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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.”
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.”
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.
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