1 Min In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.
Bookmark
Record learning outcomes
Learning objectives
After reading this feature you should be able to:
- Deal sensitively with health issues some women may find embarrassing to discuss
- Recognise the signs and symptoms of menopause and the impact they have on women’s lives
- Provide information to female customers to help them make informed choices about menopause symptom relief.
Introduction
It is not just patients who sometimes feel self-conscious discussing certain health issues. A survey of more than 200 pharmacy staff, conducted by CIG Research, found that only 65 per cent of male pharmacists feel confident talking about postmenopausal health compared to 80 per cent of their female counterparts.
“In my experience, I think it is less comfortable talking to a member of the opposite sex in relation to more intimate health issues,” says Noel Wicks, managing director and pharmacist at the Right Medicine Pharmacy group in Scotland.
“It tends to be easier if you have personal experience – perhaps a partner has had the same issue – as you can then better relate to the problem. So maybe male pharmacists could talk to a relative or partner to have more of an understanding of these issues. Hopefully getting a woman’s perspective would help make them feel more comfortable.”
Others have a different approach. “I think being a pharmacist involves providing holistic care regardless of gender,” says Sultan Dajani of Wainwrights Chemist in Hampshire. “If the awkwardness is due to a lack of confidence or inexperience, they could shadow a counterpart to see how they do it.”
Important life stage
Pharmacy teams can play a key role in supporting women through the menopause, says Rebecca Wicks, a pharmacist with a specialist interest in menopause, who works alongside her husband Noel at Right Medicine Pharmacy. “This is a stage of every woman’s life, and once women are educated and feel supported by healthcare professionals, friends, family and employers, they can embrace it positively,” she says.
“First, pharmacists can educate themselves,” Rebecca continues. “I’d recommend reading NICE Guideline 23 – Menopause: Diagnosis and Management to start. The CPPE Menopause gateway also has links for relevant CPD. Second, consider perimenopause/menopause symptoms when women are asking for advice. Symptoms are wide-ranging and women are not always aware of the link to their hormones.
“Third, apply this knowledge to your day-to-day practice to assist midlife women accordingly. For example, if a woman is experiencing recurrent UTIs, could she be experiencing symptoms relating to genitourinary syndrome of the menopause?”
Pharmacists can then direct patients to a range of resources (see box on p24). One app aiming to help women manage the symptoms of menopause is Stella, which launched in 2021 and is available from the Apple App Store or Google Play.
“Users begin with Stella’s free online menopause assessment, which recommends treatment options based on symptoms, lifestyle, preferences, and medical, medication and family history,” explains pharmacist Helen Henderson, clinical operations manager at Stella. “To date, 20,000 people have completed this assessment.
“Stella costs £45 per month for a three-month subscription, which includes personalised results and treatment options including a HRT prescription, if appropriate. The subscription also includes online doctor appointments, medication reviews and access to the Stella menopause app.” This offers “one-to-one and group coaching, menopause resources and a supportive community”.
Community pharmacists have been receptive to digital services such as Stella, says Helen Henderson. “According to the World Health Organization, digital health technology is becoming increasingly prevalent and is expected to play a significant role in shaping the future of global health. By recommending health apps like Stella, pharmacists are finding that they can empower patients with valuable knowledge about menopause even after they have left the pharmacy.”
Vaginal atrophy
Vaginal atrophy is the thinning and drying of the walls of the vagina. It is a common condition that affects many women after the menopause and is related to a drop in oestrogen production. Symptoms include vaginal dryness, discharge, urgency or urinary incontinence, and painful intercourse.
According to research by Novo Nordisk, manufacturer of the switched product Gina, 70 per cent of women have never heard of vaginal atrophy but 64 per cent are living with the symptoms; 47 per cent are living with vaginal dryness and 22 per cent say sexual intercourse can be painful.
One factor holding women back from seeking help is embarrassment. Sixty per cent admit to feeling embarrassed, 73 per cent won’t discuss their menopause symptoms with their friends and 63 per cent don’t seek treatment despite options being available.
Embarrassment also affects those meant to help them. Female pharmacists were 17 per cent more likely than male pharmacists to recommend Gina and 24 per cent more likely to recommend the Gina learning resources to colleagues.
Gina is the first form of HRT to be available as a P medicine. Gina contains locally-acting vaginal oestrogen (estradiol 10mcg) that is absorbed directly into the tissues helping to restore the integrity of the vaginal wall and ease symptoms of menopause-induced atrophy. Gina starts to rebalance pH levels in the vagina after two weeks with relief felt after eight weeks.
Gina is supplied as film-coated, vaginal tablets in a preloaded applicator and is indicated for postmenopausal women 50 years and over, who have not had a period for at least one year. The initial dose is one vaginal tablet daily for the first fortnight, followed by a maintenance dose of one vaginal tablet twice a week (leaving three or four days between doses).
Frequently asked question regarding Gina include:
- Could the vaginal tablet fall out?
The vaginal tablet should not fall out. After inserting the tablet, it sticks to the vaginal wall and dissolves. However,
if the woman is worried about this, you can suggest that she uses Gina in the evening before she goes to bed.
- Is progestogen required?
Oestrogen delivery direct to the vagina avoids hepatic first-pass metabolism, so that lower doses than those delivered orally can be utilised to achieve a treatment response. As the oestrogen stays within the vagina and low levels are released into the bloodstream, levels remain within the normal post-menopausal range. As systemic absorption of oestrogen is minimal, progestogen is not required.
- Can Gina be used by women who are recovering from surgery?
Gina should not be used by women who are having to remain immobile during recovery from surgery.
- Could Gina make a woman gain weight?
Gina is not associated with weight gain. There is no evidence that HRT can have an effect on body weight. However, women who are concerned may be advised that it is normal to gain weight around the time of the menopause.
More information about Gina available here.
Making EHC consultations less daunting...
Some patients needing emergency hormonal contraception, such as teenage girls, may feel especially nervous about seeking help – so healthcare professionals have been coming up with innovative ways to make the process less daunting.
“In Scotland we offer free EHC via a PGD,” says Noel Wicks. “The form that is completed when doing the PGD is usually provided by the local health board and follows a similar format. While it is good at ensuring all the relevant information is collected, it would usually be completed by the pharmacist in the consultation. This included writing down the patient’s name and address, as well as a long list of intimate questions around the woman’s period, sexual activity, reason for needing EHC and other medication taken.
“As part of redesigning the service, we changed it so that the patient could fill in all these details and answer the relevant questions while waiting to be seen by the pharmacist. This means the pharmacist can read the form prior to the consultation, allowing more time for advice during the consultation itself.
“The feedback we received from both patients and pharmacists was that it made the consultation flow better and that it was more comfortable because there wasn’t a barrage of intimate questions at the start.
“In particular, our male pharmacists said they found the consultation much less awkward as a result.”
What is the Greene Climacteric Scale?
The Greene Climacteric Scale (GCS) can be used to assess changes in different menopause symptoms, before and after menopause treatment. Three main areas are measured: Psychological, somatic (physical) and vasomotor.
The menopause rating scale comprises a list of 11 symptoms or complaints, each of which can get 0 (no complaints) or up to four scoring points (severe symptoms) depending on the severity of the complaints perceived by the woman completing the scale.
Studies have shown that women who score over 12 are more likely to be menopausal. The GCS score can be used to assess symptoms at a point in time and then track how they change over time.
Supply issues
One of the biggest challenges facing pharmacies and customers alike is the fact that high demand for HRT products has led to some supply shortages. “It has been an intermittent issue for many years but has become more frequent recently since menopause awareness has increased and the number of HRT prescriptions has risen,” says Rebecca Wicks.
In extreme cases, a serious shortage protocol (SSP) may be issued by the DHSC, allowing pharmacists to supply alternative HRT preparations when a patient presents with a prescription for a product that is out of stock.
For medications where SSPs have not been issued, pharmacists need to consult with the patient’s GP about making an amendment.
“Communication with patients about why their medication has been changed or when they can expect to receive a supply is important. Pharmacists should draw on their knowledge to explain any changes, especially if the medication itself is different,” says Helen Henderson.
Pharmacists can further support menopause patients with lifestyle advice. “The advice given depends on the symptoms the patient has,” says Fin McCaul, managing director at Prestwich Pharmacy in Manchester. Tips might include staying cool (wearing light clothes, using fans), exercising (“small amounts and often is sometimes better”), lowering stress levels and reducing triggers such as alcohol or caffeine.
By opening up the dialogue around menopause and different medications, pharmacists can also highlight common side-effects as well as any ‘red flag’ symptoms. “For women who are on HRT, pharmacists need to explain that unscheduled vaginal bleeding is a common side-effect within the first three months of starting,” says Rebecca Wicks. “However, if this continues or starts well after this time and tends to being heavy and persistent, then referral to the GP is important.
“It is also important that women seek help from their doctor if their symptoms worsen or change, if they have medication side-effects or if their treatment no longer controls their symptoms,” she continues. “Any of the symptoms on the Greene Climacteric Scale that are impacting on a patient’s quality of life need to be taken seriously, from hot flushes and night sweats that disturb sleep to low mood, anxiety and depression. It is particularly important for us to take mental health symptoms seriously – the rate of suicide is highest between 50-54 years of age.”
Ultimately, being able to talk openly about women’s health is beneficial for all: if patients feel at ease, they’ll be more inclined to visit a pharmacy. “There is always a bit of awkwardness when dealing with any sort of intimate health-related queries, be they women’s or men’s,” says Noel Wicks. “However, I try to remember it is just someone looking for help in the same way they might be for hay fever or a cold.”
Other frequently encountered women’s health problems
Thrush is a common yeast infection that occurs when the pH or acid balance in the body becomes disturbed, causing the candida fungus to multiply, resulting in intense itching and soreness.
Thrush is often caused by taking antibiotics, as these kill other harmless bacteria allowing the candida fungus to thrive – but vaginal thrush can also be a result of hormonal changes that take place during pregnancy or menstruation; diabetes that is poorly controlled; perfumed bath products; and wearing tight or synthetic clothing. Poor toilet hygiene can be another contributing factor, as candida is present in the bowels and can easily pass to the vagina.
Treatment involves an antifungal agent (e.g. clotrimazole, miconazole) to reduce the level of candida infection in the body. These are available in antifungal pessaries, which are inserted into the vagina with a special applicator, or as intravaginal creams. Topical creams can also help to soothe itching.
“OTC medicines should only be used if thrush has previously been diagnosed and symptoms are similar to previous episodes,” says a spokesperson for Canesten. In other cases it may be appropriate to refer patients to their GP. “This includes first-time sufferers, those under 16 and over 60 years of age, pregnant or breastfeeding women, and someone who has seen no improvement within seven days of treatment, experienced abnormal vaginal bleeding, abdominal pain or is generally feeling unwell.
“If symptoms differ from a previous episode of thrush, or the person has had more than two episodes of thrush in the past six months and not consulted a GP about this for more than a year, or had a previous STI or a previous reaction to thrush treatments, or has a weakened immune system, they should see a GP first for further medical advice.”
Cystitis is a urinary tract infection that results in inflammation of the bladder. The condition can be painful and uncomfortable, but it usually clears up within a few days or can be easily treated with a course of antibiotics. Oral paracetamol or ibuprofen can be recommended to ease the pain and discomfort.
Common symptoms include pain, and frequency, urgency and difficulty in passing urine. If not treated, a serious kidney infection may develop. Women should be referred to their GP if symptoms are very uncomfortable or suddenly get worse, they develop a high temperature, are pregnant or have diabetes.
More on menopause...
Websites
- Women’s Health Concern (the patient arm of the British Menopause Society)
- NHS Inform
- Menopause Matters
- Daisy Network
- Rock My Menopause
Apps
Books
- The Definitive Guide to the Perimenopause and Menopause by Dr Louise Newson
- Menopausing by Davina McCall and Dr Naomi Potter
- Everything You Need To Know About The Menopause (But Were Too Afraid To Ask) by Kate Muir
- Menopause: The One-Stop Guide by Kathy Abernethy
- The Complete Guide to the Menopause by Dr Annice Mukherjee
Clinical
In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.