT with estradiol and micronized progesterone, both chemically and biologically identical to endogenous hormones, have a more favourable safety profile than HRT with CEE, or with synthetic progestogens like MPA.

¹Royal Brompton Hospital, Department of Cystic Fibrosis, London; National Heart and Lung Institute, Royal Brompton Hospital, London i.felton@rbht.nhs.uk

²Royal Brompton Hospital, Department of Cystic Fibrosis, London

³Royal Brompton Hospital, Department of Cystic Fibrosis, London

⁴Royal Brompton Hospital, Department of Cystic Fibrosis, London

⁵Royal Brompton Hospital, Department of Cystic Fibrosis, London

⁶Royal Brompton Hospital, Department of Cystic Fibrosis, London

⁷Royal Brompton Hospital, Department of Cystic Fibrosis, London

⁸Royal Brompton Hospital, Department of Cystic Fibrosis, London

⁹Chelsea and Westminster Hospital, London

¹⁰Royal Brompton Hospital, London, Chelsea and Westminster Hospital, London

Funding sources: Funding from the Royal Brompton Hospital Charity grant to Dr Ladina Weitnauer, Dr Amy Downes, Dr Imogen Felton.

Objective: Females with cystic fibrosis (fwCF) are experiencing increased survival with improved disease-modifying treatments, and many will now reach the age of menopause transition (MT). This UK study hypothesises that MT experience among fwCF is distinct to the general population and aims to characterise health service utilisation to improve future healthcare delivery.

Method: All fwCF aged ≥35 years receiving care at this large, pre-lung transplant UK CF centre (∼600 adults with CF) were invited to complete an electronic anonymised survey designed by the team’s CF-sexual and reproductive health quality improvement group. Results were analysed using the survey software.

Results: Among 59 respondents (47% response-rate; age 35-68years), almost half (n=29, 49%) self-reported as either peri- (n=17, 29%, median age 48.5years) or postmenopausal (n=12, 20%, median age 59 years). The median age of menopause was 51.5 years (IQR 39-56years). The postmenopausal cohort reported significant cardiovascular risk factors including hypertension (n=8, 25%), CF-diabetes (n=7, 23%), overweight (n=7, 23%) and obesity (n=4, 13%). Most women (73%) experienced distressing MT symptoms over a period of 5.2years (mean, SD +/-3.2years), but only half sought support, mostly via primary care (75%) or private specialists (31%), despite the majority’s (71%) preference for CF specialist-team advice. A third (31%) received hormone replacement therapy, with estrogen as topical formulation (92%), 41% oral progesterone, but nil testosterone replacement. Over 90% reported increased joint pain and neuro-hormonal symptoms such as poor concentration, sleep disturbances and fatigue experienced most severely. Only two thirds reported typical vasomotor symptoms. Worsening of CF-symptoms were experienced by 75% of post- and 32% peri-menopausal women, with increased mental health burden most severely reported (57%).

Conclusion: There is a lack of evidence regarding impact or management of MT in CF, where there is already an excess osteoporosis and cardiovascular disease risk. This is the first report from the UK which describes the distinct experience of MT symptoms in fwCF who have alarmingly high cardiovascular risk burden and significant impact of neuro-hormonal symptoms. With most also preferring advice from their CF team, this is indicative of the need for updated, evidence-based, interdisciplinary resources to guide therapeutic interventions in this at-risk population.

¹Consultant Gynaecologist, Queen Charlotte's & Chelsea Hospital, Imperial College, London nickpanay@msn.com

²Clinical Professor of Obstetrics and Gynaecology, George Washington University, IntimMedicine Specialists, Washington, DC, USA

³Professor, Department of Psychiatry, Queens University, Kingston, Canada

⁴Head Global Medical Affairs, Women’s Health, Bayer CC AG, Basel, Switzerland

⁵Senior Project Leader PRO, Global Market Access – Women’s Health, Ophthalmology & Hematology, Bayer AG, Berlin, Germany

⁶Principal Statistician, Bayer PLC, Reading

⁷Principle Statistician, Research and Development, Bayer AG, Wuppertal, Germany

⁸Bayer AG, Berlin, Germany

⁹Global Clinical Leader, Bayer AG, Berlin, Germany; and Charité University, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany

¹⁰Global Clinical Leader, Bayer CC AG, Basel, Switzerland

Funding sources: Studies were funded by Bayer CC AG.

Objective: Vasomotor symptoms (VMS) are common, bothersome, and persistent among many menopausal women. There is an unmet need for safe, effective non-hormonal treatments to alleviate VMS. Elinzanetant is a dual neurokinin-1,3 receptor antagonist in development for the treatment of VMS associated with menopause. We report treatment response findings of the pivotal OASIS-1 and -2 trials – two double-blind, randomised, placebo-controlled Phase 3 studies that evaluated the efficacy and safety of Elinzanetant in postmenopausal women with moderate/severe VMS.

Methods: Postmenopausal women aged 40–65 years with ≥50 moderate/severe VMS/week were randomised to receive Elinzanetant 120mg or placebo once-daily for 12 weeks; all participants were then treated with Elinzanetant for a further 14 weeks. Patients completed a daily electronic VMS diary. Treatment response, defined in this analysis as ≥50% reduction in the frequency of mean daily moderate/severe VMS at weeks 4 or 12, was analysed as two exploratory endpoints.

Results: Participants were randomised into Elinzanetant 120mg (OASIS-1: n=199; OASIS-2: n=200) or placebo–active treatment extension (n=197; n=200, respectively) groups. Overall, 79.5% (OASIS-1) and 82.5% (OASIS-2) of participants completed treatment at week 26. In OASIS-1, the proportion of participants achieving treatment response at weeks 4 and 12 was 62.8% (120/191) and 71.4% (125/175) in the Elinzanetant group, and 29.2% (54/185) and 42.0% (71/169) in the placebo group. The proportion of participants in OASIS-2 achieving treatment response at weeks 4 and 12 was 62.2% (115/185) and 74.7% (130/174) in the Elinzanetant group, and 32.3% (62/192) and 48.3% (87/180) in the placebo group. Across both trials, treatment response was similar between those who had received Elinzanetant for 26 weeks (range 81.5–81.6%) and those who started Elinzanetant after 12 weeks of placebo (84.5–86.7%).

Conclusion: OASIS-1 and -2 data analysis showed high responder rates for Elinzanetant 120mg at weeks 4 and 12, maintained through week 26, for postmenopausal women with moderate/severe VMS. Treatment response was similar in the Elinzanetant and placebo-to-Elinzanetant groups at the end of the 26-week trial. Elinzanetant is a promising novel non-hormonal treatment for VMS associated with menopause.

¹Health and Wellbeing Centre Manager, The King's Foundation meaghan.miller@kings-foundation.org

²Menopause Nurse

³Health and Wellbeing Coordinator, The King's Foundation

⁴Health and Wellbeing Coordinator, The King's Foundation

⁵Consultant Gynaecologist, London PMS and Menopause Clinic

⁶Consultant Gynaecologist, King Edward VII Hospital, London

Objective: Menopause is a significant transition in a woman life with the associated symptoms often challenging to navigate for the woman and her family. Hormone replacement therapy (HRT) has been the go-to treatment for managing menopausal symptoms but there is a growing recognition towards a more holistic approach to symptom and long-term management. In Ayrshire a holistic service was set up in 2016 by the King’s Foundation and the local NHS with the objective of supporting women presenting to Primary Care with menopausal symptoms.

Methods: Individuals were referred by health care professionals and attended a 6-week programme for 3 hours each week. This is based at the Health & Wellbeing Centre at Dumfries House and provides a holistic educational approach to creating wellbeing including HRT, nutritional guidance, complementary and psychological therapies. Individual assessment is made at the beginning and end of each programme using the Warwick Edinburgh Mental Wellbeing Scale and the Greene Climacteric Scale with qualitive information gathered by questionnaires.

Results: 533 women have attended the course since 2016. Warwick Edinburgh Mental Wellbeing Scale is a 14-item scale with 5 response categories, summed to provide a single score rating between 14-70. Increasing score is evidence of benefit. The results have shown an increasing difference of an individual average of 9.6 points.

The Greene Climacteric Scale is used to measure menopausal symptoms and is split into three categories, psychological, physical and vasomotor and look for a decrease in these symptoms. This was introduced this in 2020 and the results have shown an individual average reduction of 5.7 points.

Conclusion: This programme demonstrates an integrated approach to menopause offers holistic and personalised care, empowering women to navigate this life stage with resilience and vitality. It is time to embrace a comprehensive approach to menopause care that honours the complexity of women’s’ health and promotes overall long-term well-being.

¹ST6 in Obstetrics and Gynaecology, Shrewsbury and Telford NHS Trust mary.clark7@nhs.net

²ST6 Registrar in Obstetrics and Gynaecology, Shrewsbury and Telford NHS Trust

³Consultant in Obstetrics and Gynaecology, Shrewsbury and Telford NHS Trust

Objective: Referrals to the menopause clinic for testosterone and low libido have steadily increased. Locally, we have written prescribing information for primary care to follow, after testosterone initiation in the menopause clinic. This prescribing information adheres to British Menopause Society (BMS) guidelines but has only recently been introduced. The objective of this audit was to determine if the BMS guidelines are currently being followed.

Methods: Retrospective case note review of a selection referrals to the Menopause by two speciality registrars training in Menopause. The electronic patient records were reviewed using pre-determined criteria and recorded on the same secure spreadsheet.

Results: A total of 245 patient notes were reviewed, of these patients 35 had been specifically referred to request testosterone. 33 of these 35 patients were able to fully discuss testosterone in the menopause clinic. All patients were already taking Hormone replacement therapy (HRT). 32 patients reported that their libido had changed around the time of the menopause. Only 15 patients were already taking vaginal estrogen. 6 patients did not have a baseline testosterone level prior to commencement of testosterone. 24 patients were subsequently started on testosterone. Only 10 patients had reported testosterone levels at 3 months. 4 were referred for psychosexual counselling.

Conclusion: This audit demonstrated how locally we would benefit from keeping a specific log of patients on testosterone. This is to ensure that patients have their baseline testosterone levels and subsequent monitoring, to make sure testosterone levels are being kept in the physiological range.

Our audit showed only a small proportion of patients were already using vaginal estrogen, Vaginal dryness can be a contributing factor to low libido. By increasing uptake in vaginal estrogen this may help some patients prior to their referral or potentially reduce the need for referral.

In addition, psychosexual counselling was provided for some of these patients and identified further contributing factors towards low libido, highlighting the importance of a holistic approach to the management of low libido.

In those where testosterone was not commenced, this was mostly due to low estrogen levels therefore HRT regimes were altered to optimise absorption prior to considering testosterone.

¹Obstetrics and Gynaecology trainee, Royal Victoria Hospital, Belfast Health and Social Care Trust ebailie07@hotmail.co.uk

²Obstetrics and Gynaecology trainee, Royal Victoria Hospital, Belfast Health and Social Care Trust

³Consultant Gynaecologist and subspecialist in Reproductive Medicine and BMS menopause specialist, Royal Victoria Hospital, Belfast Health and Social Care Trust

Objective: Red flag referrals for post-menopausal bleeding (PMB) have increased nationally, with bleeding associated with HRT contributing to this increase. The aim of this study was to determine if bleeding was more likely to occur with certain types of HRT and if appropriate modifications to HRT were made to prevent recurrence and re-referral.

Methods: Charts from 1986 patients seen in a red flag PMB clinic between April 2021 and April 2023 clinic were reviewed, with 257 patients (12.9%) identified as taking HRT. All patients were post-menopausal and presented with either unscheduled bleeding on continued combined HRT (ccHRT) or irregular bleeding on sequential HRT.

Results: The average age of women seen was 55.2 years. Eighteen different HRT preparations were recorded, the most common being Evorel Conti patches (37.3%), Femoston Conti tablets (16.3%) and a combination of transdermal oestradiol with oral Utrogestan (11.1%). Average time on HRT was 29.1months with 11.4% having a change in HRT preparation in the last 6 months. Ultrasound findings: 57.2%, had endometrial thickness (ET) >4mm, with 98.6% of these patients having an endometrial biopsy and 91.1% referred for hysteroscopy. Endometrial biopsy histopathology; Proliferative endometrium (32.9%), endometrial polyp (18.4%), atrophic (17.1%), hormonal effect (12.7%), insufficient (10.8%), menstrual endometrium (5.7%), endometrial hyperplasia 1.9%, malignancy 0.6%. Patient outcome (excluding patients with pre-malignant and malignant pathology); 96.9% of patients were discharged and 3.1% were referred to HRT clinic for specialist input. No change was made to HRT in 77%, HRT preparation was changed in 11%, Levonorgestrel IUS inserted in 8%, and HRT was discontinued in 4%. 22 patients (8.6%) reattended within the 2-years, all of whom had been discharged with a biopsy result of proliferative endometrium with no change to HRT.

Conclusion: In this study, certain HRT preparations were more commonly associated with unscheduled bleeding. The patients were appropriately investigated with pelvic ultrasound followed by endometrial sampling/ hysteroscopy when indicated. The significance of proliferative endometrium in patients taking ccHRT needs to be addressed, with more education required on appropriate changes to HRT including insertion of levonorgestrel IUS at hysteroscopy.

¹Medical Student, Keele University x3j46@students.keele.ac.uk

²Consultant Gynaecologist and Obstetrician, Royal Stoke University Hospital

³Consultant Gynaecologist and Obstetrician, Royal Stoke University Hospital

Introduction: Menopause is a significant landmark in a woman's life, with many experiencing pronounced symptoms, and wide social and personal implications. Management of symptoms is often achieved with hormonal replacement therapy (HRT). This is usually prescribed in primary care, but factors such as family history of cancers and other comorbidities can lead to secondary care referrals.

Objective: This audit aims to assess whether patients referred to the menopause clinic for consideration of HRT could instead be initiated on treatment in primary care.

Methods: Referral letters from primary care and clinic letters were assessed. Electronic hospital records were also assessed for other information, such as body mass index (BMI) where necessary. Data was extracted on the following: patient age at presentation to clinic, BMI, predominant symptoms, reason for referral, investigations carried out in primary and secondary care, and treatments initiated. These included HRT, Mirena coil (IUS), non-hormonal therapies and lifestyle management.

Results: 118 patients fulfilled the selection criteria and were seen in the menopause clinic. They were referred for the following reasons: reduced libido and consideration of testosterone (n=28), family history of breast or ovarian cancer (n=17), ineffective prior management (n=16), unclear (n=14), venous thromboembolic (VTE) disease (n=10), another medical comorbidity (non-VTE or estrogen sensitive cancer) (n=12), personal history of breast or ovarian cancer (n=9), troublesome bleeding on HRT (n=5), premature ovarian syndrome (POI) (n=4) or other reasons (n=3). Testosterone primary care is not on the GP formulary for women, so all of these referrals were following local guidance, as were all referrals for personal history of breast or ovarian cancers, troublesome bleeding, prior ineffective management and POI. Family history of breast or ovarian cancers and histories of VTE may be safely managed in primary care in many instances. Referrals for other health conditions and those with unclear reasoning could have been managed in primary care following guidance.

Conclusion: Given additional support, primary care practitioners could initiate HRT for more patients in primary care following the BMS guidelines, reducing pressure on secondary care facilities.

¹GP, Highgate Group Practice, Highgate, London samantha.joseph1@nhs.net

²GP, Highgate Group Practice, Highgate, London

Background: Prevalence of testosterone prescribing in general practice has increased. The BMS guidelines advise patients to have an initial 3 month blood test following commencing testosterone replacement and then yearly checks, to ensure levels remain within the physiological range for women and therefore minimise adverse effects.

Aim: To assess the levels of serum testosterone in pre and postmenopausal women

Methodology: Primary care data of women who were perimenopausal and postmenopausal was collected during a search on the EMIS database. The search was obtained between 1st January 2024 and April 8th 2024. All women who were being prescribed testosterone and had their testosterone level monitored were included.

Results: The age range of women was 47yrs to 60 yrs (mean 53.2 years). Across a three-month period, 18 women had a 3/12 testosterone blood test taken. This level varied from <0.4 to 17.8. 7/18 women had a testosterone level in the normal range. 2/18 had a level below normal range suggesting problematic absorption/compliance. 9/18 women (50%) had a raised testosterone level which needed actioning.

Conclusions: There is a marked variation in levels of serum testosterone amongst women. This may be due to many different factors: absorption properties and half-life of the preparation used, amount of testosterone being applied, the timing of the venesection and variation in testosterone levels throughout the day. There may also be other factors contributing to libido which are not just linked with testosterone levels.

¹Menopause Lead, WTE Directorate, NHS England adebukola.ayoade@nhs.net

²MSc, University College London

³Institute for Women’s Health, University College London

⁴Co-Founder, ItsMenopause

⁵Medical Student, University College London

Funding sources: Institute for Women's Health, University College London.

Objective: The United Kingdom, a multi-ethnic country, reflects diversity with 4.2% of the population in England and Wales identifying with a Black background in 2021. Despite this diversity, most menopause research has primarily focused on a Caucasian population, leaving the perspectives of other British ethnic groups significantly underrepresented. The Fawcett Society’s 2022 report “Menopause and the Workplace” has brought to the fore the significant disparities in access to care and treatment among women from ethnic minorities. It is crucial to determine if Black women’s experiences of menopause differ significantly from those of Caucasian women.

Methods: A previous survey for women over 40 served as a template for this study. The survey was validated by conducting 3 interviews with women from the Black community and advice from menopause experts. The survey was advertised on 4 social media platforms (Instagram, Facebook, LinkedIn and Twitter) from 12/4/2023 to 27/12/2023.

Results: Data from 377 women was included. Most women were postmenopausal (38.2%), or peri-menopausal, (32.6%). The majority were happy about no longer having periods (57%). 88.3% had no menopause education at all. Only 5% felt very informed about the menopause before age 40. Most women only started thinking about the menopause between ages 40-49. The most common source of information was from friends (54.6%). They looked for information as their symptoms started (42.2%) or a long time after getting symptoms (30.8%). The most common symptoms experienced by more than 60% of the participants was brain fog (66.6%), night sweats (62.9%), hot flushes (61.3%) and poor concentration (61.3%). The most common method used to alleviate symptoms was exercise (52.3%), closely followed by nutrition changes including reduced alcohol/caffeine (45.4%). Many participants wished for more information specifically on the menopause experience of Black women and felt their GPs often failed to understand their preferences and the menopause experience of an ethnic minority.

Conclusion: These data show some similarities and differences to our surveys mainly completed by white women. Black women may experience menopause in a different way which may stem not only from biological variances and cultural attitudes but also from their unique life experiences.

¹GP and Menopause Specialist, South London grainnereihill@nhs.net

²Nurse Consultant, Gynaecology, Guys and St. Thomas' NHS Foundation Trust, London

³Consultant Gynaecologist, Guy's and St Thomas' NHS Foundation Trust, London

⁴Consultant Gynaecologist, Guy's and St Thomas' NHS Foundation Trust, London

Objective: Based on the growing prevalence of osteoporosis and the associated morbidity and mortality, primary care needs to focus on the management of osteoporosis and provide a similar emphasis given to the prevention of cardiovascular disease. This poster therefore aims to summarise the assessment, diagnosis and management of osteoporosis in women, in particular reviewing the use of hormone replacement therapy as a pharmacological treatment for osteoporosis.

Methods: A search was run on EMIS and women who had been diagnosed with osteoporosis between the ages of 50-60 were included in the study. This accounted for 100 patients. Key words included, “Osteoporosis” “Menopause” “HRT” “Estrogen” “Progesterone” “DEXA” and “Bone scan.” Documents and historical medications were also reviewed. Treatment options for osteoporosis in this study included bisphosphonates, anabolic medications, Selective estrogen receptor modulators and HRT.

Results: 100 patient notes were analysed. 14 patients had received no treatment for their osteoporosis. Only 14% of patients had a FRAX assessment recorded in their notes. HRT was not discussed as a management for either menopausal symptoms or osteoporosis in 56% of cases. Women who did have evidence of HRT discussion, often had brief consultations that often appeared to be patient led, often with the recommendation to rebook to discuss in further detail. Of the 100 patient notes that were analysed, 55 women were identified as requiring GP practice input and a targeted appointment in order to optimise their osteoporosis and minimise their fracture risk.

Conclusion: Osteoporosis is 3 times more common in women than men. Increasing life expectancy means that women now live 1/3 of their lives after the menopause. It is vital to challenge the antiquated viewpoint that osteoporosis is an inevitable outcome of the ageing process and recognise that Osteoporosis is a major non-communicable chronic disease with significant cost and health implications. Proactively completing FRAX assessments, requesting DEXA scans, ensuring up to date treatment plans are visible and discussing individualised treatment options with patients who have been diagnosed with osteoporosis is vital.

¹GP, Community Gynaecology Service, Oxfordshire lara.walford@nhs.net

²Consultant Gynaecologist, Guys and St Thomas' NHS Foundation Trust, London

³Consultant Obstetrician and Gynaecologist, Guys and St Thomas' NHS Foundation Trust, London

⁴Nurse Consultant in Gynaecology, Guys and St Thomas' NHS Foundation Trust, London

Objective: The aim of this audit was to identify all the women within one GP surgery on oral hormone replacement therapy (HRT) and whether they should consider changing their regimen to a safer form of HRT, taking into account their individual lifestyle factors.

Method: Three separate EMIS searches were carried out for all 11,500 patients registered at the GP surgery prescribed the following in the last 12 months:

Cyclical HRT tablets.

Continuous combined HRT tablets.

Estrogen only HRT tablets.

Results would be compared to recommended best practice standards by the British Menopause Society (BMS) and Primary Care Women’s Health forum (PCWHF).

Results: Within the audit period:

Twenty three women were prescribed oral cyclical HRT. Seventeen women needed changing to continuous regimen, preferably transdermal.

Thirty seven women were prescribed continuous HRT. Twenty one needed review for discussion of regimen due to age and VTE risk due to BMI/smoking status. These women had generally been on their regimen for years on repeat and had not had reviews in the last 12 months.

Twenty six women were prescribed estrogen only HRT all of which were appropriate at initiation. Of these 8 had Mirena’s. Two women had expired Mirenas for HRT purposes, one of which had recently been diagnosed with breast cancer. One patient had her Mirena removed elsewhere but continued to take estrogen only HRT.

Conclusion: This audit found that standards based on BMS and PCWHF recommendations were not met. Patients were not being reviewed annually with regards their HRT. When they were, discussion of risk was not documented regarding changing regimen to a safer form. Doctors at times got confused between prescribing cyclical and continuous tablets.

Separating the estrogen and progesterone components offers much more flexibility and choice to women but leaves potential for the woman taking unopposed estrogen if she misunderstands/forgets the rationale of the progesterone component. Mirena expiring in situ seems to be a particular risk and is likely to become more problematic as the licensing for contraception has now increased to eight years.

¹FRCOG Consultant Gynaecologist, University Hospitals Leicester NHS Trust olivia.j.barney@uhl-tr.nhs.uk

Objective: An extensive audit of 1y worth of patients referred on the 2WW endometrial pathway to amend the local pathway to reduce unnecessary referrals, invasive procedures and patient anxiety.

Methods: All patients referred to UHL on the 2WW Endometrial referral pathway between 5.5.20 to 4.5.21 were included (n= 2198). Data were collected prospectively. Further in depth evaluation on the first 4 month’s patients referred (n=702) was carried out, as well as all patients diagnosed with cancer during the year.

Results: • 28 day FDS (Faster Diagnosis Standard) met in 1445/2198 – 66% • 62 days FDS target met in 48/151 cancers- 32% – 129 were endometrial cancers (EC) (5.8% of all referrals) • 133/702 (19%) 2WW referrals were inappropriate of whom 8 were diagnosed with cancer. • Investigations carried out (we do not do “see and treat” at UHL) o 1916 – OPH/Pipelle (identified 54% of EC) o 615 – Ambulatory polypectomy (identified 33% of EC) o 76 – Daycase hysteroscopy (identified 12% of EC) o 1 EC was detected only at hysterectomy • 4 women out of 2198 referrals had been taking HRT when diagnosed with EC • 11/129 EC were in women under age 55y (8.5% of EC) o Average age of EC was 69y o All were Type 1 – Endometrioid EC • There was no significant difference in any diagnosis between ethnicities. • 47/702 had previous Ca Breast – 12 diagnosed with EC, 1 hyperplasia and 1 ovarian cancer • 86/702 had Diabetes – strongly associated with EC especially if White • 151/702 referred with unscheduled bleeding on HRT o No EC with ET <8mm without other USS features noted • Ultrasound descriptor of endometrium o No EC with Fluid <2mm unless other suspicious features also present o ≥2mm fluid in the cavity can be associated with EC o Cystic /echogenic foci /polyp descriptors correlated with polyp o Vascular /suspicious descriptors correlated with EC • Re-referrals within 12 months unlikely to be EC

Conclusion: • 2WW is not required for Unscheduled bleeding on HRT but still need timely assessment where ET >8mm • Re-referrals on 2WW within 12 months are unnecessary • Older women with unprovoked PMB more likely to have EC especially if diabetic

¹Obstetrics & Gynaecology ST1, Cwm Taf Morgannwg University Health Board, South Wales alexandra.buckle@doctors.org.uk

²General Practice ST1, Cwm Taf Morgannwg University Health Board, South Wales

³Consultant Obstetrician & Gynaecologist, Cwm Taf Morgannwg University Health Board, South Wales

Objective: To assess the extent of inappropriate referrals to the Gynaecology Rapid Access Service (GRAS) for postmenopausal bleeding (PMB) following new/changed hormone replacement therapy (HRT) in the previous 6 months.

Methods: Audit standard – The British Menopause Society advises unexplained vaginal bleeding in postmenopausal women should be referred after 4-6 months following new or changed HRT on an urgent suspected cancer pathway.

This is a prospective audit, running May 2023 to present in GRAS, Royal Glamorgan Hospital, South Wales. Those included are patients with PBM on HRT referred from General Practice (GP) to GRAS. A percentage was calculated of those with new/changed HRT within 6 months of referral (aka inappropriate referral), plus review of investigations for neoplastic diagnosis.

Results: Sample size at the time of writing (19/02/24) was 37. In 16% (6/37) of referrals, HRT had been started/changed within the previous 6 months. Overall, 8% of patients referred with PMB on HRT were referred at or prior to 3 months since starting/changing HRT. The referrals were spread throughout the audit time frame. None of the patients referred within 6 months of new/changed HRT had a neoplastic diagnosis.

Conclusion: Despite being a small sample, none of the patients with PMB following new/changed HRT had a neoplastic diagnosis. This audit demonstrates patients with PMB following new/changed HRT are consistently being inappropriately referred which does not meet the audit standard.

The ramifications of this are felt at a patient level, as the process causes avoidable inconvenience and stress. Additionally, at a service level. In both primary and secondary care, there is unnecessary referral administration and the opportunity cost of resources & services used.

Going forward, two interventions will be delivered. First, an advice & guidance sheet for GP on PMB and HRT referral guidelines. Second, return of referral if within 6 months of new/changed HRT, with request to re-refer once appropriate time elapsed. After interventions delivered, the audit will resume data collection for a further 6-months to re-audit and assess for change in practice.

¹GP, Willow Bank Surgery, Stoke-on-Trent bala.sankarasubbu@stoke.nhs.uk

Objectives: All patients who have been prescribed HRT in the last 1 year have been identified. 1. Was the HRT prescribed as BMS guidelines? 2. Did the patients attend review of HRT at least once in 12 months? 3. To identify Patients > 60 years on oral HRT and swap them to suitable transdermal preparations if appropriate 4. To identify Patients with sequential HRT – to see if they need to be switched continuous combined HRT.

Methods: 50 Patients were identified who were on HRT. 2 of them > 60 years were taking oral HRT. 13 out of 50 patients did not have any review for the last 12months. 13 were called for review with practice nurse or GP.

Results: 50 Patients were prescribed HRT as per guidelines. 2 patients who were on oral HRT were called for review and appropriate transdermal preparations were issued. 13 patients were called for review of HRT before further issue. 1 patient on review – noted to have worsening migraines. Her estrogen gel was reduced to 2 pumps per day and was booked a follow up appointment. All patients who were on sequential HRT were reviewed. 1 patient on sequential HRT was NOT taking the micronized progestogen as prescribed. The importance of taking the progesterone was discussed with the patient and follow up appointment was booked.

Conclusions: Following this audit, A template for HRT review has been created which includes the type of HRT, side effects experienced by patient – like migraines and PV bleeding. When HRT is requested by patient, the receptionist is aware to check the last date of HRT review and if its more than 6 months, the receptionist to book in with the nurse or GP for HRT review. If the patient is unable to attend, then to send the template through messages. Template can be filled by nursing staff for care home patients.

¹Consultant Gynaecologist, Royal London Hospital, London a.morin@nhs.net

²GP trainee, University College Hospital, London

³Trust Doctor, University College Hospital, London

⁴Foundation Doctor, University College Hospital, London

⁵Associate Specialist in Reproductive Medicine, UCLH, Hon Associate Professor in Women's Health, University College London, BMS Menopause Specialist

Objectives: NICE guidelines on management of menopause in 2015 and 2019 suggested that for healthy symptomatic women, the benefits of HRT outweigh the risks. HRT remains the most effective treatment for menopausal symptoms. After years of reticence, the demand for HRT is exponential. Consequently, bleeding on HRT is increasingly reported. We suspect that it burdens the gynaecological cancer pathway. We audited the referrals for “Bleeding on HRT“ and the impact on gynaecology outpatient services.

Methods: We compared referrals to target gynaecology clinics over April and October in 2019, 2021 and 2023. The clinic lists were obtained from hospital electronic record system (EPIC). The referrals for ‘Unscheduled Bleeding on HRT’ were analysed specifically looking at ultrasound scan findings, and further investigation/histology results.

Results: A total of 779 referrals were reviewed. The number of referrals for ‘Bleeding on HRT’ to target clinics increased from 12.6% in 2019-2021 to 20.7% in 2023. This was statistically significant (z=2.92. p=0.003). The endometrial thickness (ET) measured on transvaginal ultrasound was less than 4.5 mm in 75% of women. A total of 29 patients underwent an endometrial biopsy. Histology results were benign in 27 out of 29 cases. No cases of malignancy were found. 88% of patients were using continuous combined HRT and more than half used HRT via a transdermal route. The proportion of patients using transdermal HRT combinations in this group increased over the years: 36% in 2019, 49% in 2021 and 70% in 2023.

Conclusion: We demonstrate a significant increase in referrals for bleeding on HRT. In most women the endometrium was thin, and no further investigations were indicated. However, the 2-week referral consultations capacity was impacted. We believe that these patients could be managed in primary/community care models with a risk-factor based approach to investigations and changes to the progestogenic part of HRT.

¹PhD, Postdoctoral Researcher, Department of Nutritional Sciences, School of Life Course Sciences, King’s College London, London georgios.pounis@kcl.ac.uk

²PhD, Senior Nutrition Scientist, Zoe Ltd, London

³PhD, Senior Data Science Manager, Zoe Ltd, London

⁴Medical Director, ZOE Ltd, London, UK and Emory University School of Medicine, Atlanta, USA

⁵Data Scientist, Zoe Ltd, London

⁶PhD, Nutrition Research Scientist, Zoe Ltd, London

⁷PhD, Head Nutritionist, Zoe Ltd, London

⁸CEO, Zoe Ltd, London

⁹PhD, Professor, Departments of Nutritional Sciences and Twin Research and Genetic Epidemiology, King’s College London, London

¹⁰PhD, Professor, Department of Nutritional Sciences, School of Life Course Sciences, King’s College London, London

¹¹PhD, Reader, Department of Nutritional Sciences, School of Life Course Sciences, King’s College London, London

Funding sources: George Pounis’ research was funded by the British Menopause Society. Zoe Ltd supported this analysis with its resources and access to datasets and provided a travel grant to allow presentation.

Objective: This work assessed symptom number and severity in a large peri- and postmenopausal population, utilising app-based data collection to generate a novel index capturing menopause symptom burden.

Methods: Baseline data on menopause symptoms (20 vasomotor, sexual, psychological and somatic), symptom severity (0-not at all, 1-a little, 3-quite a bit and 5-extremely), and other characteristics of 70,412 participants of the ZOE PREDICT 3 app-based study (n=27,932 peri- and n=42,480 postmenopausal) were analysed (NCT04735835). The Menopause Symptom Tracker Score (MSTS, copyright © 2024 ZOE Limited) was generated as the sum (0-100) with higher values reflecting greater symptom burden. Subscores were computed for the four symptom domains. Dietary assessment was performed through an app-based food frequency questionnaire (PREDICT-FFQ) and diet quality assessed using the Healthy Eating Index-2020 (HEI, score 0-100).

Results: Prevalence of menopausal symptoms was high with 66.0% and 41.2% of peri- and postmenopausal participants experiencing more than 12 symptoms, respectively (P<0.001). Mean MSTS was greater in peri- versus postmenopausal groups; 32.2±16.6 vs. 22±16.9 (P<0.001). Symptoms with the highest severity (i.e. 5-extremely) rates in perimenopausal participants were: weight gain and slowed metabolism (30.7%), low libido (26.2%) and fatigue (24.3%); and in postmenopausal participants were: low libido (23.2%), weight gain and slow metabolism (19.5%) and fatigue (12.6%). Perimenopausal participants showed higher mean domain-specific MSTS in the vasomotor, psychological and physical domains and lower in the sexual domain compared to postmenopausal (P for all<0.001). A 20-unit increase in HEI diet score was associated with 4 and 5.6 units decrease in MSTS in peri- and postmenopausal groups respectively (β-coefs=-0.20 and -0.28, P<0.001). Each 5 kg/m2 increase in BMI was associated with 2.5 and 2.3 units increase in MSTS in peri- and postmenopausal women, respectively (β-coef=0.5 and 0.46, P<0.001).

Conclusion: This novel MSTS captured symptom prevalence and severity in a large sample population, identified variations in symptoms among peri- and postmenopausal populations and relevant associations with diet and BMI.

¹Institute for Women's Health, University College London, London joyce.harper@ucl.ac.uk

²Division of Medicine, University College London, London

³Division of Medicine, University College London, London

⁴Innovation and Enterprise, University College London, London

⁵Institute for Global Health, University College London, London

Funding sources: Business and Innovation Partnerships and Knowledge exchange funding teams in UCL Innovation & Enterprise.

Objective: Women often enter perimenopause lacking information and support, with significant impacts on their physical, emotional and social wellbeing. Working with the public and key stakeholders, we are co-designing an inclusive, accessible, evidence-based menopause education and support programme. The project is supported by the British Menopause Society and the Royal College of Obstetricians and Gynaecologists, with Wellbeing of Women and Sophia Forum as charity partners. We have established an advisory board, conducted two stakeholder workshops, 12 focus groups, and an online survey to inform programme development. Here we present results from our survey.

Methods: Between 10/01/24 and 22/03/24 we conducted an anonymous online survey using Qualtrics. Survey development was informed by literature review and discussions with key stakeholders, and a pilot with 40 women. Inclusion criteria were age ≥18 years, and being a woman, transgender man or non-binary individual born female. Participants were recruited through personal/professional networks, and social media.

Results: We report results from 2004 respondents. The topics most respondents wanted covering were definitions of menopause, symptoms, diagnosis, lifestyle modification, management, and life post-menopause. Over 90% thought the programme should be delivered online; 74% thought it should be delivered face-to-face in group settings. The majority stated a preference for between two and six sessions, every two to four weeks, lasting one hour. When asked who should facilitate sessions, 69% said a non-healthcare provider whereas 65% preferred a healthcare provider.

Conclusion: This work has allowed us to develop In Tune (UnIted KiNgdom Menopause EducaTion and SUpport for EveryoNE). Our main programme will be aimed at peri and postmenopausal people. Modelled on antenatal classes, it will combine education and peer support, and will be rigorously evaluated using complex intervention frameworks (subject to funding). We have also developed “Be Prepared for Menopause”, to be tested in Summer 2024, to improve menopause awareness and knowledge in those aged <40 i.e. before they reach perimenopause.

We believe the time is right for In Tune, a UK-wide programme to allow people to be in tune with menopause, in tune with their bodies and in tune with each other.

¹GP, Ashburton Surgery, Devon klambert@nhs.net

²GP, Rolle Medical Practice, Exmouth

³Nurse Consultant Gynaecology

⁴GP The Wooda Surgery, Barnstaple

⁵GP, Litchdon Medical Centre, Barnstaple

⁶GP, Budleigh Salterton Medical Practice, Devon

⁷ANP, Compass House Medical Centre, Brixham

Funding sources: NHS Devon Integrated Care Board.

Objective: The BMS Vision for menopause care in the UK (revised 2021) states that all healthcare professionals (HCPs) should have a basic understanding of the menopause and know where to signpost women for advice, support, and treatment. It aspires to every GP practice having at least one nominated HCP with a special interest in menopause. Within Devon, there is currently no NHS specialist Menopause provision. There is also limited core training despite a significant increase in menopause consultations over the last years. There is a compelling need to provide a broad cover of evidence-based HCP teaching in menopause.

Method: In 2022, as clinicians spread throughout Devon with BMS training we came together and secured funding of £30000 via the Integrated care board to provide menopause education within primary care. Our framework was to follow the BMS vision for menopause care in the UK. We offered a place for a 1 day recorded teaching event for at least one HCP from each of the 120 practices in Devon to attend. With a view to networking/support at locality levels and an increase in knowledge for that individual with an anticipation that it be transferred back into their practice. Prior to attendance a pre-education questionnaire was completed. The face to face event was held on 19th January 2024, the education was provided by ourselves and external speakers from the BMS and International menopause society. General menopause and common troubleshooting topics were covered.

Results: • 65% cover of attendance at the event (79 of 120 practices) • Attained excellent feedback with 90% of delegates. • The recorded teaching is available to all Devon HCPs to access till July 2024. To date we have had 164 views.

Conclusion: The education event achieved broad cover of locality attendance across Devon, and was a grounding of grassroots knowledge. To grow this further we are providing ongoing support and education at a locality level with regular shorter in person or virtual events. Future plans include the development of a Devon wide digital resource for both HCPs and patients using evidence-based links. We continue to work towards a specialist service development.

¹Applied Sports Technology, Exercise and Medicine (A-STEM) Research Centre, Faculty of Science and Engineering, Swansea University, Swansea

²Applied Sports Technology, Exercise and Medicine (A-STEM) Research Centre, Faculty of Science and Engineering, Swansea University, Swansea r.churm@swansea.ac.uk

³School of Nursing and Health Sciences, Sciences Complex, University of Sunderland, Sunderland

⁴Diabetes Research Group, Grove Building, Swansea University, Swansea

⁵Applied Sports Technology, Exercise and Medicine (A-STEM) Research Centre, Faculty of Science and Engineering, Swansea University, Swansea

Objective: Estrogen decline in women post-menopause can increase their of increasing central fat mass termed abdominal obesity. There is limited evidence on the effect of feasible lifestyle adaptation on adiposity markers in an at-home environment in women who are overweight & post-menopause. This study evaluated the effects of an 8-week home-based, equipment-free, high-intensity interval training (HEFHIIT) with the Mediterranean-style diet (MD) on adiposity markers in physically inactive, overweight post-menopausal women.

Methods: Thirty women (56.7 ± 3.9 years, FMP > 12 month, BMI: 30.5 ± 5.2 kg/m²) were randomly allocated to three groups: HEFHIIT and MD (EX+D), HEFHIIT only (EX), and control group (CTL). The intervention groups were instructed to perform HEFHIIT thrice weekly with/without MD, without calorie restriction. Body weight, body mass index (BMI), waist and hip circumference (WC; HC), visceral adipose tissue (VAT), total body fat percentage, leptin and adiponectin were assessed at baseline and after 8 weeks. Within-subjects data were performed using the student paired t-test, and treatment effects between groups were analysed using one-way analysis of covariance (ANCOVA) with baseline values as covariates, with the Bonferroni test used for post-hoc analysis.

Results: Adherence to HEFHIIT sessions were 85% for EX and 96% for EX+D. Significant reductions in WC and VAT mass were observed in both EX and EX+D (p<0.05). In EX+D, there were significant improvements in weight (p=0.005), BMI (p=0.004), HC (p=0.03) and body fat percentage (p=0.013). Compared to CTL, weight, BMI and WC decreased in EX and EX+D (p<0.05). There were also reductions in HC and body fat mass between CTL and EX+D (both p=0.01), and VAT mass (p=0.007) between CTL and EX. Leptin and adiponectin remained unchanged in all groups (p>0.05).

Conclusion: This study advocates the importance of regular exercise via a feasible home-based method, for improving abdominal obesity in women post-menopause. The addition of MD further improved weight, BMI and total body fat percentage. The high adherence rates suggests that women post-menopause should be encouraged to adopt these easily implementable lifestyle changes. Improving abdominal obesity is pivotal in maintaining long-term outcomes in cardiometabolic health, emphasising the need for sustained efforts.

¹Dr August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany susann.eichler@drwolffgroup.com

²Dr August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany

³Dr August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany

⁴Dr August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany

⁵Dr August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany

⁶Dr August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany

Menopausal decline in circulating levels of sex hormones often results in atrophy of the vaginal epithelium that can manifest as a chronic condition called genitourinary syndrome of menopause (GSM). Vaginal dryness, burning, pain and itching are bothersome atrophic symptoms of GSM for affected women, thus negatively impacting activities of daily living and sexual satisfaction. The severity of GSM symptoms is among others related to a rise of the vaginal pH from acidic to more basic and changes in the ration of the three vaginal epithelial cell types (parabasal, intermediate, and superficial). The aim is to evaluate changes in epithelium maturation and vaginal pH under treatment with a non-hormonal, lactic acid containing pessary, and to assess its efficacy and tolerability on GSM symptoms. Therefore, a prospective, open-label clinical trial was performed, including 43 postmenopausal women with atrophic vaginal symptoms. The investigational pessary was applied for the first 7 days once daily and the subsequent 35 days twice a week. Vaginal maturation index (VMI), vaginal health index (VHI), pH values and status of Lactobacillus flora of the participants before, during and after treatment were compared. Participants filled out questionnaires that enabled the calculation of a total severity score for subjective atrophic symptoms and impairment of daily and sexual life. Data showed a significant decline in vaginal pH and the proportion of parabasal cells in VMI, while there was a significant increase in the proportion of intermediate cells in VMI. In vast majority of women, the Lactobacillus flora status remained decreased and a significant reduction in the scores rate severity of symptoms was observed. Quality of life assessed by day-to day impact of vaginal aging questionnaire, and VHI also clearly improved over the study period. The tolerability was rated as 'good' or 'very good' by most of the women and by the investigator. No serious adverse events and only a low number of mild adverse events rated as related to the pessary were reported. Our data suggest that locally applied lactic acid was able to improve atrophic vaginal changes in postmenopausal women, thus providing an alternative option for the treatment of GSM symptoms.

¹GP and Menopause Specialist, Knightsbridge Medical Centre, HCA Chiswick Medical Centre, King Edward VII Hospital rebecca.hayes1@nhs.net

²GP Registrar, Knightsbridge Medical Centre

³Community Pharmacist, Knightsbridge Medical Centre

Objectives: To review the past 6 months of HRT prescribing in primary care at Knightsbridge Medical Centre to ensure adequate endometrial proception and identify any unscheduled bleeding with reference to the British Menopause Society (BMS) endometrial protection guidelines.

Method: System One was searched for all prescriptions for oestradiol in the past 6 months in all preparations split and combined. Then, each record was reviewed to see if a progestogen was needed and prescribed, recording dose, type, duration, any unscheduled bleeding and if two week referrals (TWR) were generated. Estrogen was divided into BMS categorised low, medium and high dose.

Results: HRT had been prescribed to 214 patients in the past 6 months, 33 patients were excluded as unsuitable, resulting in 181 patients on combined HRT; 99% of prescriptions were as separate estrogen and a progestogen with micronized progesterone (MP), accounting for 81% of total progestogen prescriptions. There were no prescriptions for oral combined HRT. 30% of all prescriptions had high dose estrogen with 1% of patients having MP prescribed at a proportionally higher dose. 25% of patients had unscheduled bleeding; 82% were taking micronized progesterone (48% high dose estrogen all on standard dose MP), 13% with Mirena coil (60% high dose estrogen), 2% on a combined patch. The unscheduled bleeding resulted in 60% of patients having a TWR; 60% had a normal hysteroscopy, 3% polyp, 23% hyperplasia and 13% pending.

Conclusion: The preference for transdermal estrogen and MP enables high dose estrogen prescribing. In light of the poor uptake of proportional progestogen prescribing, primary care needs to utilise embedded computerised prompts when prescribing higher dose oestradiol and to ask community pharmacists to refer to back to GPs when insufficient progestogen is prescribed. This simple management change should reduce the rate of unscheduled bleeding and lower the TWR, improving patient care and reducing the burden secondary care. Of note, 20% of TWR could have been avoided with the new unscheduled bleeding guidelines from the BMS.

¹GP and BMS Menopause Specialist, The Wooda Surgery, Bideford jdanielson@nhs.net

Objective: To establish the demand from patients registered at a 9000 patient Devon GP practice for menopause care in an ICB that currently has no commissioned specialist menopause service, and elicit patient views on the care that they currently receive.

Methods: System One clinical reporting was used for case-finding to establish numbers of women coded as presenting with a condition related to menopause from January 2020 – January 2022. All women registered at the surgery over the age of 40 were then offered the opportunity to take part in an anonymous survey via text regarding their perception of menopause care at the surgery.

Results: 5% of women at the practice had consulted regarding menopause from January 2020- January 2022, and 21% had consulted regarding menopause at any time in the past. 42% of women with breast cancer consulted regarding menopause symptoms in this period.

Of the 1778 surveys sent there were 675 respondents. 66% had consulted the surgery at any point regarding their menopause symptoms. Only 30% of these women felt confident that they had received the help they needed.

Themes that emerged in negative responses:

• Not having options presented • Feeling that early menopause was not recognised • Women told they were ‘too young’ to be menopausal • Inappropriate use of FSH testing • Anti-depressant use when presenting with menopause • HRT inappropriately stopped • Sense of GP reluctance to prescribe HRT • Lack of regular reviews of HRT • Lack of information around alternatives • Sense of embarrassment from many women about presenting with symptoms • Desire for proactive information about menopause for women 89% of respondents felt that they should have access to specialist menopause care.

Conclusion: Extrapolated to the North Devon population of 96000 (2018 data) it is not unreasonable to assume that around 13000 women in the region have at some point consulted their GP regarding menopause symptoms. Breast cancer patients (for example) often require specialist input and present with symptoms disproportionately frequently in our practice. The need for education in primary care and the appetite from women for specialist care is clear, and a specialist pathway for Devon ICB should be developed.

¹GP and Women's Health Fellow in Kent, Riverview Park Surgery, Gravesend samar.ahmed@nhs.net

Funding sources: the Women’s Health Fellowship in Kent is funded by NHS Kent and Medway Integrated Care Board through the Training Hub.

Background: In Kent and Medway, there has been a lack of focus on Women's specific issues including the Menopause, however, recent years have shown a significantly growing demand for these services. The NHS in Kent and Medway is implementing the Women's Health strategy for England, and improving Menopause Services is a top priority.

Objective: The aims of this ongoing Project is to Evaluate the current Menopause Services in Kent and Medway from the perspective of service users (women) and service providers (primary care professionals) and to suggest methods that may help with the improvement of the current services.

Methods: Over 700 women participated in an online survey to express their concerns regarding the service and suggestions on how it may be improved. This was followed by focus groups and the results were thematically analysed. A second mixed methods survey is currently being rolled to include the perspective of primary care professionals on how the service may be improved and the data analysis is due to be finalised soon. The questions on this survey were informed by the responses of women on the first survey by women.

Results: 720 women responded to the Survey. Women reported mixed experiences with menopause but the main themes that emerged from the qualitative analysis of the Women's Survey were: concerns regarding the waiting time to initiate menopause treatment including HRT, lack of holistic approach to management, lack of joined-up services leading to treatment inequality, the need for accessible and reliable information and the education of women on self-care , the need for health care professionals' education around menopause diagnosis and management and the potential role of women's health hubs on service improvement.

Conclusion: Menopause symptoms have significant impacts on women's daily lives including work, relationships and mental health. In Kent and Medway there is an overwhelming view that women feel unprepared for the array of symptoms and need more support from professionals and the society in general. Further analysis of data from health care professionals will help in remodelling menopause services in the area for a better outcome.

¹Obstetrics and Gynaecology Registrar, Sheffield Teaching Hospitals NHS Foundation Trust miyuki.omura@nhs.net

²Consultant Obstetrician & Gynaecologist, Sheffield Teaching Hospitals NHS Foundation Trust

Background: The incidence of iatrogenic premature ovarian insufficiency (POI) is rising with improvements in cancer survival in young women. The British Menopause Society (BMS) recommends commencing hormone replacement therapy (HRT) until the natural age of menopause to minimise the impact of POI.

Currently, HRT does not seem to adversely affect prognosis in most ovarian cancer survivors. However, no evidence exists for the safety of HRT in ovarian germ cell tumours. Some germ cell tumours can be hormone sensitive and current BMS guidelines recommend HRT should be avoided in this subset on theoretical grounds. This poses a dilemma regarding whether to advise patients to take HRT or not.

Objective: We present a case series of three patients treated for ovarian germ cell tumours and discuss their individualised management with HRT for POI.

Methods: Patients with germ cell tumours were identified in the specialist ‘Late Effects Clinic’ at Sheffield Teaching Hospitals. Consent was obtained and their electronic notes were reviewed.

Results: All three individuals developed POI after surgery and chemotherapy. The first individual had ovarian stroma test positive for estrogen receptors with immunohistochemistry (IHC) testing. After multidisciplinary team (MDT) discussion, she decided to commence HRT. The other two women had surgery outside of the UK so no IHC data was available. One patient opted to commence HRT in view of significant menopausal symptoms while the other patient opted not to commence HRT due to the unknown risk of estrogen replacement with ovarian germ cell tumours.

Conclusion: We suggest a holistic and individualised approach when assessing and advising women. We recommend IHC testing for estrogen and progesterone receptors and discussing the results at a menopause MDT meeting. If IHC testing is not possible, we recommend working on the premise that the tumour sample may have estrogen receptor positivity. The outcome of the meeting should be discussed with the patient and a joint decision made on whether they wish to continue HRT or not, after discussing the risks and benefits. Further studies on hormone receptors in ovarian cancers are required to help predict the risk of recurrence.

¹Cardiovascular Health Sciences Research Group, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool k.a.roberts@ljmu.ac.uk

²Cardiovascular Health Sciences Research Group, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool

³Cardiovascular Health Sciences Research Group, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool

Funding sources: Dr Kirsty Roberts holds a Daphne Jackson Fellowship funded by the British Heart Foundation for the purposes of this research.

Objective: Hot flushes (HFs), the major pathophysiological symptom of the menopause, represent extreme thermoregulatory events, with sudden and intense feelings of heat causing skin reddening and sweating that have a profoundly negative impact on quality of life. Hormone replacement therapy can alleviate hot flushes, but is not suitable for everyone, including breast cancer patients. Few alternative treatments are available, largely due to an incomplete understanding of the physiological mechanisms underpinning HFs. Dampening central thermoregulatory responses has been achieved with the recently approved neurokinin 3 receptor antagonist Fezolinetant, which offers non-hormonal treatment for moderate to severe HFs. However, it is currently unknown if the function and/or structure of skin blood vessels and/or sweat glands are affected by the menopause or contribute locally to HFs. For example, estrogen deficiency and/or morphological changes with advancing age could possibly affect key vascular, sudomotor and/or neural structures or function that could induce more frequent and larger increases in skin blood flow consistent with HFs. The aim of this ongoing research is to therefore examine skin blood vessel and sweat gland function and skin structure in pre- and postmenopausal women who do and do not experience HFs.

Methods: Following informed written consent, conforming to the Declaration of Helsinki, Health Research Authority approval (22/NW/0300) and online registration (clinicaltrials.gov: NCT06222073), three cohorts (premenopausal/healthy, postmenopausal [+flush], postmenopausal [-flush]) will undergo cutaneous microdialysis to assess skin blood vessel and sweat gland function by perfusing increasing doses of vasoactive drugs (acetylcholine, sodium nitroprusside, calcitonin gene-related peptide), followed by a skin biopsy that will be stained to highlight blood vessels and sweat glands. Dose-response curves will provide between-groups analysis of skin function. For the size/number of blood vessels and sweat glands in skin samples, data will be analysed between groups using a one-way ANOVA.

Results: Clinical trial in progress.

Conclusion: Identifying functional and/or structural changes in skin blood vessels or sweat glands in women with HFs would increase our understanding of their cause(s) and side effects, and help to design effective treatments, including interventions that can manipulate the activity of the skin blood vessels and/or sweat glands via pharmacological or non-pharmacological methods.

¹Post CCT Fellow Reproductive Medicine, Leeds Teaching Hospitals NHS Trust, Leeds; Consultant in Reproductive Medicine & Surgery, CARE Fertility, Seacroft Hospital, Leeds jennifer.tamblyn@nhs.net

²Specialist Nurse Hysteroscopist, Leeds Teaching Hospitals NHS Trust, Leeds

³Consultant Gynaecologist, Leeds Teaching Hospitals NHS Trust, Leeds

Objective: Unscheduled vaginal bleeding is a recognised side-effect of hormone replacement therapy (HRT). In the absence of risk factors for endometrial cancer (E Ca), adjustments to progestogen dose and/or HRT preparation, may be appropriate. We aimed to establish whether certain HRT preparations increase the risk of unscheduled bleeding. This may help guide HRT modification and E Ca risk assessment.

Methods: Single centre, retrospective evaluation of 425 (Jan 2023-Dec 2023) women referred with unscheduled bleeding as a 2-week wait. Detailed analysis was conducted for 49 women, with baseline demographics, HRT regimen details and patient outcomes assessed.

Results: The overall E Ca detection rate was 2 (0.47%) per 425 women. Subgroup analysis (n=49) found the mean age was 55y (41-68y), with most women ‘White-or Mixed-British ethnicity’ (n=38; 76%). Mean BMI was 28 (19-47; n=46); 30.6% (n=15) 30 and 4.1% (n=2) 40.

Most women used continuous-combined HRT (ccHRT, n=43; 87.8%), with 5 (10.2%) using sequential HRT (sqHRT) and 1 (2.04%) tibolone. ccHRT preparations included gel (n=12; 27.9%), estrogen-only patch (n=9; 20.9%) combined patch (n=18; 41.9%) and oral (n=4; 9.3%). Endometrial protection varied with 21 (42.9%) using micronized progestogen (100-200mg), 25 (51.0%) synthetic oral/ transdermal progestogen and 3 (6.1%) 52mg LNG-IUD. Current and total HRT duration ranged from 3-120 months (m) and 3-240m respectively; only 2 changed HRT <6m ago, one of which had 2 minor risk factors for E Ca.

Overall, 10 (20.4%) women received initial HRT advice and guidance. For 39 (79.6%), transvaginal ultrasound was performed, with an endometrial thickness (ET)>4mm measured for 17 (48.6%) ccHRT users and >7mm for 2 (66.6%) sqHRT users. Of these, 21 (42.9%) received HRT advice and guidance and 18 (36.7%) had a hysteroscopy; 5 had a polypectomy (10.2%), 14 (28.6%) endometrial biopsy and 5 (10.2%) LNG-IUD insertion. One woman (2% subgroup, 0.235% total) was diagnosed with hyperplasia with atypia (ET 7mm); she had no known risk factors for E Ca.

Conclusions: No clear difference in progestogen type and/ or HRT preparation was identified. As anticipated, LNG-IUS use was lower. Larger, prospective data is required to more accurately evaluate whether certain HRT preparations increase the risk of unscheduled bleeding.

¹Midwife and PhD student, Northumbria University sarah.chalhoub@northumbria.ac.uk

²Associate Professor of Psychology, Northumbria University

³Associate Professor of Psychology, Northumbria University

⁴Assistant Professor, Social science, Northumbria University

Funding sources: PhD funded by Northumbria University.

Objective: The aim of this QES was to explore women’s feelings in relation to the impact of sexual changes during menopause.

Methods: A qualitative feminist design was applied to the systematic search process, the review was registered with Prospero (CRD42021296101). Rigor was upheld using structured Pico search strategies and PRISMA reporting guidelines. Inter rater reliability was assessed using Cohens Kappa calculation, with methodological quality assessed using Joanna Briggs, Critical Appraisal tool for qualitative studies. Reflexive thematic analysis (Braun and Clarke (2021) was used to analyse the data, with a unique interpretation from a practicing midwife.

Results: 19 papers were selected for analysis, with data from 489 women who had lived experience of menopause transition. Participants in the selected studies had all been recruited purposively. The selected papers represented a global perspective from women in 9 different countries (Iran (n=3), Lebanon (n=1), UK (n=4), USA (n=5), Ireland (n=1), Spain (n=1), Taiwan (n=1), Sweden (n=1), Australia (n=1)). Four main themes specifically emerged from the analysis about sex and the impacts on feelings during menopause: Sense of Loss, Meaningful Connection, Finding Solutions and Sexual Confidence.

Conclusion: Despite a global representation with unique and individual groups of women, data analyses revealed similar themes and experiences for women when exploring how sexual changes affected their feelings of wellbeing. This is an important factor when assessing psychological wellbeing without bias. Additionally, certain groups of women appeared to have greater levels of in-built resilience, better social support, happier relationships, and a positive outlook, while others did not. Sexual confidence and satisfaction were influenced by women's ability to adapt and find solutions, this ability to adapt appeared to act as a protective factor to these women, who in turn described greater feelings of wellbeing. Providing holistic, timely assessment and education, without sigma for women must be a priority for healthcare providers.

¹Advanced Nurse Practitioner, Sexual Health, Havens Health, Peacehaven, East Sussex ruth.bailey1@nhs.net

²Menopause Specialist

Objective: To examine initial assessments of patients with menopausal symptoms undertaken by practitioners in primary care, to determine how consistently support is given to make lifestyle changes in managing weight and increasing exercise.

Methods: A retrospective study was carried out to examine the notes of a sample of 40 patients with a BMI of 30kg/m2 or over, attending clinic for an initial menopause assessment in a 6-month period. A simple audit tool was used to record documented evidence of discussion of lifestyle interventions including advice on weight management and increasing exercise, provision of evidence-based resources and referral to specialist support for weight management programmes.

Results: • All records in the sample clearly recorded the patient’s body mass index (100%). • 60 % of patient records had recorded a discussion about the effectiveness of lifestyle changes to manage symptoms. • 39% of consultations recorded that a relevant patient information leaflet or link to a website had been issued. • 10% of patients in the sample had been referred to a tier 3 weight management programme with their consent. • 21% of consultations contained no record that a lifestyle intervention had been discussed or a relevant resource issued. • An incidental finding showed 2 prescribing errors in relation to endometrial protection (one expired 52 mg LNG-IUD and one use of Kyleena for endometrial protection).

Conclusion: Results demonstrated that health care practitioners consistently assessed patient’s BMI, and 60 % of consultations showed evidence that some discussion of lifestyle strategies had taken place. However relevant resources were not offered consistently, and opportunities for referral to specialist services were missed. Current guidance (NICE 2018) recommends that women should be given lifestyle advice as part of individualised management and this audit shows that more work is needed to ensure that this is delivered consistently in primary care. Recommendations for practice were made and a further area for audit identified.

Reference

1. National Institute Clinical Excellence (2015) Menopause: Diagnosis and management Available at: https://nice.org.uk/guidance/NG232

¹Consultant Clinical Biochemist, Leeds Teaching Hospitals NHS Trust

²GP, North Leeds Medical Practice bori.jassim@nhs.net

³Consultant Endocrinologist, Leeds Teaching Hospitals NHS Trust

Objective: Hypoactive Sexual Desire Disorder (HSDD) presents a persistent absence or deficiency of sexual fantasies and desire, in some individuals leading to significant distress or interpersonal difficulty. While its aetiology encompasses various biological, psychological, and social factors, testosterone deficiency is recognised as a potential contributor. Testosterone therapy has been explored as a treatment option for individuals with HSDD during the menopause, particularly those with low testosterone levels. However, its efficacy remains debatable, with inconsistent results observed across studies. Additionally, testosterone supplementation carries potential risks of adverse effects including acne, hirsuitism, alopecia, deepening of the voice and enlarged clitoris. Therefore, the use of testosterone in treating HSDD necessitates careful consideration, individualised approach, and close monitoring by healthcare professionals. The British Menopause Society (BMS) issued guidance to GPs and other healthcare professionals around the use of Testosterone Replacement Therapy (TRT) in HSDD. To determine compliance against these guidelines, we audited patients from the West Yorkshire region being prescribed TRT for HSDD.

Methods: We audited 12 months of data for patients on TRT against the BMS guidance. The data was extracted from our laboratory information management system from September 2022 to September 2023 searching for females >45years with a testosterone request. These were randomly examined to identify patients who had been prescribed TRT. Data from the first 100 patients identified were collated and reviewed against the BMS guidelines.

Results: We determined that 97% of patients had a baseline testosterone measurement with 94% of those had a testosterone concentration <1nmol/L. Only 1/3 of patients started on TRT had a follow-up measurement of testosterone within 3 months, and 1/5 of patients still had no follow-up at 6 months. Around half of the patients prescribed TRT had a raised testosterone (mean T = 3nmol/L). Of these patients, 30% had no reduction in dose or follow-up within 3 months. SHBG was measured sporadically but its clinical application is limited.

Conclusion: In response to our audit, which clearly demonstrated poor compliance with the BMS guidelines, a multidisciplinary team developed local guidelines to provide more clarity over testing, including information around timing, collection, and interpretation of testosterone results.

¹Consultant Gynaecologist, Mid York NHS Teaching Trust veena_kaul@hotmail.com

²GP, New South Gate Surgery, Wakefield

Objective: There is a national increased demand for menopause care in Primary and Secondary Care, resulting in long waiting times for appointments – currently 62 weeks in the NHS Trust menopause clinic. A collaboration between Primary and Secondary Care in Wakefield District sought to address the demand, improve education amongst professionals, standardize care, reduce waiting times and improve support for women particularly in ethnic groups.

Method: Frome early 2023, regular meetings of a working group consisting of a Consultant Gynecologists Lead for Menopause Care, a Clinical Pharmacist, a GP with an interest in Women's Health, Senior Managers from Secondary and Primary Care and Communication Officers.

Results: Developments: 1. Locally developed Menopause Guidance and HRT formulary based on BMS guidance launched December 2023 2. 2 Educational Launch meetings delivered jointly by Consultant and GP remotely to Primary and Secondary Care, in December 2023 and January 2024. 3. A Primary Care audit of menopause information provided to women from different ethnic backgrounds showing women from non white British backgrounds were less likely to request or be offered advice about the menopause or receive an HRT prescription than white British women. 4. Developments of leaflets for women about menopause and HRT in the five most commonly spoken languages in our local community, English, Polish, Romanian, Punjabi and Urdu.

Developing Workstreams 1. Joint working on development of a Women's Health Hub , developing women's health champions in each PCN across the district, who plan to meet regularly with the Consultant in an MDT approach for discussion about complex cases. 2. A pilot of a GP with special interest providing intermediate advice and guidance for referrals into the Specialist Menopause Service for patients whose care can be managed using the locally developed guidance, to reduce waiting times and improve access for those women who require secondary care input.

Conclusions: Effective collaboration between Primary and Secondary Care can improve both education of professionals and patients, standardize care and improve and support for women requiring Menopause care.

¹ST6 Obstetrics & Gynaecology, Homerton University Hospital, London alice.howell6@nhs.net

²GP, Winchmore Hill Practice, London

³Consultant in Diabetes & Endocrinology, Whittington Hospital, London

⁴Consultant Gynaecologist, Whittington Hospital, London

⁵Consultant Obstetrician & Gynaecologist, Whittington Hospital, London

⁶GP, The Gynaecology Collaborative, Haringey & Islington, London

Objective: The BMS ‘Vision for menopause care in the UK’ states that all “All healthcare professionals (HCPs) with a special interest in menopause should have access to BMS Menopause Specialists for advice, support, onward referral and leadership of multidisciplinary education.”

Our objective was to locate the HCPs with a special interest, and all the BMS Specialists in our region to meet, learn, network, discuss referral pathways and plan for multidisciplinary education.

Method: The North Central London (NCL) Integrated Care System (ICS) includes all the NHS organisations within Haringey, Islington, Camden, Enfield and Barnet. This includes five NHS Trusts, three of which have specialist and subspecialist menopause clinics. The lead for menopause care across NCL gathered a working group of local BMS specialists to organise a one-day face-to-face conference for networking, learning, and collaboration for all HCPs across the region with an interest in menopause care.

A varied and inclusive programme was developed with sessions for beginners, specialists, leaders, trainees and trainers. The faculty and speakers were made up of endocrinologists, gynaecologists, GPs, psychologists, BMS nurses, SRH consultants and community gynaecologists.

The conference was run as a not-for-profit and sold out prior to the event. The seventy delegates were made up of GPs, endocrinologists, psychologists, pharmacists, gynaecologists, SRH consultants and community gynaecologists all of whom worked within the ICS.

Results: The feedback was fantastic. 94% of delegates said they would recommend the conference to their colleagues and 98% felt that the sessions were pitched at the right level. Delegates and faculty enjoyed the opportunity to network and be updated by a variety of speakers.

Conclusion: The one-day conference was a successful step to pursuing the BMS ‘vision for menopause care’ in NCL.

Since the conference, a regional bi-monthly MDT meeting for complex cases has been set up, unification of care pathways has reduced secondary care referrals, a specialist menopause clinic in the community has been introduced, doctors, nurses and pharmacists have started BMS qualifications due to an increased number of advanced menopause trainers and a local monthly menopause meetup has begun for all staff in one of the NHS Trusts.

¹Consultant Nurse, Aneurin Bevan University Health Board, Wales nikki.noble@wales.nhs.uk

Objectives: A large study of women living with HIV found that nearly half of all participants stated they did not have enough information about the menopause, leaving many feeling under-prepared. Women also described particular challenges during the menopause as a result of living with HIV.

Method: Service improvement project/audit: Retrospective review of electronic notes. Includes all women living with HIV aged 45 to 56. Objectives of audit:

Are women living with HIV aged 45 to 56 being assessed for:

Menstrual changes • Vasomotor symptoms (flushes and sweats) • Sleep disturbances • Mood changes Vaginal symptoms – dryness, itching, painful SI

Results: 28 women aged between 45 and 55 were seen in the HIV service between August 2022 and August 2023.

n8 (29%) already under the care of the menopause service.

n2 (7%) are on waiting list for menopause service.

n3 (11%) were offered referral to the menopause service but declined.

n2 (7%) were being prescribed HRT by their GP.

n1 (4%) was a previous patient of the menopause service.

n12 (43%) patients remaining (of these 4 were pre menopause)

Conclusion: Gaps identified in care:

Sleep problems and vaginal dryness were not assessed in 79% and 82% patients respectively.

Recommendations

1) Add the following questions to electronic checklist for all women who attend HIV clinic between the ages of 45 – 55 to assess symptoms annually:

LMP, any menstrual changes, any vasomotor symptoms (flushes and sweats), Sleep disturbances, any vaginal symptoms – dryness, itching, painful SI.

Offer referral to menopause service if experiencing systems.

2) Current wait for menopause clinic 12 to 13 months – considering expedited service for referrals from HIV clinic.

3) Develop a patient information leaflet re: HIV, Menopause and sleep – outlining sleep hygiene techniques that can help to improve sleep. Involve patients in the development of the leaflet

4) Consider running a special HIV and menopause clinic at HIV clinic as patients will be familiar with this environment and hopefully feel comfortable and safe there.

5) Consider teaching session re: menopause and HIV for HIV team

6) Develop flowchart for managing vaginal dryness – if this is the only symptom

¹GP Locum and Menopause Specialist, Liberty Menopause Care, High Peak, Derbyshire eward1@nhs.net

²Consultant Gynaecologist, The Manor Hospital, Oxford

Objective: Timely identification, diagnosis and management of sarcopenia

Methods: Review of up to date literature base & evidence

Results: Sequelae of sarcopenia include frailty, falls, osteoporosis, increased fracture risk, loss of independence and disability in addition to increased risk of development of cardio metabolic disease diabetes and all cause mortality. Financially, the excess annual costs of sarcopenia in the UK are estimated at £2.5 billion for the provision of health and social care. Resistance exercise and adequate protein intake improve outcomes and reduce loss of muscle mass and strength in older adults. However, resistance exercise in particular is undertaken by a minority of the general population. The challenge remains to raise awareness of its unique benefits and increase accessibility, taking both time and significant investment. Clinicians keen to improve outcomes today for their patients can be encouraged by evidence of a much more simplistic and achievable intervention; by reducing sedentary behaviour in the more accessible form of walking and increasing daily step count improves measures of sarcopenia. We argue this ought to be encouraged at every clinical opportunity, as would be done for smoking cessation. Sarcopenia is a disease process developing over a lifetime, along which are many opportunities for intervention. This is of particular importance with regards to girls and women considering reduced uptake of exercise compared to males and the sudden change in hormone levels and body composition that accompany the menopause transition. There is much to be done to raise awareness both amongst clinicians and the wider public.

Conclusion: Timely identification, diagnosis and management of sarcopenia is imperative for retaining independence into older age and elongating health span. This is in addition to reducing the financial burden of this disease alongside the mounting costs of an ageing population. These interventions are essential for the health of the nation and Social Care System.

¹Consultant Gynaecologist, University Hospitals Dorset NHS Foundation Trust mark.pickering@uhd.nhs.uk

²Physician Associate, University Hospitals Dorset NHS Foundation Trust

³Consultant Gynaecologist, University Hospitals Dorset NHS Foundation Trust

⁴Consultant Gynaecologist, University Hospitals Dorset NHS Foundation Trust

⁵Consultant Gynaecologist, University Hospitals Dorset NHS Foundation Trust

Objective: Nationally, referrals to fast-track services for unscheduled bleeding on HRT (UB on HRT) have increased. At University Hospitals Dorset (UHD) our gynaecology fast track referrals increased by 64% between 2018/19 and 2023/24. A separate audit showed that 46.3% of our post-menopausal bleeding referrals were women on HRT.

Methods: In November 2023 we launched a Dorset wide UB on HRT GP led pathway for post-menopausal women without significant risk factors for endometrial cancer. Women experiencing unscheduled bleeding after 6 months from initiation of HRT were sent for a transvaginal ultrasound scan in primary care. Post-menopausal was defined as cessation of periods for >1 year, or >50 years of age and established on any HRT prior to cessation of periods. If the endometrial thickness was ≥4mm they were then referred to the gynaecology fast track service. Patients with endometrial thickness <4mm were advised to manage HRT and progesterone dose as per the BMS tools for clinicians' resources. Data has been collected prospectively from hospital and primary care electronic records.

Results: To date 214 patients have been referred to the pathway of which 118 patients have had ultrasound scans. Out of the 118 patients 51 (43%) had endometrial thickness ≥4mm. Thus far 24 patients have been seen by fast-track gynaecology: 17 for thickened endometrium, 3 for incidental ovarian cysts and 4 for a suspicious cervix. No cancers have been identified so far and 4 patients have had hysteroscopic confirmed endometrial polyps. The remaining 67 patients had an ET <4mm and remained in primary care.

Out of the 214 patients, 17 (8%) were on sequential regimes. 186/214 (87%) patients were on transdermal preparations. 27/214 (12.6%) patients are on high doses of estrogen (4 pumps estrogel, 100mcg patch, 4mg oral estradiol). 27/214 (12.6%) patients are on moderate does of estrogen (3 pumps estrogel, 75mcg patch, 3mg estradiol).

Referrals to the post-menopausal bleeding (PMB) fast-track gynaecology clinic have reduced from 180 to 134 patients/ month since the introduction of the pathway.

Conclusion: Since the introduction of the pathway 67 patients have avoided fast track referrals which has significantly reduced our PMB referral rates.

¹ST6 in Community Sexual & Reproductive Health, Guys and St Thomas' NHS Foundation Trust, London Neha.Pathak@gstt.nhs.uk

²Consultant Gynaecologist, Guys and St Thomas' NHS Foundation Trust, London

³Consultant Gynaecologist & Medical Information Officer, Guys and St Thomas' NHS Foundation Trust, London

⁴Consultant Gynaecologist, Guys and St Thomas' NHS Foundation Trust, London

Background: The menopause service at Guy’s & St Thomas’s NHS Trust serves the Southeast London population. From Sep 2022-2023, a total of 1,387 patients were seen (614 new; 773 follow ups) with 451 new referrals. Patients face long wait-times for a first appointment (waitlist: 959 patients including 781 follow-ups). The Getting It Right First Time (GIRFT) programme recommends reducing wait times by reducing the first to follow up ratio through patient initiated follow up and information to support self-management.

Objective: To evaluate digital template letters to reduce the first to follow up ratio and support self-management. Using GIRFT recommendations as the standard, we aimed for a first to follow-up ratio of 1:0.5, equivalent to discharging 50% of new patients to primary care or patient initiated follow up (PIFU) with detailed information.

Methods: Using a “plan, do, study, act” (PDSA) approach, we developed and implemented digital templates on EPIC software to facilitate rapid detailed summaries and recommendations. A ‘smartlist’, or predefined list of options, can be selected to build notes for generic menopause, early menopause/POI, and cancer-specific letters. Tailored information on hormonal (including testosterone and vaginal estrogens) and non-hormonal treatments can be selected, including dosage plans, monitoring and alternatives to empower community care. The smartlist was implemented in Jan 2024. Discharge outcomes post-implementation were measured against the GIRFT standard. A focus group measured user feedback (n=8).

Results: In Feb 2024, 34% of patients were discharged. The first to follow-up ratio was 1:0.57 which equates to 43% of new patients being discharged to primary care or PIFU. This is only 7% less than the target. Positive feedback from users included the templates being good for standardisation of letters, increasing the quality of information provided by junior doctors and education for patients to empower them to access care in the community and self-manage. Suggestions for improving implementation included template modifications and individual training.

Conclusion: Flexible digital templates can support standardisation of clinic letters, streamlining clinics and patient education to address long waiting lists in line with GIRFT recommendations. A repeat PDSA cycle including patient feedback will be completed in May 2024.

¹University of Birmingham

²Southern Health NHS Foundation Trust peter.phiri@southernhealth.nhs.uk

³Liverpool Women’s Hospital

⁴University of Ruhuna, Sri Lanka

⁵University of Ruhuna, Sri Lanka

⁶University of Ruhuna, Sri Lanka

⁷University of Ruhuna, Sri Lanka

⁸University of Ruhuna, Sri Lanka

⁹University of Peradeniya, Sri Lanka

¹⁰General Sir John Kotelawala Defence University, Sri Lanka

¹¹Peshawar Medical College, Pakistan

¹²Peshawar Medical College, Pakistan

¹³Hock Toh-Sibu Hospital, Ministry of Health Malaysia, Sarawak, Malaysia

¹⁴University of Birmingham

¹⁵Southern Health NHS Foundation Trust

¹⁶University of Coventry

¹⁷University of Sheffield

¹⁸Manchester Metropolitan University

¹⁹University of Edinburgh

²⁰University College London NHS Foundation Trust

²¹University of Aberdeen

²²Southern University of Science and Technology, China

²³University College London NHS Foundation Trust

²⁴University College London

²⁵Southern Health NHS Foundation Trust

²⁶Nnamdi Azikiwe University, Nigeria

²⁷University of Campinas, UNICAMP, Brazil

²⁸Southern Health NHS Foundation Trust

²⁹Southern Health NHS Foundation Trust

³⁰Narh-Bita Hospital, Ghana

³¹KK Women’s and Children Hospital, Singapore

³²Mahidol University, Thailand

³³Trauma Healing, Scotland

³⁴University of Birmingham

Objective: A mixed methods study was conducted with an overall aim to explore the mental health impact among menopausal women and trans-men in the UK. A key primary objective was to report the impact due to perimenopause, menopause, and post-menopause symptoms in the workplace among working women and trans-men in the UK.

Methods: An interim analysis was performed on a sub-set of participants (n=25) using descriptive statistics and a thematic synthesis. The data used for this analysis was pre-processed from qualitative interviews.

Results: A key theme identified was the presence of a negative impact on participant’s wellbeing that led to either a reduction or change in employment. Participants also reported an increase in awareness about menopause in the workplace. The severity of symptoms was a key factor that disrupted working patterns, particularly low mood, verbal episodal memory loss, tiredness and hot flushes. Approximately 60% of participants stipulated that menopause negatively impacted their concentration, focus and confidence. Some participants reported that their employers provided support through written leaflets, access to support groups and referral pathways to psychology services (28%), whilst 24% indicated that a menopause-friendly policy was available in the workplace. Approximately 16% reported to have had flexible working available to them. Twenty-four percent of women could manage at work, whilst another 24% of participants reported that they were not coping well at work.

Conclusion: The findings indicate that better workplace support should be provided, especially since two-thirds of the participants experienced symptoms that disrupted their work, yet less than one-third received any support. Perimenopause and menopause are not specifically protected under the Equality Act in the UK, and our findings provide early evidence that this should be a consideration.

¹Medical Student, University of Dundee niamhfabri@outlook.com

²Lecturer in Postgraduate Medical Education, University of Dundee

³Senior Clinical Lecturer, University of Dundee

Objective: To support women presenting with the menopause, doctors need to be prepared by their undergraduate education to discuss and manage menopause symptoms. However, a survey reports that 41% of UK medical schools do not include menopause teaching within their curriculum (menopausesupport.co.uk, 2021). The objective of this study is to explore the teaching and understanding of the menopause within the MBChB (Bachelor of Medicine, Bachelor of Surgery) degree programme at the University of Dundee (UoD).

Methods: This mixed methods case study explored the menopause teaching content of the UoD MBChB curriculum. A quantitative, two-stage content analysis determined the level of menopause teaching provided within the Obstetrics and Gynaecology (O&G) block teaching materials (including PowerPoint slides and audio recordings of lectures and tutorials). An open-ended questionnaire was emailed to preclinical and clinical medical students and semi-structured follow-up interviews were used to gather students’ responses concerning their knowledge of menopause and perceptions of teaching received during pre-clinical and clinical years.

Results: The content analysis results confirmed that the UoD curriculum contained teaching on menopause symptoms, treatments, and conditions that women were at greatest risk of developing during and post menopause. However, questionnaire responses revealed all (24) students surveyed reported a lack of confidence in their menopause knowledge and their ability to effectively consult with patients presenting with the menopause.

Conclusion: Whilst there was teaching on the menopause, much of this teaching was confined to a couple teaching sessions and did not explicitly mention the menopause. Using results from both forms of data collection, improvements to the curriculum were suggested. For example, the incorporation of menopause teaching into tutorials and additional blocks and making the linkages to menopause more explicit in both lectures and tutorials.

Reference

1. Menopausesupport.co.uk (2021) Menopause Support Survey Reveals Shocking Disparity in Menopause Training in Medical Schools. – menopausesupport.co.uk. [online] Available at:<https://menopausesupport.co.uk/?p=14434> [Accessed 11 November 2021].

¹Data Scientist, Cardiff University, Health & Her, Cardiff andrewsR16@cardiff.ac.uk

²Senior Data Scientist, Swansea Medical School, Swansea University, Swansea

³CEO and co-founder of Health & Her, Cardiff

⁴Neuropharmacologist, Welsh School of Pharmacy & Pharmaceutical Sciences, Cardiff University, Cardiff

Funding sources: The Waterloo Foundation, Health & Her.

Objective: This study investigated the influence of medical diagnoses on menopausal symptoms using medical data provided by Health & Her app users.

Methods: Utilising linear regression, we assessed how various medical conditions, including polycystic ovary syndrome (PCOS), premature ovarian insufficiency, cancers, depression, anxiety, uterine fibroids, endometriosis, and autoimmune disorders, predict menopausal symptom scores. Secondary analyses focused on distinct symptom patterns, such as vasomotor (night sweats, hot flushes, sleeping problems), psychological (low mood, low energy, anxiety, poor concentration, brain fog, memory loss), urogenital (sensitive bladder, vaginal dryness, loss of libido, painful sex), and physical symptoms (dizziness, headaches and migraines, digestive issues, bloating, joint aches, skin problems, weight gain, palpitations). Symptom patterns were identified via exploratory factor analysis. Regression analyses controlled for medical treatments and gynaecological surgeries, Hormone Replacement Therapy, hormonal contraception, supplement use, age, and total menopausal symptoms.

Results: Data from 86,638 app users revealed depression as the strongest predictor of increased symptom scores, followed by cancer treatment and bilateral oophorectomy. Endometriosis, adenomyosis and uterine fibroids predicted reduced symptom scores. Bilateral oophorectomy and premature ovarian insufficiency had the largest impact on increased vasomotor and urogenital symptoms. PCOS, adenomyosis, endometriosis, and fibroids were associated with decreased risks of vasomotor symptoms. Autoimmune disorders and depression increased risks of physical symptoms, while cancer treatment and breast or gynaecological cancers decreased such risks. Depression and anxiety were strong predictors of increased psychological symptoms, whereas endometriosis, adenomyosis, and fibroids were associated with decreased psychological symptoms.

Conclusions: Our findings provide novel insights into menopausal symptoms relative to medical history, with depression exerting the strongest influence on symptom scores. The results from bilateral oophorectomy and premature ovarian insufficiency suggest that vasomotor and urogenital symptoms are very sensitive to lower estrogen levels. Notably, women with cancer or undergoing cancer treatment were less likely to report physical symptoms, possibly due to the cancer being the dominant condition. In line with prior findings, endometriosis, adenomyosis, and fibroids were associated with decreased symptoms possibly due to the symptoms of these conditions abating during the menopause transition. Results underscore the need for healthcare professionals to consider comorbidities when supporting women with menopausal symptoms.

¹GP, Grafton Medical, Dublin, Ireland fitzgelo@tcd.ie

²Menopause Health, Dalkey, Ireland

³Menopause Health, Dalkey, Ireland

Funding sources: Partial funding received from Smart D8, Dublin.

Objective: Menopause and the City, a community pilot-project, sought to create a better educational ecosystem around menopause health. It aimed to provide individuals, families, and friends in Dublin 8, a socioeconomically challenged district, with the tools and knowledge to navigate menopause effectively. By offering a blend of digital resources and in-person workshops, the project sought to empower women to manage symptoms using self-management strategies but equally know when to seek professional help appropriately.

Method: The project aimed to achieve this through the development of an open resource digital Menopause platform (https://informd.ie/menopause) and through a number of free in-person workshops.

Launched October 16th 2023 ahead of World Menopause Day 2023, multiple menopause workshops were held throughout the community of Dublin 8 through to March 2024 aligning with International Women’s Day 2024. Given the success of the project these workshops have been extended to all Dublin areas.

Results: Since the launch of the project on the 16th October 2023 the platform has had 1,210 new users (up to date Thursday 14th March 2024).

Pre-workshop assessments revealed a baseline knowledge score of 2.84 regarding menopause and 2.64 concerning information sources. Following participation, attendees reported a significant increase in understanding, with a post-workshop knowledge rating averaging 4.2. Statistical analysis using paired t-tests demonstrated a statistically significant difference (p < 0.05) between pre- and post-workshop knowledge scores, confirming the effectiveness of the intervention. Moreover, all respondents expressed confidence in their ability to access reliable menopause information after attending the workshops, unanimously affirming their usefulness.

Conclusion: Raising awareness about menopause symptoms and self-management strategies is pivotal in empowering individuals to take control of their health

The increase in knowledge and confidence in accessing reliable information reflects the effectiveness of the program.

Through Menopause and the City there has been increased knowledge and enhanced awareness of reliable information sources on menopause. The observed knowledge enhancement and improved self-management reflect the effectiveness of targeted health education in the community.

¹Clinical Research Fellow in Dermatology, University Hospitals Sussex NHS Foundation Trust, Brighton hamisha.salih2@nhs.net

²GP and BMS Menopause Specialist, Foundry Healthcare, Lewes

³GP and BMS Menopause Specialist, Brighton and Hove Community Menopause Clinic

⁴Consultant Dermatologist, University Hospitals Sussex NHS Foundation Trust

Objective: The peri and post-menopausal period of a woman’s life is driven by declining ovarian function leading to a hypestrogenic state. The skin contains estrogen receptors and impairment of the skin barrier is noted in estrogen deficient skin.1 It is therefore expected that this may affect the normal function of the skin and common skin conditions. We suspect that these symptoms experienced may be underreported and, when they are reported, may not be considered associated to the menopause.

Methods: We conducted an observational study exploring the symptoms women experience during the peri-menopausal and post-menopausal time. Patients seen in a community-based specialist menopause clinic were invited to complete a questionnaire.

Results: 32 responses were collected. 77% of respondents were on hormonal treatments, of which estrogen therapy was most frequently taken. The most reported skin symptoms included dry skin (78%) and itchiness (75%). Dry mouth was the commonest reported oral symptom and 84% of women experienced at least one hair symptom since the onset of their menopause. 91% also reported experiencing at least one vulval symptom. 50% noticed worsening in a previously diagnosed dermatological disorder and 63% of patients reported skin symptoms that they had attempted to manage themselves without consulting their doctor. Dermatology Life Quality Index (DLQI) was also collected for each patient, which showed an average score of 6 and ranged up to 17, indicating a moderate impact on the quality of life of peri and post-menopausal women.

Conclusion: Our results highlight the significant effect the menopause can have on quality of life and the wide range of dermatological symptoms associated with it. Patients appear reluctant to seek medical support for skin symptoms related to the menopause and consequently may not receive optimal treatment. It is paramount that dermatologists and menopause specialists are aware of the immense impact menopause has on the skin, hair, vulva and mouth. Further research is required to explore management options including hormone replacement therapy for skin symptoms associated with the menopause.

Reference

1. Rzepecki A, Murase J, Juran R et al. Estrogen-deficient skin: The role of topical therapy. Int J Women’s Dermatol 2019; 5:85–90.

¹Year 5 Medical Student, Cardiff University School of Medicine, Cardiff evansfrancesca23@gmail.com

²Consultant in Sexual & Reproductive Health and Menopause Lead, St Cadoc's Hospital, Newport

Objective: To assess whether women under 45 years old are receiving counselling on the risks of surgical menopause, risks and benefits of hormone replacement therapy (HRT), use of testosterone and lifestyle interventions prior to bilateral salpingo-oophorectomy (BSO).

Methods: Data from 56 patients aged under 45 years old who underwent BSO from 1st January 2020 to 2nd May 2023 in Aneurin Bevan University Healthboard (ABUHB) was extracted from Clinical Workstation (CWS). A proforma was built on the Audit Management and Tracking (AMaT) page for ABUHB based on the guidelines in the British Menopause Society’s Surgical Menopause Toolkit. A proforma was completed for each of the 56 patients using available notes on CWS.

Results: According to the documentation, 68% of patients received no counselling on the risks of surgical menopause and 20% of women were not offered HRT. Benefits of HRT were not discussed with 88% of patients and risks were not discussed with 98%. Testosterone was offered to 7% of patients and lifestyle advice was provided to 2% of patients.

Conclusion: The majority of patients in this study were not being adequately counselled on the short- and long-term effects of surgical menopause, the risks and benefits of HRT or the use of testosterone and lifestyle interventions in symptom management after BSO. Going forward, we have implemented a counselling checklist for healthcare professionals and a patient information leaflet with the intention of repeating the audit in the future.

¹GP and SPCR Primary Care Clinicians Career Progression Fellowship, University of Bristol jo.burgin@nhs.net

²GP and NIHR In-Practice Fellow, University of Bristol

³Research Fellow, University of Bristol

⁴Professor of Primary Care, University of Bristol

Funding sources: Research undertaken as an NIHR Academic Clinical Fellow at the University of Bristol.

Objectives: 1) Explore health beliefs and concerns of women presenting with mood changes in the perimenopausal age range, and whether these are addressed in Primary Care consultations. 2) Explore General Practitioners’ (GP) understanding of mood changes in the perimenopause and impact on consultations.

Methods: Participants were women aged 45-55 who presented to their GP in the last 6 months with a mental health symptom, and GPs recruited from an Integrated Care Board area. Online semi-structured interviews were undertaken and thematically analysed.

Results: 18 women and 11 GPs participated in interviews lasting between 30 and 60 minutes.

Consultation agenda setting: Consultations were seen as “patient-led” by both patients and doctors. However, patients reported feeling inhibited and unable to bring up menopause themselves, even if this was a key concern. Some patients described having their concerns dismissed.

Many GPs described a standardised approach to mental health consultation that rarely changed based on patient age or sex; they reported not routinely enquiring about perimenopausal symptoms, even for women in the perimenopausal age range.

Symptom attribution: Patients initially attributed mental health symptoms to recent life events. However, many felt hormonal fluctuations contributed to their symptoms, with perimenopause creating instability or lowering resilience for dealing with normal stressors.

GPs were aware perimenopause symptoms could be misattributed, particularly for women with other complex physical and mental health conditions.

Awareness and training: Patients and GPs commented on increasing perimenopause awareness. GPs described a lack of menopause training during medical school, but some in GP specialist training. GPs who had a doctor with a special interest in menopause in their practice found this useful as a way to keep up-to-date.

Conclusions: Patients presenting with mental health symptoms in the perimenopausal age range feel hormones influence their symptoms but are rarely asked about this in consultations. Consultation agendas are set by patients meaning that many will not express perimenopause-related concerns due to lack of awareness or confidence. GPs would benefit from standardised training to increase awareness of mental health presentations in the perimenopausal age range and to address this directly in consultations.

¹Psychiatry CT2, Avon and Wiltshire Partnership NHS Trust grace.denton@nhs.net

²Psychiatry ST4, Avon and Wiltshire Partnership NHS Trust

³Psychiatry ST4, Gloucester Health and Care NHS Trust

⁴GP and Menopause Specialist, University Hospitals Bristol and Weston NHS Trust

⁵Consultant Gynaecologist/Menopause Lead, University Hospitals Bristol and Weston NHS Trust

Objective: The effect of menopause on mental health is well recognised. Menopausal women report higher rates of depression and anxiety (1). Without recognition and treatment, this impacts negatively on quality of life (2). The National Institute for Health and Care Excellence (NICE) and the British Menopause Society (BMS) recommend cognitive behavioural therapy (CBT) and an individualised approach for women experiencing depression and anxiety in menopause. This project collected data on current mental health provision for women seeing UK menopause specialists.

Methods: Psychiatry, gynaecology and general practice clinicians designed an online survey using NICE / BMS guidance, current evidence and local referral / funding pathways. This was piloted on health care professionals in primary and secondary care before review by BMS Council Members. The survey was emailed to members of the BMS.

Results: 139 responses came from menopause specialists across 15 UK Deaneries. 71% from primary care and 29% from secondary care. 65% offer CBT for mood symptoms but 99% reported suboptimal provision for CBT. 43% thought over half their patients with mood symptoms would benefit from psychological support, but 80% had no designated mental health practitioner. 35% have referred to secondary mental health services for support. When asked what would help, 83% desired improved access to CBT, 65% wanted psychological support within menopause clinics, 53% wanted guidance on managing mood symptoms in menopause and 39% wanted an MDT clinic.

Conclusion: The results suggest poor provision of psychological interventions, particularly CBT, for women experiencing mood disorders in menopause. Improved access to psychological therapies and improved cross-specialty working were identified as methods of addressing this. Locally, these results have formed the basis of a service funding bid for CBT and development of a pilot cross-speciality gynaecology/psychiatry MDT Hub.

References

1. Albloshi, S., Taylor, M., & Gill, N., (2023). Does menopause elevate the risk for developing depression and anxiety? Results from a systematic review. Australasia Psychiatry, 31 (2): 165-173.

2. Hooper, S.C., Marshall, V.B., Becker, C.B., LaCroix, A.Z., Keel, P.K., Kilpela, L.S., (2022). Mental health and quality of life in post-menopausal women as a function of retrospective menopause symptom severity. Menopause, 29 (6) 707-713.

¹ACP, Liverpool Heart and Chest Hospital janet.green@lhch.nhs.uk

Objective: Following an informal survey of cardiology consultants at a tertiary cardiology centre, it became apparent that there is little consensus of what to do in terms of continuing hormone replacement therapy (HRT) for women admitted with an acute coronary syndrome (ACS). The purpose of this project was to reach a consensus amongst practising clinicians and provide women with accurate, balanced and evidence-based information on the individualised risks and benefits of HRT, especially following a cardiovascular event.

Methods: A literature review was conducted using all available evidence regarding the initiation or continuation of HRT in patients who have had an acute coronary syndrome. The literature review included the following themes, HRT and cardiovascular disease risk and or prevention, the timing of HRT initiation and cardiovascular disease prevention, the timing hypothesis and routes of delivery, HRT in established cardiovascular disease and which HRT preparation. Findings following the literature review were presented to the whole consultant body by way of an education meeting.

Results: The results of the literature review demonstrated that HRT is recommended for use in women who are perimenopausal or menopausal for symptom relief. The presence of cardiovascular disease is not a contra indication either in the acute phase or long term. When commenced in younger women who have not been menopausal for more than 10 years, HRT may reduce the risk of CVD and all-cause mortality.

Conclusion: A policy change has been implemented to ensure that HRT should not be routinely discontinued or suspended in the acute phase of an ACS and any ongoing prescription of HRT will be continued for women admitted with an ACS, unless the consultant in charge has specifically decided to discontinue it. The GP discharge summary will reflect that HRT has been discussed with women and state if it should continue to be prescribed. Women will be encouraged and enabled to participate in shared decision-making and make informed choices about their HRT in the context of their cardiovascular disease and their quality of life.

¹ST6 West Midlands trainee, Shrewsbury and Telford Hospital NHS Trust chanda_pun@yahoo.com

²SAS, Shrewsbury and Telford Hospital NHS Trust

³ST3 West Midland trainee, Royal Stoke University Hospital, Stoke-on-Trent

⁴Consultant Obstetrician and Gynaecologist, Lead for the project, Shrewsbury and Telford Hospital NHS Trust

Objective: Since the 'Davina Effect', there has been rise in the demand for HRT, with a significant increase in HRT prescriptions up by 35% compared to 2021/22, as result there has been an increase in patients presenting with Postmenopausal bleeding on HRT attending our one stop hysteroscopy clinic. The aim of this study was to identify the number of cancers in patients presenting with postmenopausal bleeding who are taking HRT attending our one stop hysteroscopy clinic.

Methods: • Prospective study with a sample size of 100 cases • Patient selection – Any patient coming to one stop hysteroscopy clinic with Postmenopausal bleeding on HRT. • Sample period: 1st January 2023 to end of August 2023 • Data was collected from the patient directly in the designed proforma then scanned to the Microsoft Excel.

Results: • 91% were postmenopausal with average age of 50-59 years and 90% of patient were taking continuous combined HRT. 9% were premenopausal on sequential HRT. • 61% of women were on HRT for >12 months however 4% were referred within 3 months of HRT and 10% within 3-6 months. • Following transvaginal ultrasound scan, 9% of patients were reassured and discharged, 36% underwent endometrial biopsy and 55% underwent hysteroscopy and endometrial biopsy. • 2% were diagnosed with endometrial cancer and 89% had normal histology with a benign cause to explained their postmenopausal bleeding. • Of the two patients diagnosed with endometrial cancer, one patient had a endometrial thickness (ET) of 4mm and one of 13mm. The patient with an ET of 4mm was also low risk with a normal BMI, and had been on HRT for 6 months.

Conclusion: • Cancer rate detected in our population is 2% which is very similar to the national rate (1-2%) • This result highlights the importance of investigating patients with Postmenopausal bleeding on HRT with endometrial thickness of >=4 mm.

References

1. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/tog.12553 Unscheduled bleeding with hormone replacement therapy. Fulva Gajjar Dave MBBS MD MRCOG, Tolu Adedipe MBBS MRCOG, Stewart Disu MRCOG, Raphael Laiyemo MRCOG published: 16 January 2019 https://doi.org/10.1111/tog.12553

2. https://www.bgcs.org.uk/wp-content/uploads/2021/11/British-Gynaecological-Cancer-Society-v13-for-website-with-figure1.pdf

British Gynaecological Cancer Society (BGCS) Uterine Cancer Guidelines: Authors

3. https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

¹O&G Registrar ST5, North Bristol Trust Katherine.Lattey@nbt.nhs.uk

²Consultant Gynaecologist/Menopause Lead, University Hospitals Bristol and Weston NHS Trust

³Consultant Gynaecologist, Royal United Hospitals, Bath

⁴O&G Registrar, University Hospitals Bristol and Weston NHS Trust

Objective: Evidence suggests that bilateral salpingo-oophorectomy (BSO), in the absence of hormone replacement therapy (HRT), in pre-menopausal women can increase cognitive decline and reduce overall survival. The aim of this project was to determine if pre-menopausal women undergoing BSO at the time of hysterectomy, were appropriately offered ovarian conservation or HRT/non-hormonal alternatives.

Methodology: This was a quality improvement project between two secondary care gynaecology units in Severn region (a gynae-oncology and an endometriosis centre). Data was collected retrospectively over a six month interval from outpatient clinic letters, pre-operative assessment proformas, operation notes, inpatient records and discharge notes.

Results: 97 pre-menopausal women had a hysterectomy for benign indications of whom 62.8% had ovarian conservation. Of the 36 who had a concurrent BSO; 66.6% were counselled on, and discharged with, HRT. Twelve (33.3%) had no documented preoperative counselling about early menopause or HRT; two were offered HRT with the histology letter, one discharged without HRT due to the ‘associated thrombotic risk post-operatively’ and in nine women there was no documentation of HRT or alternatives on discharge.

Of 16 pre-menopausal women who had BSO as part of cancer treatment, 50% had early menopause / HRT discussion pre-operatively and were discharged with alternatives +/- HRT advice. The remaining eight women had no documented pre-operative counselling and postoperatively, six of these were discharged with no alternatives/HRT advice (four had an estrogen receptor negative cancer on final histology).

In summary, 12.3% had suboptimal pre-operative counselling if BSO occurred with a benign condition and 30.7% of the combined cohorts had suboptimal postoperative menopause care on discharge.

Conclusions: Although pre-operative menopause counselling was considered good at 87.7%, ovarian conservation should be offered to 100% of eligible women (gold-standard care). Post-operative menopause care was suboptimal at 69.3% – despite open access to monthly menopause service MDT sessions, six monthly education sessions and an ‘Alternatives to HRT’ patient leaflet. A cross-city pre- and post-operative menopause care guideline, and a surgical menopause patient leaflet, have been developed to improve patient experience/outcomes and to facilitate integrated care with primary care colleagues by providing clear reasons for starting, or holding, HRT on discharge.

¹O&G Clinical Teaching Fellow, Northwick Park Hospital, London megan.spearman2@nhs.net

²Consultant Pharmacist, Northwick Park Hospital, London

³Medical Clinical Teaching Fellow, Northwick Park Hospital, London

⁴Medical Student, Imperial College London

⁵Medical Student, Imperial College London

⁶Medical Student, Imperial College London

⁷GP and Menopause Specialist, Northwick Park Hospital, London

⁸Consultant Gynaecologist, Northwick Park Hospital, London

⁹Consultant Sexual and Reproductive Health, Central Middlesex Hospital, London

Objectives: With social media influence, and government and NHS drivers, there has been an increase in menopause awareness and management. With 29% increase in hormone-replacement-therapy (HRT) prescribing between 2022-23, this will increase further with introduction of the new HRT-prepayment certificate in April 2023 (NHSBSA, 2023). Partly due to celebrity sway, there is patient expectation towards transdermal estrogen with natural progesterone HRT. This audit was undertaken to evaluate the prescribing of natural progesterone in a specialist clinic patient population.

Method: This retrospective audit of 366 menopause clinic appointments over 6 months [05.01.23-22.06.23] was undertaken for patients seen by an MDT within an outpatient secondary care setting. Exclusion criteria: appointments not attended, incorrectly booked or with inaccessible records. Data collected via electronic patient records; results analysed using Microsoft Excel. For prescribing of natural progesterone, we assume our recommendations to the GP are enacted.

Results: Of 327 (89%) appointments audited, the patient age ranged between 30-84 years (median age 53). HRT was recommended for 288 (88%) patients. HRT was not recommended in cases including antiphospholipid syndrome, breast cancer without genitourinary symptoms, advanced age, patient choice. For 26 (9%) patients, topical estrogen treatment only advised.

171 (52%) patients were postmenopausal, 61 (19%) perimenopausal, 46 (14%) with premature ovarian insufficiency and 20 (6%) with surgical menopause. For 22 patients (7%) with Mirena IUS in situ, their menopause phase could not be accurately defined. 243 (88%) of those recommended HRT were advised a combined regime – 154 (53%) continuous; 67 (23%) sequential and 22 (9%) with Mirena.

For patients accepting combined HRT, one third (81) were recommended natural progesterone. Of these 81 patients, 77 (95%) were recommended transdermal estrogen in combination. Of those recommended natural progesterone, 68 (84%) were for doses in line with current BMS guidance and licensing. For 10 patients the off-label recommendation involved doubled doses of natural progesterone to combat unfavourable bleeding.

Conclusion: This audit has identified that within our specialist clinic complex patient population, a recommendation for natural progesterone was made for one third of patients suitable for combined HRT use. When not prescribed in line with licensing, this was due to issues with vaginal bleeding.

¹GP, St. Catherine's Surgery, Cheltenham celia.cotton@nhs.net

Objective: To assess why a large percentage of women with risk factors for Venous Thromboembolism (VTE) are on oral Hormone Replacement Therapy (HRT) and to suggest improvements in the safety of prescribing.

Method: An audit of all patients taking oral HRT (excluding Micronised Progesterone) was conducted across 3 GP surgeries. These 70 patients’ notes, aged 28-72 years, were analysed against the British Menopause Society’s consensus statement for prescribing HRT. This asserts that transdermal HRT should be considered first line for women at risk of VTE, including those with a body mass index (BMI) over 30. The results and perceived current barriers to safe prescribing were discussed with clinicians to create a consensus to improve care. After the audit, patients identified as being at the highest risk of VTE, or with inadequate data to assess this, were reviewed in clinic.

Results: 20% of patients audited had 2 or more risk factors, whilst 10% had 4. The most frequent risk factor was a BMI over 30 (35% of patients) but more surprisingly 43% had no weight recorded for the last 3 years. 27% of patients were over 60 yrs. 13% were smokers. 60% had no blood pressure reading in the last year nor were any recordings found of a personal or family history of VTE. When women were reviewed the majority were unaware of the risks, or alternative forms of HRT available. Several had been prescribed oral HRT post operatively without consideration of their medical history.

Conclusion: Individuals requiring HRT should be counselled and assessed fully regarding their VTE risk annually so that they can make an informed choice. This has not been happening due to: inadequate staff and patient education, and the increasing pressure on practices to focus on income generating activities, of which menopause care is not one.

In addition, without an official UKMEC style classification for risks, these conversations are less simple than stratifying risks for hormonal contraceptive use. To date, 50% of the women with multiple risks identified in the audit have switched to transdermal options and systems have been introduced to educate and empower staff and patients.

¹GP specialty trainee, NHS Lanarkshire stacey.smillie4@nhs.scot

²Consultant Gynaecologist, NHS Greater Glasgow and Clyde

³Consultant Gynaecologist, NHS Lanarkshire

Objective: – To explore the current referral indications to the NHS Lanarkshire menopause clinic and identify any areas for improvement in practice.

Methods: 200 clinic appointments from August 2021 to May 2023 at the menopause clinic were reviewed retrospectively. Return appointments and any appointments lacking clinic letters were excluded, leaving 175 patients (n=175).

The referral letter and clinic letter were reviewed from each new patient clinic appointment. The indication for referral, referrer type (General Practitioner (GP) or secondary care), referral type (advice only or routine referral), and the outcome of the clinic appointment were recorded. The data was analysed to identify patterns in referral indications.

Results: 92% of referrals were made by GPs, with 8% being referred from other gynaecology clinics. 13% of referrals were made seeking advice only, but these patients were seen in clinic. 36% of referrals were with regards to safety concerns with hormone replacement therapy (HRT) in the context of the patient’s personal or family medical history. The most common medical conditions were breast cancer, venous thromboembolism, and cardiovascular disease. 15% of referrals were due to intractable menopausal symptoms despite HRT, or side effects on HRT. 6% of referrals were for management of primary ovarian insufficiency.

23% of referrals were due to low libido or requests for testosterone treatment. The outcomes of these consultations varied, with 29% commencing a trial of testosterone therapy, but in 54% of cases, the recommendation was to amend the patient’s HRT regime, without testosterone. From the 14 patients referred from other gynaecology clinics, 7 (50%) were regarding starting HRT in an uncomplicated patient or following bilateral salpingo-oopherectomy.

Conclusion: Referral practice is highly varied, but many referrals were made due to concerns about safety of HRT in the context of the patient’s personal or family medical history, or for testosterone therapy. With waiting times for secondary care clinics increasing, creation of an advice service, or distribution of information regarding testosterone therapy to GPs would be some possible strategies to improve future referral rates.

¹ST6 trainee, Obstetrics and Gynaecology, Queens Medical Centre, Nottingham University Hospitals isharjpt24@gmail.com

²Consultant Gynaecology and Menopause Specialist, Nottingham University Hospitals

³Lead for Gynaecology Two week wait and Menopause service, Nottingham University Hospitals

Objectives: We performed a retrospective audit of the referrals sent to the specialist Menopause Clinic at NUH from January 2022-December 2023. We looked at the indications for the referrals and the follow-up duration in the clinic before discharging them to primary care.

Methods: Patient data were collected, including patient demographics, the indication for referral, date of referral and consultation, waiting time and follow-up.

Results: Our unit received 536 referrals over 24 months (January 2022 to December 2023).

Women referred to the menopause clinic were aged between 21 and 81. The mean age for referral was 50 years. Of the 536 referrals, 9.5% were less than 40 years of age, 17.1% were between the age of 40 and 45 years, 20.5% were between the age of 46 to 50 years, and 52.7% were more than 50.

The average waiting time to be seen in the Menopause clinic from initial referral was 3 months, with a range of 2 and 12 months. Out of the 536 referrals, 78.9% were referred by GP, 11.7% were referred by Oncology services, and 9.4% cases were referred by other specialities. 17% were seen within 5 weeks of referral, and 67% were seen within 5 to 12 weeks of referral. 42% of cases were given a Patient Initiated Follow Up (PIFU) appointment (6-12 months), 28% of cases were followed up in 6 months, 18% of cases were followed up in 4 months, 10% of cases were discharged after the first appointment, and 2% did not attend.

13 cases were referred from Breast services, 33 cases were referred from Gynae-oncology, and 16 cases from the Oncology department. Referrals from gynae oncology included 4 cases who had treatment for cervical cancer, 11 cases of BRCA carriers who were offered bilateral salpingo-oophorectomy, 10 cases who had treatment for endometrial cancer and 3 cases who had treatment for ovarian cancer. The common symptoms noted were vasomotor, low libido and psychological.

Conclusion: Maintaining efficiency in running a menopause service is imperative. PIFU along with subsequent reviews at the GP surgery, helped create availability for new referrals to the Menopause service.

¹BMS Menopause Specialist, Cwm Taf Morgannwg Health Board helen.bayliss2@wales.nhs.uk

²Final Year Medical Student, Cardiff University

Objective: To evaluate the need for specialist primary care menopause hubs in Cwm Taf Morgannwg (CTM) health board

Methods: For this service evaluation, a nine-question online survey investigating menopause care and reasons for referral was sent out to fifty Primary Care practices across the CTM health board. There was a total of 65 anonymous responses with quantitative data extrapolated into percentages and qualitative information was analysed for content and thematic areas, with similarities linked together and formulated into a word cloud. The main aim of the questionnaire was to evaluate current provision of menopause care in the community.

Results: 48 participants (73%) expressed expertise in delivering menopause care and 43 (65%) were aware of a specialist menopause clinic for referrals in the health board. 34 (52%) said testosterone was not prescribed in their practice. 32 (48%) said that they did not have patient information leaflets about HRT within the surgery. 14 practitioners said they would like to receive further support for menopause management, specifically with more accredited courses made available. Referral to secondary care was most prompted by family history of breast cancer, support for prescribing testosterone and if multiple preparations were trialled with no improvement in symptoms.

Conclusion: There is an established need for more accredited courses for healthcare professionals and development of a specialist menopause resource for use in primary care. To lessen wait times for specialist services, increased consistency and support is required for primary care practitioners. Following this study, my aim as a medical student is to provide recommendations to CTM health board centred around increased menopause training in both primary and secondary care, with menopause awareness sessions as well as developing a menopause care guide for practitioner use in primary care.

¹Obstetrics and Gynaecology Trainee, Liverpool Women's Hospital fiona.choi3@lwh.nhs.uk

²Gynaecology Consultant, Liverpool Women's Hospital

Objective: Testosterone supplementation can be considered in menopausal women with low sexual desire if HRT alone is not effective. Long term effects of testosterone therapy amongst women are still unknown; hence, current guidelines of the British Menopause Society (BMS) advise close drug monitoring. Baseline levels should be checked before starting treatment and then repeated after 6-12 weeks of treatment. If these levels are normal, annual monitoring of Testosterone levels on treatment should be performed. This service evaluation project aimed assess Testosterone use in women in a tertiary menopause service.

Methods: Clinical records of 433 patients who had started testosterone therapy between January 2020 and July 2023, were retrospectively analysed. Data collected included baseline serum testosterone and monitoring levels after starting treatment. Continuation rates and reasons for discontinuation were also recorded.

Results: Since the BMS guidance on Testosterone monitoring was introduced in December 2022, baseline levels have increased from 3% in 2020 to 56% by mid-2023. Rates of monitoring of serum testosterone after starting treatment has increased from 33% in 2020 to 40% by mid-2023. 189 of the 433 (43.6%) patients were confirmed to discontinue treatment; no specified reason for discontinuing was declared for most of the cohort (152/189, 80.4%); specified reasons include side effects (n=20, 11%), not being sexually active (n=3, 2%) and lack of response (n=14, 7%).

Conclusion: After publication of the BMS guidelines (Dec 2022), our rates of baseline testosterone monitoring seemed to improve significantly. However, rates of subsequent monitoring after commencing treatment remain low but we expect these numbers to improve with recent implementation of local trust guidelines. Discontinuation rates are quite high, and women should be advised of this when being counselled about the potential benefits of treatment.

¹Menopause Specialist and GP, Co-founder My Menopause Centre; Leeds NHS Menopause Service drclarespencer@mymenopausecentre.com

²Senior Lecturer, MA & BA (Hons) Interpreting: BSL/English, Faculty of Arts, Business & Social Sciences, University of Wolverhampton

³Principal Lecturer, Sign Linguist, Faculty Apprenticeship Lead, Faculty of Science and Engineering, University of Wolverhampton

⁴Sensory Services Manager, BID Services

⁵Menopause Specialist and GP, My Menopause Centre; Hednesford Medical Practice, Cannock

⁶Co-founder, My Menopause Centre

Objective: Research conducted in 2018/19 (S1) for BID services showed that women in this community experience health inequality, have a lack of awareness/knowledge of the menopause, and lack access to relevant resources in British Sign Language (BSL).

The objective of this work (S2) was to: • Assess the extent to which the findings had changed • Raise awareness/understanding of menopause/symptoms/treatment options • Gain further insights into barriers/challenges faced • Use insights/learnings to co-create menopause-related BSL resources with D/deaf women whose first/preferred language is BSL and those who identify as hard of hearing to help close identified gaps

Methods: 7 in-person menopause-related workshops (90-120 min) held over 10 months at BID/Birmingham; each led by a menopause specialist doctor/dietician/fitness expert with a BSL interpreter; 6-8 participants in each; median age-range 50-59. N=30 written surveys completed (of which n=25 by workshop participants).

Results: Comparison of S1/pre-workshop & S2 results showed: • Claimed menopause knowledge higher in S2: S1/60% didn’t know/were unsure about the menopause vs 36% in S2 • 53% didn’t know/were unsure of the age menopause starts • Average of 9 symptoms reported in S1, 7 in S2. Similar to S1, the most common symptoms were tiredness (70%), vasomotor symptoms (57%) and mood/cognition related, e.g. mood swings (66%) • 47% didn’t attribute symptoms to menopause (S1/55%) • 63% didn’t know/were unsure what HRT was (S1: 90% unaware of treatment options/how they work) • 70% hadn’t talked to their GP about menopause (S1/66%) • 75% said they needed more information on menopause in BSL (83%/S1)

Post-course results indicated 58% fully/agreed that the workshop helped them to understand more about the symptoms of menopause.

Qualitative workshop learnings indicated: • Greater time needed to deliver information and ensure informed consent • Female BSL interpreters facilitated greater questioning • Need for simplified information (e.g. pictorial) • Often the menopause concept was not available in BSL

Conclusions: Women who are D/deaf or hard of hearing experience additional/significant challenges in receiving menopause care, and lack awareness of the knowledge gap.

Longer healthcare professional appointments are needed with access to female BSL interpreters.

Menopause information should be available in BSL/visual ways to aid understanding and facilitate informed consent (work underway on BSL menopause-specific glossary).

¹Consultant in Sexual & Reproductive Health, Liverpool Women’s NHS Foundation Trust paula.briggs@lwh.nhs.uk

²Bayer, Berlin, Germany

³Bayer, Reading, UK (at the time of the study)

⁴Oracle Life Sciences, New York, USA

⁵Oracle Life Sciences, New York, USA

⁶Bayer, Sao Paulo, Brazil

⁷Bayer, Whippany, USA (at the time of the study)

⁸Bayer, Whippany, USA

⁹Bayer, Berlin, Germany

¹⁰Bayer, Berlin, Germany

¹¹Bayer, Whippany, USA

¹²Bayer, Reading, UK

Funding sources: Study funded by Bayer.

Objective: Vasomotor symptoms (VMS) and sleep disturbances are common and highly bothersome symptoms in menopausal women. They frequently co-occur and are associated with negative impacts on quality of life (QoL). This study assessed sleep disturbances and VMS among perimenopausal and postmenopausal women from European countries.

Methods: Data were analysed from perimenopausal and postmenopausal women aged 40–65 who completed the internet-based National Health & Wellness Survey in the UK, Spain, Italy, Germany, and France in either 2017 or 2020 (the most recent years with available data from sleep-related patient-reported outcome measurements). Women were first categorised by the presence or absence of VMS, then by menopause-related sleep disturbances. In a stepwise classification approach for sleep conditions, women first self-reported the presence or absence of insomnia. If, in the absence of insomnia, women reported sleep symptoms occurring at least weekly or sleep difficulties, including difficulty falling asleep, night-time awakenings, and daytime somnolence, they were considered to potentially have menopause-related sleep disturbances.

Results: This study included 20,220 perimenopausal and postmenopausal women; 26.6% from France, 24.1% from Germany, 23.9% from the UK, 14.3% from Italy, and 11.1% from Spain. Of the 5,312 perimenopausal women (mean age 48.6 years), 39.7% experienced no VMS in the past 12 months; of these, 24.8% had menopause-related sleep disturbances. Among the perimenopausal women with VMS, 31.6% had menopause-related sleep disturbances. Of the 14,908 postmenopausal women (mean age 57.1 years), 56.0% experienced no VMS; of these, 25.1% had menopause-related sleep disturbances. Among the postmenopausal women with VMS, 33.8% had menopause-related sleep disturbances.

Conclusion: Menopause-related sleep disturbances were common in perimenopausal and postmenopausal women, with similar proportions in both cohorts. They were more common in women with VMS, reported by approximately a quarter of those without and a third of those with VMS. These data, therefore, demonstrated that the prevalence of menopause-related sleep disturbances is high overall, regardless of the presence of VMS. Sleep disturbances should be properly recognised and promptly addressed to mitigate potential negative impacts on women’s QoL during the menopause transition.

¹Associate Specialist in Reproductive Medicine, Hon. Associate Professor in Women’s Health, University College London, Reproductive Medicine Unit, University College London Hospital vikram.talaulikar@nhs.net

Objectives: Menopause and HRT are being increasingly talked about in media and public forums. There remain differences in terminology used to address common vasomotor symptoms of menopause and treatments such as hormone replacement therapy. As part of service improvement project in our specialist menopause clinic, we conducted a survey to assess women’s preferences of use of terminology related to menopausal symptoms and hormone replacement therapy and their perceptions of current media focus on menopausal health issues in a tertiary specialist menopause clinic.

Methods: Women above the age of 18 attending menopause clinic at UCLH were offered to take part in a quick anonymous paper survey to answer the following 4 questions. 1. When estrogen with or without progestogen hormone is prescribed as a treatment of menopausal symptoms, should we call it Menopausal Hormone Therapy (MHT) or Hormone Replacement Therapy (HRT)? 2. Should we say ‘hot flushes’ or ‘hot flashes’? 3. There is increased talk about menopause in media and other communication channels – is this good or not good? and 4. Is the current message in media about menopausal transition – positive, negative, or neutral?

Results: 102 women participated in the survey over a period of 7 months between September 2023 to March 2024. 41.1% (41) of respondents were up to or below the age of 45 and diagnosed with premature ovarian insufficiency or early menopause. 59.8% (61) were in the age group of 46 to 65. 9.8% (10) reported surgical menopause. Majority of women (92) preferred the term hormone replacement therapy (90.1%) while 10 preferred MHT (9.8%). 81 (79.4%) women preferred the term hot flushes to hot flashes (21, 20.5%). All women (100%) felt positive about increased menopause talk. While 3 women (2.9%) felt the message was negative, 45 appeared neutral (44.1%) and 54 (52.9%) felt it was positive.

Conclusion: This is a small one tertiary menopause specialist clinic survey which showed that majority of women attending the service preferred use of hormone replacement therapy over menopausal hormone therapy. Majority of participants preferred the term hot flushes to describe vasomotor symptoms of menopause. All women felt good about increased conversation about menopause in the recent times and most women thought that the current message in the media related to menopause was positive.

¹Clinical Research Fellow, University College London Hospital rosalindjoyalexandra.brewster@nhs.net

²O&G Registrar, Whipps Cross Hospital, London

³GP Registrar, Whipps Cross Hospital, London

⁴O&G Registrar, Whipps Cross Hospital, London

⁵Consultant Gynaecologist, University College London Hospital

⁶Associate Specialist in Reproductive Medicine, University College London Hospital

⁷Consultant Endocrinologist, University College London Hospital

⁸Consultant Gynaecologist, Whipps Cross Hospital, London

Objective: To determine tertiary care practice of prescribing testosterone to women attending menopause clinic and to assess its tolerability and side effects.

Methods: Retrospective electronic notes review of patients attending the University College London Hospital (UCLH) menopause clinic between 2019-2023 and Whipps Cross Hospital (WCH) menopause clinic between Jan 2021-July 2023. Patients prescribed testosterone were identified and included.

Results: Between 2019-2023, 1099 women attended the menopause clinic at UCLH. Of these, 179 women were started on testosterone. There was an average length of 5.7 years between their last menstrual period and receiving testosterone. The majority (64.8%) were started on testosterone at their first appointment with the most common indication being sexual dysfunction (50.3%), other indications included fatigue and brain fog. Testogel was the most frequently prescribed preparation (67.6%).

At the time of starting testosterone treatment, 8.4% were on oral estrogen replacement, 75.4% were on transdermal estrogen replacement therapy, and 16.2% were not on estrogen replacement primarily due to contraindications.

Within the study period, 107 (59.8%) of the women started on testosterone treatment attended follow-up; 13.1% reported side effects (including heavy legs and breast tenderness) whilst 29.9% reported benefits (most frequently being generalised improvement in symptoms and increased libido). Out of 179 patients, 23.5% discontinued treatment; 11.2% discontinued for unspecified reasons and 3.9% discontinued due to side effects.

Comparing UCLH prescribing practice to WCH, over a 2.5 year period, 28 women were initiated on testosterone. Of these, 46.4% were started on testosterone at their first appointment. Similarly to UCLH, 17.9% discontinued treatment and 7.1% discontinued due to reported side effects.

Conclusion: This data provides useful real-world experience regarding testosterone prescribing. Across two menopause clinics, 16.3% and 7.7% of all women were prescribed testosterone therapy. Testosterone is generally well tolerated with less than 10% discontinuing treatment due to side effects. Interestingly, women reported improvements beyond that of improved libido, despite this being the only licensed indication. Further prospective data is required to determine clinical utility of testosterone in women experiencing the menopause.

¹Obstetrics and Gynaecology SpR and Clinical Research Fellow, Imperial College, London rd909@ic.ac.uk

²Medical Student, Imperial College, London

³Consultant Obstetrician and Gynaecologist and Professor of Reproductive Medicine University College London Hospitals and University College London

⁴GP and Clinical Lecturer in Primary Care, Warwick Medical School

⁵Consultant Gynaecologist, Imperial College NHS Foundation Trust

⁶Consultant Gynaecologist, University Hospitals Dorset NHS Foundation Trust

⁷Obstetrics and Gynaecology SpR and Academic Clinical Fellow, University College London

⁸Endocrinology SpR and Clinical Research Fellow, Imperial College London

⁹Consultant in Sexual and Reproductive Health, Liverpool Women's Hospital

¹⁰Consultant Gynaecologist and subspecialist in Reproductive Medicine, Birmingham Women's and Children's NHS Foundation Trust

¹¹Consultant Gynaecologist and subspecialist in Reproductive Medicine, King’s College Hospital, London

¹²Consultant and Reader in Reproductive Endocrinology, Imperial College London

Objective: Off-license use of testosterone is endorsed by the British Menopause Society for the management of hypoactive sexual desire disorder (HSDD) provided that a biopsychosocial approach has ruled out other causes and the patent is adequately estrogenised. The literature suggests testosterone therapy may have value in other menopausal symptoms but data is conflicting and high quality trials are warranted. We designed a survey to establish the views of patients to inform research design and outcome measures.

Methods: A concise online survey was created, comprising of 17 questions, utilising a combination of Likert scales, multiple-choice questions, and free-text options. Demographic respondent information was also collected. Active from February 2022-September 2023, the survey was distributed via social media and responses were anonymous.

Results: There was a total of 7292 respondents; 92% within the age category 40-59. 85.6% were already on HRT and 28% also receiving testosterone. 98.9% of all respondents had previously or contemporaneously experienced symptoms of the menopausal transition. Only 5.6% of respondents did not think high quality study into this area was important. 79.8% of respondents would be enthusiastic to enrol in such a study. When asked to rank importance as a research outcome on a Likert scale (1=not at all, 10= extremely important) >80% of respondents ranked low mood, tiredness and brain fog as ≥ 8/10. 64.1%, 58.5%, 58.4%, 39.5% and 37.9% ranked a 10/10 for brain fog, low mood, tiredness, aches and pains and weight gain respectively. When asked to select the single most important symptom, 35.2% chose brain fog, 21.2% low mood, 16.6% tiredness, 9.7% aches and pains and 9.4% weight gain. 7.8% of patients selected ‘other’ and free-text analysis found clusters to include all symptoms being of equal importance, anxiety, poor sleep, vasomotor symptoms, bone health and muscle strength.

Conclusion: Our survey demonstrated patient appetite for further study into the value of testosterone therapy to treat symptoms of the menopausal beyond that of HSDD. This data could inform study design with a view to improving treatment outcomes for many women.

¹ST4 O&G Trainee, South Eastern Trust, Northern Ireland nialladoherty@hotmail.co.uk

²Medical Student, University of Ulster, Belfast

³Medical Student, Queens University, Belfast

⁴Consultant Gynaecologist, South Eastern Trust, Northern Ireland

More women are choosing to take HRT during menopause thanks to better patient awareness and support. Recent statistics show patients are receiving a wider range of HRT preparations. In England in 2022-23, there were 11 million items for HRT prescribed (47% increase from 2021-22). This has in some cases caused short supply of medications.

NICE recommends that progesterone should be prescribed along with estrogen in menopausal women with a uterus to provide endometrial protection. Our trust has seen an exponential increase in referrals of women having unscheduled bleeding on HRT. This is placing significant burden on the region, especially as there is no funding for specialist menopause clinics in Northern Ireland. Our aim is to educate primary and secondary care in correct pathways to avoid overburdening the system.

Objectives: To review the number of women undergoing hysteroscopy in day procedure unit (DPU) who are taking HRT. To review the HRT preparations these women are using. To review endometrial hyperplasia rates. To review the number of Mirena IUS inserted at hysteroscopy.

Methods: A review of the last 50 hysteroscopy cases in the DPU setting in SE trust. Cases were reviewed using electronic care records. Women under 40 years were excluded.

Results: The patient cohort had an age range of 40-77. The average BMI was 35.14. 50% of patients were on HRT, 16% of these were taking Utrogestan. 90% of these patients had an endometrial sample taken. 10% of these had a diagnosis of endometrial hyperplasia from their biopsy. 2% of all patients had a diagnosis of endometrial cancer. 20% of patients had a Mirena IUS fitted at the time of their procedure.

Conclusion: There were high numbers of patients having hysteroscopy using HRT. If proposed pathways for referral and investigation are followed it is expected that this number would reduce. Therefore, resulting in fewer women undergoing unnecessary procedures. In accordance with guidance, we should offer Mirena IUS to patients to reduce episode of unscheduled bleeding. We propose more access to Mirena insertion which may help with unscheduled bleeding and prescription shortages.

¹PhD Researcher, Manchester Metropolitan University Hannah.L.Smee@stu.mmu.ac.uk

Funding sources: jointly funded by Manchester Metropolitan University and White Rose Trust Doctoral Partnership (ESRC).

Objectives: (1) To measure the impact of menopause status and menopause symptoms on secondary school women teachers work outcomes (2) examine the role of the work environment in women teachers work-related menopause experiences.

Methods: A survey was developed which was comprised of two parts, Part A uses a cross-sectional design to establish the relationship between symptom severity, menopause status and work outcomes across a sample of secondary school women teachers (n=258). Self-reported survey data assessing work ability (Work Ability Score)(WAS) and menopausal symptoms (Menopause Rating Scale)(MRS) were used. Single item measures were included for absenteeism and intention to leave the workforce. Part B uses three sets of self-constructed Likert scales to examine menopausal work-related experiences across three domains, work outcomes, work environment and work policy (n=170).

Results: A logistic regression was carried out to assess the effect of age, menopause status, HRT use, symptom severity, teacher responsibility and hours worked on the likelihood of participants having poor-moderate work ability (n=258). The overall model was statistically significant when compared to the null model, (χ2 (6) = 39.765, p < .001), with symptom severity being the only significant factor (p=<.001) which increased the likelihood of participants having poor-moderate work ability.

Peri- and post-menopausal status women had a significantly lower WAS scores compared to pre-menopausal (mean 7.10 vs 7.03 vs 8.07, F(3,256) = 5.323, p = .001) and teachers who intended to leave teaching had a significantly higher symptom severity score, compared to those who wanted to remain in teaching (mean 29.1688 vs 24.8298, F(2,255) = 8.301, P= <.001). Absenteeism was not associated with symptom severity or menopause status.

Likert descriptive statistics demonstrated a range of problems for teachers during the menopause across the three domain measures.

Conclusion: Findings evidence a statistically significant relationship between menopause status, symptom severity and some work outcomes. Women teachers are finding their work environment problematic during the menopause, with stress, job demands and the structure of the school day making the menopause more difficult to manage. Menopausal women teachers may be at a heightened risk for decreased work ability and intention to leave the workforce.

¹GP, East Cowes Medical Centre, Isle of Wight selwestmore@doctors.org.uk

Objective: Many learning-disabled women are predisposed to an earlier menopause than the general population (1,2) and have higher rates of osteoporosis (3). Whilst menopause discussions have become mainstream, learning-disabled women have been side-lined. Not one government report on women’s health considers learning-disabled women.

The aim of this study was to investigate GPs experiences of supporting learning -disabled women with menopausal symptoms and whether the menopause was recognised by GPs when learning-disabled women attended GP surgeries.

Method: 15 GPs from the same county participated in semi-structured interviews. The interviews were transcribed verbatim and analysed using Reflexive Thematic Analysis

Results: A single GP had seen a learning-disabled women ask about the menopause in a consultation once, and only 1 GP had ‘diagnosed’ a learning-disabled woman as perimenopausal in a consultation. All GPs felt that it was not an issue that had been considered at a health check, either by themselves or the other clinicians that undertook them. GPs were happy to prescribe the pill for learning disabled women at menarche but 12/15 felt uncomfortable about initiating HRT in this cohort. Many reflected on cases where perimenopause was not considered, and learning-disabled women were instead issued psychiatric medication or antibiotics unnecessarily.

Conclusion: 20 years on, little has changed from the conclusions found by McCarthy (4.) of GPs experiences. Further research is needed to explore how we can address this.

1. Panay, N., Anderson, R. A., Nappi, R. E., Vincent, A. J., Vujovic, S., Webber, L., & Wolfman, W. (2020). Premature ovarian insufficiency: an International Menopause Society White Paper. Climacteric, 23(5), 426–446. https://doi.org/10.1080/13697137.2020.1804547

2. Schupf, N., Zigman, W., Kapell, D., Lee, J. H., Kline, J., & Levin, B. (1997). Early menopause in women with Down’s syndrome. Journal of Intellectual Disability Research, 41(3), 264–267. https://doi.org/10.1111/j.1365-2788.1997.tb00706.x

3. Burke É, Carroll R, O'Dwyer M, et al. (2009). Quantitative examination of the bone health status of older adults with intellectual and developmental disability in Ireland: a cross-sectional nationwide study. BMJ Open, 9:e026939. doi:10.1136/ bmjopen-2018-026939

4. McCarthy, M. (2002b). The Menopause and Women with Learning Disabilities. Updates, The Foundation for People with Learning Disabilities. Mental Health Update 3(14). https://www.learningdisabilities.org.uk/learning-disabilities/publications/menopause-and-women-learning-disabilities

¹Consultant Obstetrician and Gynaecologist, Princess Anne Hospital, University Hospitals Southampton humera.fayyaz@uhs.nhs.uk

²Physician Associate, Princess Anne Hospital, Southampton

³Princess Anne Hospital, Southampton

Objective: There has been an increase in referrals on gynaecology urgent suspected endometrial cancer pathway (USECP). The majority of this workload is contributed by the referrals for unscheduled bleeding on HRT. We therefore carried out a retrospective study to find out the extent of this workload with an intention to introduce a separate pathway for unscheduled bleeding on HRT.

Design: It is a retrospective case review of cases that were referred on USECP over a period of 6 months from January 2023 to June 2023 in Princess Anne Hospital, University Hospitals Southampton NHS Trust.

Methods: The electronic records of all women referred for unscheduled bleeding on HRT were reviewed to assess their demographics, type, duration and adequacy of HRT and the histological outcome. This histological outcome was then compared with those women who had post-menopausal bleeding and were not taking HRT.

Results: The total number of referrals during six months were 840. 343(41%) of these referrals were for unscheduled bleeding on HRT and 497(59%) of women with post-menopausal bleeding who were not taking HRT. The average age of women referred for unscheduled bleeding on HRT was 56, average BMI of 27 and average duration they have been on HRT was 32 months. 46/343(13.4%) of women were receiving inadequate endometrial protection (progesterone) at the time of referral. 51/343(14.8%) women were taking oral HRT and 292/343(85.13%) were on transdermal HRT . 166/292(56.8%) of these were taking Utrogestan for endometrial protection. The histological outcome amongst HRT vs non-HRT showed the incidence of cancers: 0.58% vs 7.9%, atypical hyperplasia 0.58% vs 3.2%, hyperplasia, 1.4% vs 1.3% respectively.

Conclusions: Our study showed that more than two thirds of USECP referrals were for unscheduled bleeding on HRT and comparatively have much less incidence of cancers than non- HRT referrals. Our audit together with the new joint guidelines by BMS for unscheduled bleeding on HRT would facilitate the safe introduction of a referral pathway for these women. This would allow us to gather more information from the primary care at referral, provide advice and guidance and manage low-risk women in primary care.

¹Speciality Doctor, Obstetrics and Gynaecology, North Devon District Hospital, Royal Devon University Healthcare NHS Foundation Trust d.jamesfenn@nhs.net

²Consultant, Obstetrics and Gynaecology, North Devon District Hospital, Royal Devon University Healthcare NHS Foundation Trust

³Foundation Year 1, North Devon District Hospital, Royal Devon University Healthcare NHS Foundation Trust

Objective: To check if we are taking the opportunity to assess risks of fractures in susceptible women?

Is appropriate life style advising and recommendations offered to support and promote bone health?

Method: Retrospective audit. We looked at 25 women between the ages of 50 to 65. We looked at risk assessments and recommendations to prevent osteoporotic fractures performed in clinic

Assessment of risk factors

• Family history of osteoporotic fractures

• Previous anorexia or BMI less than 18

• Previous fragility fractures

• Smoking

• Alcohol intake

• Associated Rheumatoid arthritis, Premature ovarian failure

• Current or previous steroid use

• Relevant drug history

We checked if the following recommendations were made:

• Lifestyle advise

• Advise on calcium, Vitamin D, Bisphosphanates

• Hormone replacement therapy

Results: We found that there was a lack in assessment and documentation of risk factors and recommendations of changes. Hence, we proposed a change which would be in the forms of displays in the clinical areas

Conclusion: Although, we cannot include all aspects of counselling and awareness in outpatient setting, it is important that women are aware of osteoporosis and measures to reduce fractures. Osteoporosis related fractures lead to morbidity and mortality. Loss of mobility It curtails independent living which is a key to survival in many women.

We should also consider the financial impact on the system. Osteoporotic fractures cost the NHS around £4 billion annually and hip fractures account for the occupancy of around 4000 hospital beds in the NHS at any one time across England, Wales and Northern Ireland

Reference

1. (https://www.nhfd.co.uk/files/2019ReportFiles/NHFD_2019_Annual_Report_v101.pdf).

We propose a poster in clinical areas. This would be in the form of catchy visual aids to promote bone health. It would serve as reminders to screen in clinic, spread awareness and bring about changes in life style. We believe this is a simple yet effective measure which would could go a long way in changing someone’s quality of life.