After reading this feature you should be able to:
As a group, women are often very engaged with their health but there is always room for community pharmacy to offer useful help and advice. Not only that, but pharmacy teams also have an important role in helping spot symptoms that could lead to more serious health issues.
The support available in pharmacy may be particularly welcome for women living with conditions such as endometriosis, which receive comparatively little attention. However, endometriosis itself has recently been the focus of some NICE guidance in a bid to reduce the average diagnosis time of around eight years.
So let us consider some common gynaecological health problems, and the advice and support community pharmacy can offer – starting with endometriosis.
Over 1.5 million women in the UK have endometriosis – a gynaecological condition affecting females of childbearing age. It occurs when tissue similar to the lining of the womb grows in other areas of the body, including the ovaries, fallopian tubes, bladder or bowel, but most commonly in the pelvic region.
This tissue responds to hormones in the same way as the lining of the womb but, with no outlet, it can result in inflammation, scarring and adhesions, leading to a range of symptoms including severe and chronic period pain, heavy or irregular periods, fatigue and lack of energy, depression and feelings of isolation, pain on sexual intercourse and fertility problems.
Endometriosis has no definitive cause and the only conclusive way to determine if a woman has it is through a laparoscopy, usually done under general anaesthetic.
Research by Endometriosis UK shows that it typically takes around seven to eight years for a correct diagnosis to be made (at least two years before a woman initially goes to her GP and then four years going to and from the GP before being referred for a laparoscopy). Pharmacy has a vital role in helping women recognise symptoms and access the treatment they need as soon as possible.
“One of the curious things about endometriosis is that some women have many lesions without pain, while others with only a few lesions are in agony,” says Dr Karen Gardiner, managing director of Purple Orchid, a women’s self-care company. “This means some may be in the pharmacy regularly to buy painkillers and others may be having trouble getting pregnant without knowing that endometriosis is implicated in infertility.”
There is currently no cure but treatments including drugs, surgery and complementary therapies can be used to help manage the pain, reduce the severity of symptoms and improve the quality of life for women living with the condition.
Dr Gardiner says pharmacy teams should refer women to their GP “if they have pelvic pain which is usually worse during periods or when going to the toilet during periods, pain during or after sex, or if they feel sick, have constipation or diarrhoea during periods”, as these can be markers for other conditions.
It is estimated that over half of women in the UK suffer period pains (dysmenorrhoea), which are caused by the muscles of the uterus contracting to help expel the lining of the womb during a period.
While some women experience mild discomfort, others may suffer from very painful periods, which can affect their ability to get on with their day-to-day lives. OTC pain relief (e.g. ibuprofen, paracetamol, aspirin or naproxen) could be recommended as well as self-help measures such as using a hot water bottle, self-heating patch or pack that is warmed in the microwave.
Some women find regularly taking vitamin B6 can help, as it seems to have a direct effect on the pain and facilitates the breakdown of excess oestrogen, while many find that taking magnesium helps prevent menstrual cramping.
Dr Gardiner points out that, in such cases, it is important to recognise that a seemingly simple symptom can be an indicator of something more serious. “For example, a young woman who has had dysmenorrhoea since her periods began is different to a woman who has recently had painful periods. A secondary cause, such as cancer, is more likely if symptoms started after several years of painless periods.
“Customers should be referred to their GP if they have missed two or three periods, have pain during periods that stops them doing their normal activities, if they need tampons and sanitary pads together, if they are flooding into their clothes or bedding, or if they are trying unsuccessfully to get pregnant.”
Menorrhagia is when women have very heavy and painful periods, which leads to excessive blood loss and interferes with quality of life. This can occur alone or in combination with other symptoms.
A period is considered to be normal if blood loss is between 20-60ml (4-12 teaspoonfuls) and heavy if blood loss is 60-80ml or more (about half a teacupful or more). However, as it is difficult to measure the amount of blood lost, a period is considered heavy if it causes one or more of the following:
• Flooding through to clothes or bedding
• Frequent changes of sanitary towels or tampons
• Double sanitary protection (tampons and towels)
• Passing large blood clots.
Young girls may experience heavier periods when they first start menstruating, but this usually settles down with age. If it doesn’t, Dr Gardiner points out that the intra-uterine device, Mirena, was licensed for heavy periods before also being used as a contraceptive. Anticoagulants can be prescribed in certain circumstances if there is a blood clotting disorder.
Menorrhagia can be an indicator of polycystic ovary syndrome (see below), pelvic inflammatory disease, fibroids, endometriosis, under-active thyroid, blood clotting disorders or even cancer – all of which need to be borne in mind, she says.
Polycystic ovary syndrome (PCOS) affects 5-10 per cent of women, according to the charity PCOS UK. Symptoms usually start in adolescence (although some women do not develop them until they are in their early to mid-20s) and can include irregular or a complete lack of periods; irregular or no ovulation; difficulty becoming pregnant; unwanted facial or body hair; oily skin or acne; alopecia; weight problems; depression; and mood changes.
The pharmacy team is ideally placed to help with, for example, weight management issues (weight gain can make symptoms worse but losing weight can help alleviate them). Managing weight is also particularly important for women who have a family history of diabetes or heart disease, as overweight women with PCOS who have insulin resistance have an increased risk of developing type 2 diabetes.
The risks and benefits of hormone replacement therapy are an ongoing cause of confusion for women. There have been many negative headlines about the risks of HRT, one of the most recent examples being a scientific review that last year reported women on HRT are at a small increased risk of blood clots and possibly stroke. The link was made by the international Cochrane group, which looked at clinical trials involving 40,000 women. Researchers estimated that for every 1,000 women taking HRT, six would suffer a stroke and eight would experience a blood clot.
Maureen Talbot, British Heart Foundation senior cardiac nurse, says the risks of taking HRT for an individual have to be balanced against the benefits, which are relief from menopausal symptoms that some women find can have a significant impact on their quality of life. “It is important that women have a full understanding of the risks and benefits of HRT and should talk these through with their pharmacist or GP,” she advises.
Purple Orchid runs EveryWoman Day (everywomanday.com) each September to raise awareness of lesser known women’s health conditions. “Women can be stuck with these problems for life and therefore they have to manage them for life,” says Karen Gardiner, “so by sharing information, more women can potentially improve their symptoms and reduce their suffering.
Lives can be improved by talking about what works and what doesn’t, what makes things worse, how to cope with the debilitating effects and simply how we get through each day of pain, exhaustion, depression and other difficulties.”