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A holistic approach to better outcomes

In March this year, the Department of Health and Social Care (DHSC) announced the launch of women’s health hubs to improve access and quality of care in services for menstrual problems, contraception, pelvic pain, menopause care, and more.

These women's health hubs are part of the Government’s wider Women’s Health Strategy for England, which launched in August 2022, promising to tackle complex and overlooked issues such as menstrual and gynaecological health, pregnancy and fertility, cancers, menopause and violence against women and girls. 

Community pharmacy plays a significant part in the Government’s Women’s Health Strategy, with growing recognition that pharmacy teams could play an increasing role in this area, partly due to their accessibility and ability to reach disadvantaged communities. POM to P switches for progesterone-only contraceptive pills and HRT (oestradiol) vaginal tablets have widened access, while in October 2022, the General Pharmaceutical Council (GPhC) highlighted the role pharmacy professionals play in safely dispensing sodium valproate, an anti-epileptic medicine that increases the risk of birth defects and persistent developmental disorders if taken during pregnancy. 

However, there are concerns that any enhanced role for community pharmacy in this area will be stymied by barriers including funding and IT infrastructure. PSNC/Community Pharmacy England recently announced that without more funding, pharmacies are unable to deliver the much-needed and much-anticipated Pharmacy Contraception Service, for example. There have also been a lot of issues around HRT supplies – and while the new Prescription Prepayment Certificate (PPC) for HRT has recently been launched, this isn’t as clear cut as it seemed initially. 

“A menopause service is one of the potential future options that we have considered as a way to make best use of independent prescribers in community pharmacy,” says Alastair Buxton, CPE’s director of NHS services. 

“However, while such services may be highlighted in the vision for the future of community pharmacy which is being developed for us by Nuffield Trust and The King’s Fund, our current focus is on addressing the funding and capacity challenges which pharmacy contractors are currently suffering. 

“Any future NHS proposals for service developments within community pharmacy must be fully funded, with appropriate structures in place to support the development of pharmacy teams’ skills and the efficient implementation of services in practice.”

“Any future NHS proposals for service developments within community pharmacy must be fully funded”

Women’s Health Strategy plan

According to the Women’s Health Strategy, all healthcare professionals need to be well informed to be able to provide or direct women towards the best care possible, including information on self care and advice on treatment options throughout their life. 

The six-point 10-year plan involves:

  • Tackling taboos and stigmas, ensuring women are listened to by healthcare professionals
  • Ensuring women can access services that meet their reproductive health needs across their lives, and prioritising services for women’s conditions, such as endometriosis
  • Addressing disparities in outcomes among women – ensuring that a woman’s age, ethnicity, sexuality, disability or where she is from does not impact upon her ability to access services or treatment
  • Better information and education – ensuring ready access to accurate information and giving healthcare professionals the initial and ongoing training they need 
  • Greater understanding of how women’s health affects their experience in the workplace
  • Supporting more research into women’s health conditions.

Better education for healthcare professionals and improved service provision are singled out as priorities, with many women reporting they can’t easily access information on menstrual wellbeing or gynaecological conditions like endometriosis and fibroids. 

Domestic violence and 'Ask for Ani'

In January 2021, the Home Office launched its ‘Ask for ANI’ (Assistance Needed Immediately) scheme through community pharmacies, to provide a safe and discreet way for victims of domestic abuse to access support from the police or other domestic abuse support services. 

Ask for ANI is now being run by Hestia’s UK Says No More campaign ( 

Day Lewis Pharmacy joined the Ask for ANI scheme in February this year, with employees receiving specialist training in safe spaces and domestic abuse awareness. “At Day Lewis, we take pride in supporting our local communities in every way we can,” says Rachna Chhatralia, Day Lewis superintendent pharmacist. “Unfortunately, we are aware there has been a sharp rise in the number of domestic abuse cases since the pandemic. We hope by making our consultation rooms a safe space for people, we can continue to support members of the local community who may be experiencing domestic abuse.”

Participating pharmacies display posters in their windows and in store to let customers know that they can approach staff to seek help. When someone uses the codeword “ANI” or asks for help, a member of the pharmacy team will lead them into the consultation room. They then check whether that person is in danger and wants the police to be called (via 999 in an emergency or otherwise via 101) or will assist them in contacting a national domestic abuse helpline or local support services.

Feeling heard

Women often feel they are not being listened to when pain is their main symptom – for example, being told that heavy and painful periods are “normal” or that they will “grow out of them”.

“There can be a stigma attached to women’s health issues, which could mean that women feel uncomfortable discussing menstrual bleeding and bladder incontinence,” says Lucy Morris, patient services manager at Numark. 

“This could lead to women living with abnormal symptoms that reduce their quality of life and, in some instances, could result in late cancer detection. Pharmacists who work within women’s health can reduce stigma and make their patients feel more comfortable by encouraging conversations, being culturally aware, approaching conversations sensitively and providing public awareness campaigns within the pharmacy.”

In March this year, the Royal College of Obstetricians and Gynaecologists (RCOG) said basic care is often challenging for women, who may find themselves shuttled back and forth between GP surgeries, sexual health clinics and hospitals due to the way treatments are funded and delivered. Gynaecology waiting lists have risen significantly since the pandemic began, leaving thousands of women self-managing symptoms such as heavy menstrual bleeding and pain.

“Referrals to secondary care currently need to go through a GP,” says Thorrun Govind, chair of the Royal Pharmaceutical Society in England. “So if a community pharmacist is the first port of call, they have to refer patients back to their GP to have the same conversation yet again before they can be referred to a specialist.” 

Govind says that for many women’s health issues, there should be direct referral pathways from pharmacy to secondary care. 

A February survey by RCOG revealed that over 60 per cent of the 2,000 UK women asked have at least one symptom of poor pelvic floor health (such as urinary incontinence or urgency) and nearly one in four have never done pelvic floor exercises, which can prevent and improve these symptoms. Most women haven’t spoken to anyone in the NHS about their pelvic floor health and over half of the women who had experienced symptoms of pelvic floor dysfunction have not sought help from a healthcare professional.

“Our research shows too few women are receiving information about pelvic floor health or the risk factors that can increase the chance of developing pelvic floor dysfunction,” says Dr Ranee Thakar, RCOG president, adding that issues like incontinence and pelvic organ prolapse are too often viewed as “normal” after childbirth. 

Dr Thakar says a lack of knowledge and feelings of embarrassment often prevent women seeking help for difficult symptoms, adding that “every health professional” has a role to play in tackling stigma and helping women protect their pelvic health. 

Govind agrees that community pharmacists are well placed to offer support for many women’s health problems, but says there just isn’t the funding. “Community pharmacists can help women be more confident in their own bodies,” she says, citing physiotherapy referrals as an area where pharmacies could help reduce primary care red tape for women. 

Improving access

Many women report finding it difficult to access appropriate menopause care. NHS England is working with the Wellbeing of Women charity to develop an awareness-raising package among key healthcare professionals to ensure more women are advised to seek support earlier in their menopause.

“Community pharmacies now offer low dose HRT vaginal tablets to women with symptoms of the menopause without a prescription,” says Dr Thakar.

She says pharmacists should facilitate conversations with women about the different treatment options available, including lifestyle changes; HRT should not be “seen as the only treatment option”.

The new PPC for HRT came into effect in England at the beginning of April, seeking to cut the cost of prescriptions for patients receiving one or more of the eligible HRT medicines. 

While this is a positive step, CPE is concerned that the certificate is launching without the IT in place to support it. PPC holders will still pay prescription charges for all other medicines. As this is a different approach from the three- or 12-month PPC, procedures and systems need to be updated as soon as possible. In addition to this, some HRT products are still subject to shortage protocols.

Dr Thakar says ongoing HRT supply issues “create barriers” to pharmacies supporting women, adding that the DHSC “must consider and build on” the recommendations made by the HRT taskforce around access.  

These supply issues can add to the stress burden already faced by many menopausal women. A recent survey by Anxiety UK and Kalms found a strong association between menopause, perimenopause and anxiety symptoms, with 85 per cent of 179 surveyed women saying menopause had triggered their anxiety and 61 per cent being prescribed antidepressants as a result.

Anxiety UK CEO Nicky Lidbetter says: "Anxiety is a prevalent symptom of the menopause, but awareness amongst women and indeed healthcare practitioners is low. Societally, most of us are familiar with hot flushes and weight gain as being symptoms of the menopause; this survey however shows that we need to get much better at recognising anxiety as being a key symptom."

Heightened levels of anxiety may partly be caused by hormonal changes influencing the production of mood-regulating neurotransmitter serotonin, explains Kathy Abernethy, immediate past chair of the British Menopause Society. 

“The needs of patients who are transitioning or transitioned should be a focus in any women's health plan”

Expanding roles 

Govind says community pharmacies have a lot of potential in all areas of women’s health due to their accessibility. “Pharmacies are ideally placed to support women before they are thinking of getting pregnant, for example,” she says, explaining that staff can advise on breastfeeding as well as health issues like mastitis and postnatal depression. But all this requires “better education, better training, an expanded workforce and better IT infrastructure within pharmacy”, she adds.

Dr Thakar believes that due consideration must be given to what is clinically safe and appropriate to access via pharmacies without a prescription or clinical guidance. “Within contraception, there are additional barriers to community pharmacies providing long acting reversible contraception (LARC) such as implants and coils,” she says. 

“We know that currently there are challenges in accessing LARC, with women facing long waits for appointments. Many GPs do not offer LARC fittings as it is not currently financially viable for practices to do so, which could also present a barrier to this being rolled out within pharmacies. 

“If LARC fittings were to be expanded to community pharmacists, it would be important to ensure that pharmacists were experienced and had the correct skills to make LARC fittings a positive experience for women in this setting, with a private room for these fittings to take place.”

Morris says it’s crucial that recognition is given to the needs of transgender patients when looking at what could be done better within women’s health services. “The needs of patients who are transitioning or transitioned should be a focus in any women’s health plan,” she says. “To make women’s health services more accessible, pharmacy teams should make themselves as approachable as possible to make patients feel comfortable and safe to discuss their health with pharmacy teams. The language used around topics of women’s health should be considered, factual and empathetic to achieve this.”

Views from the P3pharmacy panel

This is a really important area for us, but I feel we still don’t offer enough help for women. There are new products such as Gina, and I’m currently in a bid to set up a menopause clinic in our pharmacy, as we get so many queries about symptoms like hot flushes and vaginal atrophy. There’s so much more about menopause and HRT in the news these days, and that has encouraged women to feel more confident about talking about this and asking for advice. We can also now offer the mini pill, which is a huge advantage for both women and pharmacies.

This is a very important category, and we have a lot of patients looking for alternatives to HRT due to shortages and trouble adjusting to therapies. The most common queries are around brain fog and flushing, as well as vaginal thrush. Top sellers for us in this category include Canesten and Well Women’s Health. Women are more open regarding the menopause and are wanting relief without the addition of hormones. I would advise putting products at the counter so you can easily suggest a more private conversation in the consultation room.

This is a very big category, with queries ranging from pregnancy to menopause. In pregnancy, our best sellers are ClearBlue tests and Valuepak folic acid. We are hoping our recent training on Gina for post menopause vaginal dryness will convert into sales. We are seeing higher demand for menopause advice and related products. Bold and eye catching is a must for this category. We site this section at eye level, directly opposite the pharmacy entrance to ensure maximum visibility and reduce the need for directing customers to this often sensitive subject area.

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