10 Min In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.
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Record learning outcomes
Learning objectives
After reading this feature, you should:
- Understand some of the reasons why disparities persist between men’s and women’s health
- Be familiar with common men’s health problems and how to help
- Be aware of the latest thinking on prostate cancer and erection problems.
Key facts
- Men in the UK die younger than women and are more likely to take their own lives
- Many men don’t know how and when to access health and wellbeing support
- Pharmacy teams are ideally placed to help men overcome barriers to care, such as difficulty seeing a GP.
The disparity between men’s and women’s health persists, with men living four years fewer than women in the UK, and one in five men dying before the age of 65 years.
According to the Men’s Health Forum’s ‘The Real Face of Men’s Health 2024’ report, many men have poor health literacy compared with women, and they lack the skills to know when they need help and where to go for it.
The report, which launched during the Forum’s annual Movember campaign, also found that 61 per cent of men face barriers in seeing a GP. These include long waits, inconvenient opening hours and a belief that GPs only deal with very ill people. Community pharmacies can make a difference here by promoting ease of access to a healthcare professional, educating men about health issues and making sure pharmacies are places where men feel comfortable.
Amy O’Connor, Movember’s global lead, policy and advocacy, says: “Our research shows that men’s first healthcare encounters have a profound impact on their willingness to re-engage – 82 per cent of men who feel satisfied say they will seek help in future. Our men have made it clear that healthcare professionals actively listening to their concerns is incredibly important, so pharmacists can play a pivotal role here.”
George Sandhu, Well Pharmacy’s deputy pharmacist superintendent, says: “Barriers to men seeking healthcare often stem from fear of embarrassment, lack of awareness and accessibility. Pharmacy staff can provide a welcoming and discrete atmosphere to make men feel comfortable.”
Common problems
Erectile dysfunction
“The bottom line is that erectile dysfunction (ED) won’t just go away on its own,” says Sanofi, whose healthcare brands include Cialis Together, an ED treatment available over the counter through pharmacy. The company says it is important that men don’t ignore the potential signs of ED, although many do. “Many men who experience ED may delay seeking treatment due to embarrassment and fear of the impact on their sex lives or relationships. Thankfully, there are effective treatments to help.”
According to a study commissioned for ED treatment Viagra Connect, up to one in four men in the UK have experienced some degree of erection problems in the past 12 months. However, difficulty accessing treatment via conventional primary care services, including GPs, can be a barrier to care.
“Men of any age can develop erectile dysfunction, but it is important to note that ED is not just a problem for men in middle and older age,” says pharmacist Mark Burdon, who is an adviser to Eroxon, a topical treatment gel. “One study has reported that over a quarter of new ED cases are diagnosed in men under 40.”
According to Sanofi, a psychological component known as performance anxiety is common in men with ED. “However, a purely psychological problem is seen in only 10 per cent of [cases],” it adds. More common risk factors are similar to those for cardiovascular disease and include age, obesity, hypertension, diabetes, fatty liver disease, sleep apnoea, lack of exercise, smoking and alcohol consumption.
“ED is also a common side-effect of certain medicines, such as SSRIs, antihypertensives and prostate medications, which pharmacists are ideally placed to advise on,” says Burdon.
For men who are not at high cardiac risk, pharmacists can consider recommending drug treatment with a phosphodiesterase-5 inhibitor. “Pharmacists should refer men who have suffered with ED for a month or more, or if the man has obesity, diabetes or CVD,” he says.
“Pharmacy staff can provide a welcoming and discrete atmosphere to make men feel comfortable”
ED concerns? Check online
To help men who may feel uncomfortable starting a discussion about erection problems in the pharmacy, Viagra Connect (sildenafil) and Cialis Together (tadalafil) both offer online forms that can be filled in at home or wherever men feel comfortable, and brought into the pharmacy.
This can help to initiate conversations with pharmacists or their teams, which can then be continued in the consultation area. Customers can be discreetly signposted to the online checkers, for instance by displaying information posters in the pharmacy:
- Viagra Connect: viagraconnect.co.uk/en-gb/suitability-checker
- Cialis Together (within the FAQ section): cialistogether.com/en-gb/about-cialis-together#how-it-works
Mental health
Suicide is the UK’s biggest killer of men under the age of 50 years. “Latest data shows there were more than 4,000 suicide deaths registered among males in England last year and it is long been established that men are around three times more likely to take their own lives than females,” says Katie Hardcastle, senior research manager at Samaritans.
“There are several factors which increase the suicide risk for men, including relationship breakdown, unemployment and not having the same type of social network as most women.
“In a Samaritans report, we heard about missed opportunities for less well-off middle-aged men to access support in their lives, including during contact with health professionals.
“The research highlighted the need for more proactive engagement with men who are experiencing difficult life events or showing signs of struggling.”
Pharmacies can help by providing a private space for men to talk openly. Pharmacists could encourage them to contact their GP, explain how they can self-refer to talking therapies, and signpost them to local and national organisations.
Samaritans has a useful guide to starting a conversation with a customer you may be concerned about called SHUSH:
- Show that you care
- Have patience
- Use open questions
- Say it back
- Have courage.
Men can also be signposted to:
- CALM: thecalmzone.net / 0800 58 58 58
- Samaritans: samaritans.org / 116123
- Men’s Health Forum: menshealthforum.org.uk
- Hub of Hope: hubofhope.co.uk, a gateway to local organisations that can help.
Incontinence
According to Bladder Health UK, around 10 per cent of men experience urinary incontinence. It is often caused by an enlarged prostate and can occur after prostate surgery or because of a condition such as Parkinson’s.
Customers should be referred to their GP if they don’t know the cause of their incontinence.
Pharmacy teams can explain that there are now many male-specific incontinence pads and types of underwear (disposable and washable) available, which are discrete and effective.
Bladder Health UK has a support line to refer men to: 0121 702 0820.
Cardiovascular disease
Heart disease is one of the top five causes of premature death in men in the UK – and hypertension is one of the main risk factors.
NICE estimates that around a quarter of UK adults have hypertension, with prevalence increasing with advancing age, rising to more than 60 per cent in people aged over 60 years. Men are slightly more likely to be affected than women, with global age-standardised prevalence in adults aged 30-79 years being 32 per cent among women and 34 per cent in men in 2019.
This is an area where pharmacy can make a difference. Less than 40 per cent of men in England and Wales currently take up the offer of an NHS Health Check. “Pharmacists can work with local GPs and community organisations to promote NHS Health Checks during community events, integrating them into broader health discussions,” says George Sandhu.
The NHS Community Pharmacy Blood Pressure Check Service is important here, and pharmacies can promote the service to men and educate them about how to improve their heart health. “At Well Pharmacy, we not only offer blood pressure checks in-store but also organise mobile health clinics that bring these vital services to convenient locations,” he says.
“This approach makes it easier for men to access screenings in a familiar environment.”
“It’s not just what you ask, but how you ask it. Aim to be gentle, patient and kind”
A closer look at prostate cancer
The sad news of Sir Chris Hoy’s terminal diagnosis has helped to raise awareness of prostate cancer, the most common form of cancer in UK men and the second most common cause of cancer death in men after lung cancer.
According to NICE, around 47,600 men are diagnosed each year and about 11,600 die from the disease. One in eight men can expect to develop this type of cancer, with most being diagnosed between the ages of 65 and 69 years.
Prostate cancer is more common in older men, in men of black ethnicity and those with a family history of the disease.
Signs and symptoms
“Early prostate cancer will have no symptoms as the cancer will affect an area of the prostate not associated with urination,” says Robert Cornes, an information nurse specialist at the Orchid male cancer charity.
Men normally only experience early symptoms if the tumour is growing near the urethra. If the cancer moves beyond the prostate, it can cause symptoms which include:
- Lower back, hip or pelvic pain
- Erectile dysfunction
- Blood in urine or semen
- Unexplained weight loss.
Men who experience changes in urination are more likely to have an enlarged prostate, which is not cancerous, but they should be advised to see their GP anyway.
It is important to educate men about their level of risk. “Men with a first degree relative or black African/Caribbean men should be made aware that their risk is greater. In addition, a history of BRCA-related breast cancer in a family increases risk of BRCA-related prostate cancer,” says Cornes.
Emma Craske, senior nurse specialist at Prostate Cancer UK, says: “Black men are at twice the risk of developing prostate cancer, so it’s even more important to raise awareness in this group. Prostate Cancer UK has posters and cards that can be displayed in pharmacies.”
Early prostate cancer will usually have no symptoms.
Testing
If a man has an increased risk of prostate cancer or any symptoms, he should be referred to his GP. The GP will usually offer a urine test to rule out a UTI. A digital rectal examination (DRE) is usually offered to assess the prostate for changes. Men may also be offered a prostate-specific antigen (PSA) test. “All men over 50 are entitled to a PSA test following discussion with their GP regarding the pros and cons,” says Cornes.
PSA is a protein produced by the prostate gland, and men with prostate cancer usually have higher than normal levels. However, a raised level (normal is 0-4 nanograms/ml) doesn’t always indicate cancer. It could be due to ageing, a UTI or an enlarged prostate.
Around three-quarters of men who have a raised PSA level will not have cancer, while about 15 per cent with a normal PSA level will have cancer. A PSA test cannot distinguish between aggressive and slow growing cancers. It is best viewed as a first step in deciding if men need further tests to diagnose or rule out prostate cancer.
“Currently, there is no screening programme for prostate cancer,” says Craske. “This means that men won’t be automatically offered the test by their GP. Many men don’t realise this. There is a consensus among experts that men with a family history of prostate cancer and Black men consider PSA testing from age 45.”
Earlier this year, Prostate Cancer UK announced a £42m research programme to find the best way to screen for prostate cancer so that all men at risk will one day be invited for regular tests. Known as the TRANSFORM trial, this is the biggest prostate cancer screening trial in 20 years and is backed by the Government, the NHS and other organisations, including Movember and other charities.
In a move that will improve access to testing in the meantime, Superdrug has introduced a PSA blood test service, administered by nurses at its high street pharmacies.
Niamh McMillan, Superdrug’s superintendent pharmacist, explains: “We are committed to supporting the health of our customers and ensuring they have easy access to vital services. By introducing our new PSA blood test service across our 80 high street health clinics, we hope more men will feel encouraged and comfortable to prioritise their health and get themselves checked.” Superdrug’s PSA test costs £79.
Treatment news
“The biggest change in recent years is the use of active surveillance for men with early prostate cancer,” says Robert Cornes. “If men are suspected of having prostate cancer, an MRI of the prostate is done – and if suspicious areas are found, targeted biopsies,” he explains.
“This improves the accuracy of diagnosis, targeting specific areas, therefore allowing more accurate histopathological grading. Men with low-grade prostate cancer can often go on active surveillance. This is a programme of regular appointments with PSA/DRE examinations, further scans and biopsies as needed. If PSA rises or there is evidence of disease progression, curative treatment can be initiated, and the chance of cure will be the same as it would have been at the time of diagnosis.”
Watchful waiting is another option that is often used for men with localised prostate cancer who are not suitable for or don’t want to receive treatment. They may be offered long-term hormone therapy to control the cancer at some point. “In the past, men who had a raised PSA level would have had a biopsy as the first test at hospital,” explains Emma Craske.
“These days, men will have an MRI scan, which will determine whether they need to have a biopsy. The biopsies themselves have changed to a transperineal approach from a transrectal one, decreasing the risk of infection.”
Reducing risk
Prostate Cancer UK offers advice that pharmacy teams can pass on to customers, including:
- It is important for men to understand their risk level. The Prostate Cancer UK Risk Information Service can be accessed online via prostatecanceruk.org/risk-checker or by calling 0800 074 8383
- Maintaining a healthy weight may help to reduce risk. There are links between being overweight and advanced prostate cancer.
A downloadable diet and physical activity information leaflet for customers is available from prostatecanceruk.org - Encouraging smokers to quit. There is clear evidence linking smoking with aggressive prostate cancer.
Handling sensitive conversations
Good communication skills are essential for engaging men and making sure they feel comfortable sharing sensitive information.
George Sandhu, deputy pharmacist superintendent at Well Pharmacy, advises: “Initiating sensitive conversations can be challenging, but pharmacists can encourage discussions by asking open-ended questions about general health and wellbeing, gradually steering towards sensitive topics. Prominent, welcoming signage indicating that consultations for sensitive topics are available can reassure men.”
Pharmacist Mark Burdon says: “A report commissioned by Eroxon shows that 69 per cent of men find it difficult to discuss their intimacy issues with a health professional. This area calls for excellent pharmacist communication skills. Ask questions empathetically, and don’t offer advice too quickly before establishing what the patient understands about their erection problems. To initiate a conversation, ask whether the patient has any medical conditions, as ED is linked with CVD and diabetes.”
Katie Hardcastle, senior research manager at Samaritans, says: “Everyone has a part to play in suicide prevention and reaching out to someone in need could help save a life. It can be hard to know how to approach someone who needs help, but we know that starting that conversation at the right time can make all the difference. It could be as simple as asking a few open questions during a private consultation to encourage men to open up.”
Amy O’Connor, Movember’s global lead, policy and advocacy, says: “It is not just what you ask, but how you ask it. Aim to be gentle, patient and kind.”
Check out conversations.movember.com/en for tips and an interactive guide.
Clinical
In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.