Developing the Women’s health strategy: The British Menopause Society’s recommendations to the department of health and social care’s call for evidence

In the early part of 2021, the government launched a call for evidence to inform the development of the Women’s Health Strategy with the objective of better understanding women’s experiences of the health and care system and to help improve the health and wellbeing of women. The British Menopause Society Medical Advisory Council and the BMS Board of Trustees recommendations specific to the menopause and post reproductive health in relation to all six core themes included in the call for evidence assessing the different areas of women’s health are discussed in this document

Earlier this year, the government launched a call for evidence to inform the development of the Women's Health Strategy with the objective of better understanding women's experiences of the health and care system and to help improve the health and wellbeing of women. 1 The British Menopause Society (BMS) Medical Advisory Council and the BMS Board of Trustees provided recommendations specific to the menopause and post reproductive health in relation to all six core themes included in the call for evidence assessing the different areas of women's health. 2 Menopause is a significant life event that can affect women in a variety of ways and can have both short and long term. The average age of the menopause in western countries is 51 years and with average life expectancy in developed countries now exceeding 80, it is likely that many women will have approximately a third of their lives after the menopause and many women may experience troublesome symptoms related to the menopause for a number of years. This can have a detrimental impact on their quality of life, wellbeing and may also have a significant impact on their personal relationships and work.
Our submission follows on from the BMS Statement issued in 2011 in response to the Government's initiative to reform the NHS. The Statement included 18 recommendations to provide better health for women going through the menopause transition and beyond, and called for raising awareness of the menopause and its impact, better access to advice and treatment, and optimising benefits from lifestyle changes. The Statement also called for routine health checks for menopausal women, to provide an opportunity to advise women regarding these issues. 3 The BMS recommendations on each of the current Core Themes are as follows below:

Core theme 1: Women's voices
The BMS is aware through feedback, both direct and on social media, that many women are experiencing difficulties in having their menopause related concerns listened to and also have difficulties accessing advice and help on the menopause. One of the difficulties in accessing appropriate advice is the wide range of symptoms that women may experience, and the fact that some of these symptoms can overlap with other conditions. Whilst most women attribute hot flushes and night sweats to the menopause, many do not associate other symptoms (such as tiredness, low mood, anxiety, poor memory and concentration or sensation of brain fog) to the menopause and worry about the cause of these symptoms or may fail to understand why they are experiencing them. Menopause is a major life event, marking the end of the reproductive life cycle, and many women may experience troublesome symptoms related to the menopause for a number of years. This can have a detrimental impact on their quality of life, wellbeing and may also have a significant impact on their personal relationships and work.
The BMS viewpoint · The BMS view is that women should be encouraged to seek help for managing their menopausal symptoms. · The BMS would like to see all healthcare professionals having some understanding of the impact of the menopause and know where to signpost women for support and advice. · Many women's first 'port of call' for menopause related issues is their GP, and therefore it is very important that GPs are aware of the range of issues from the menopause and their impact. · In addition, the BMS also believes that primary care teams should aim to have at least one nominated healthcare professional with a special interest in and knowledge of the menopause.
The BMS support steps · The BMS promotes awareness of the menopause by encouraging healthcare professionals looking after women to guide them to the BMS website and the patient support section of the BMS, Women's Health Concern, where they can access written information and educational videos, identify their local menopause services based on their postcode as well as links for further resources to guide and support them. · To further support the training of healthcare professionals, in 2020 the BMS launched a new training programme to support the provision of menopause care in the UK (adapted to fit within the constraints of COVID-19) and also developed a virtual educational programme and meetings to ensure the provision of education continues during the pandemic.
Core theme 2: Information and education on women's health As referred to above, whilst most women attribute hot flushes and night sweats to the menopause, many do not associate other symptoms such as tiredness, low mood, anxiety, poor memory and concentration or sensation of brain fog to the menopause. As a result, women may fail to understand why they are experiencing them. Menopausal symptoms affect more than 75% of women. So, whilst not all women going through the menopause will experience menopausal symptoms, the majority will and over 25% describe severe symptoms. Menopausal symptoms may last for a long time with an average duration of 7 years, and one in three women experience symptoms beyond the 7 years.
The BMS viewpoint · Raising awareness of the different symptoms of the menopause and its health impact is crucial. The BMS believes there is a pressing need to increase awareness around the menopause, premature ovarian insufficiency (premature menopause) and post reproductive health and its potential impact on many women. · Women should also be made aware of resources available for guidance. The BMS view is that all women should have access to information, and be able to seek advice on how to optimise their menopause transition and the years beyond. · Women should be signposted to where they can obtain accurate information to understand the impact of the menopause and the management options available to them including hormone replacement therapy (HRT), non-hormonal options and lifestyle and diet modifications. · Whilst HRT can play an important role, women also need to be made aware that changes in lifestyle and diet (exercise, optimising weight and reducing alcohol intake) can all help in alleviating menopausal symptoms, and improve later health. Management should also be individualised to the needs of each woman rather than a 'one size fits all' approach. · In addition, to menopausal symptom management, there is a need to raise awareness and provide information on the detrimental effect the menopause can have on bone health and cardiovascular health and the risk of osteoporosis and cardiovascular disease. HRT remains the most effective treatment for menopausal symptoms and in addition has a protective effect on bone and cardiovascular health.
· The beneficial effects on bone and cardiovascular health should be discussed as part of the benefits/ risks assessment when counselling women about HRT.
The BMS support steps · The BMS encourages health care professionals looking after women to guide them to the BMS website and the patient support section of the BMS, Women's Health Concern, where they can access written information and educational videos, identify their local menopause services based on their postcode as well as links for further resources to guide and support them. · Women should be made aware of resources available for guidance.

Core theme 3: Women's health across the life course
The BMS considers that current services do not provide optimal support for women's specific needs in relation to the menopause, often with missed opportunities in earlier life to advise and prepare women for the changes at menopause. There are also significant variations in access to specialist menopause advice in different parts of the country. In addition, as detailed in the response on core theme 6 below, services have been adversely impacted by the COVID-19 pandemic and its effect on staffing issues and service delivery. HRT has been shown to have a significant protective effect against osteoporosis and related fragility fractures. Osteoporosis is estimated to affect more than two million women in England and Wales. It is estimated that 1 in 2 women in the UK will suffer a fracture after the age of 50 and the International Osteoporosis Foundation reports that a 50-year-old woman has a 2.8% risk of death related to hip fracture during her remaining lifetime. The National Osteoporosis Guideline Group (NOGG) estimates there are approximately 536,000 fractures every year in the UK caused by osteoporosis and mortality rates with femur fractures are estimated to be 20% within the first year. Cardiovascular disease remains a leading cause for morbidity and mortality in women. The British Heart Foundation has indicated that approximately 24,000 women die from coronary heart disease each year in the UK. Given the potential cardiovascular beneficial effects reported with HRT initiated in women under the age of 60 this is a further aspect that should be considered as part of the benefits/risks assessment when counselling women about HRT.
Women who suffer premature ovarian insufficiency (premature menopause before the age of 40 years) are particularly at risk of osteoporosis, cardiovascular disease and dementia. It is essential that they receive adequate hormone replacement, unless contraindicated, at least until the average age of menopause (51 years), in order to maintain their quality of life and long-term health.
The risk of breast cancer with HRT is a cause for concern for many women. And whilst there is an increase in this risk, it remains low in both medical and statistical terms, particularly when compared to other modifiable risk factors such as obesity and alcohol intake which are associated with a higher risk of breast cancer than that with HRT. This slight additional risk should be taken in the context of the overall benefits obtained from using HRT in improving quality of life as well as improving bone and cardiovascular health. As such, for the majority of women taking HRT the benefits outweigh the risks. It is important to note that the risk of breast cancer in women using HRT before the average age of menopause is no higher than that in non-menopausal women of a similar age (all other risks being equal). 4,5 The BMS viewpoint · The BMS believes that in order to provide appropriate support to women in relation to the menopause all healthcare professionals should have a basic understanding of the menopause and know where to signpost women for advice, support and treatment where appropriate. · The BMS would like to see primary care teams aiming to have at least one nominated healthcare professional with a special interest in and knowledge of the menopause. · The BMS would like to see every Clinical Commissioning Group (CCG) having access to and commissioning care to at least one specialist menopause service providing specialist input for complex patients as well as support, and education for their local teams. · The BMS considers that all women, around the time of their 45th birthday should be offered the opportunity to attend a health and lifestyle consultation to discuss a personal health plan for the menopause and beyond.
· The BMS would like to highlight the issue of premature ovarian insufficiency which occurs in 1% of women (or more, according to recent data). Young women with this distressing condition should be diagnosed and managed as efficiently and effectively as possible, through provision of sufficient healthcare education and resources, to maintain quality of life and prevent serious health outcomes. · There is a need to provide balanced information on the benefits and risks associated with HRT usage, including breast cancer. Management decisions should be made on an individualised basis after discussing the benefits and risks with each patient and should be considered in the context of the overall benefits obtained from using HRT including symptom management and improved quality of life as well as the cardiovascular and bone protective effects associated with HRT. · The BMS considers there is a need to promote menopause education and training.
The BMS support steps · The BMS set out its fundamental principles and views on menopause service provision in its guidance document 'Vision for menopause care in the UK' https://thebms.org.uk/wp-content/ uploads/2020/10/BMS-Vision-OCT2020-FINAL. pdf · To further support the training of healthcare professionals, in 2020 the BMS launched a new training programme to support the provision of menopause care in the UK (adapted to fit within the constraints of COVID-19) and also developed a virtual educational programme and meetings to ensure the provision of education continues during the pandemic.

Core theme 4: Women's health in the workplace
In a BMS National Survey in 2016, 45% of women indicated that they felt their menopause symptoms had a negative impact on their work, and 47% of those who needed to take a day off work due to menopause symptoms indicated that they would not tell their employer the real reason for their absence.
In addition to its personal impact on individual women, the menopause can have a significant impact on the workforce. It is reported that 70% of women are in paid employment. Women constitute approximately 50% of the UK workforce and it is estimated that there are more than 4 million women aged 50 and above in employment in the UK. Over the last 30 years, employment for women aged 55 and over has gone up by approximately 30% and this is likely to continue to rise.
The BMS viewpoint · The BMS believes that there is an urgent need to raise menopause awareness in the workplace including among all managers and staff. · There is a need for employers to ensure they have policies in place in relation to managing menopause in the workplace to help support their workforce with menopause related problems. · The menopause (unlike pregnancy or maternity) is not well understood or provided for in workplace culture, policies and training. There is a need for more employer awareness of the legal responsibilities for supporting staff with menopause related issues. Such awareness should particularly consider aspects in relation to: · Health and Safety at Work Act 1974. · Management of Health and Safety at Work Regulations 1999. · Equality Act 2010.
The BMS support steps · The BMS has produced guidance on menopause in the workplace to provide guidance to employers and employees. · In addition, members of the BMS Medical Advisory Council regularly provide educational lectures on this topic to guide both employers and employees. · The BMS is currently developing a dedicated section on its website to promote this important area and provide further support material.

Core theme 5: Research, evidence and data
There are many areas related to the menopause which have yet to be adequately assessed in research studies.

The BMS viewpoint
· The BMS would like to see prioritisation of menopause and post reproductive health research to allow further studies to be carried out in this area and to increase research funding opportunities dedicated to support research work in this important aspect of women's health. · It would be beneficial to have access to national data on post reproductive health, menopause and premature ovarian insufficiency, such as Clinical Practice Research Datalink (CPRD) data on HRT use including information on the uptake of HRT including new cases, ongoing use of HRT, preparations used and number of women seeking advice on menopause related issues. Having such information more readily available will help inform a better understanding of current management issues in this area. · There is a pressing need for research: · of modern and novel therapeutic hormonal and non-hormonal regimens which maximise benefits and minimise risks to menopausal women and women with premature ovarian insufficiency. · on the impact of COVID/long COVID on women and its effect on menopausal symptoms. · on the economic impact of the menopause on women, employers and wider society. There is an absence of any estimates of costs of transition in the UK for women's economic participation. Most of the work derives from other countries.
Core theme 6: Impacts of COVID-19 on women's health Many women are significantly affected by the menopause, and with the additional stress some women may be under in view of the strains on society caused by COVID-19, the impact of the menopause should not be underestimated. Many women may be suffering with menopausal symptoms and may be reluctant to approach their GPs due to concerns of not over-burdening an already busy service, and may feel they should simply endure the different symptoms they are experiencing. In addition, a proportion of menopause services have been restricted over the pandemic period due to staffing issues.

The BMS viewpoint
· There is a need to ensure in the recovery phase of the pandemic that menopause services are not overlooked. · Additionally, there is also an ongoing need to support GPs to maintain menopause service delivery in the current climate. · Restoration and maintenance of menopause services is essential not only for treating menopausal symptoms, but also to optimise women's health during the menopause transition and beyond, given that appropriate strategies promoted and instituted at midlife such as lifestyle, diet, exercise and hormonal therapies have significant primary prevention benefits, including bone and cardiovascular health and may potentially have a protective effect on the impact of COVID-19. · Women should be encouraged to seek help for managing their menopausal symptoms and should be advised that the COVID-19 pandemic should not be a reason for them to discontinue HRT or withhold starting HRT if required. Women should not feel that they may be 'overburdening' healthcare providers and should feel that their need for appropriate help and advice will be recognised. · Advice should be provided to women on how they can access menopause consultations remotely to discuss their management options and the local pathways available for having HRT prescriptions issued or renewed. · It is essential that access to face-to-face consultations remains available where a physical examination is needed (e.g. pelvic or breast examination) and access to endometrial assessment (pelvic ultrasound/endometrial biopsy/ hysteroscopy) for women for ongoing unscheduled bleeding on HRT. · Menopause services should aim to offer, where feasible, email/telephone advice and guidance to support primary care and consideration should be given for multi-disciplinary menopause clinics (MDTs) to run virtually as video MDTs and email MDTs. · There is a need to more understanding of the impact of COVID/long COVID on women and the effect it has on the management of menopausal symptoms. · The Covid-19 pandemic has resulted in a detrimental impact on menopause training as well as training in various other medical specialties. As a result, there is a need to modify the way menopause education and training are delivered, including the virtual delivery of educational meetings and online educational resources and webinars to additional educational resources that can be accessed remotely. · There is also a need to increase flexibility in delivering menopause training to overcome the limitations that have resulted from the current service provision restrictions imposed by the pandemic to make it easier and more practical for both menopause trainers and trainees, and allow a quicker turnaround in undertaking and completing training.
The BMS support steps · The BMS recognises that the ongoing provision of menopause care is likely to help many women control their often difficult menopausal symptoms. · The BMS together with the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of General Practitioners (RCGP), Royal College of Nursing (RCN) and the Faculty of Sexual and Reproductive Healthcare (FSRH) produced a framework for restoration of menopause services in response to COVID-19. The objective of the recommendations is to provide guidance to clinical practitioners on the resumption and running of menopause services in the recovery phase of the pandemic to ensure that menopause care provision is not overlooked during this period. It is essential, in this phase that the impact of the menopause and the importance of menopause services is fully recognised to prevent a setback in this vital aspect of women's health.
The framework provided guidance on the following aspects: 1.Impact of menopause on quality of life and women's health: Access to information 2.Menopause services and menopause consultations 3.Prescribing HRT and HRT shortages 4.Unscheduled bleeding on HRT: assessment and management during the COVID-19 pandemic 5.Menopause training The document can be accessed at: https://thebms.org.uk/wp-content/uploads/2021/04/ Joint-Framework-Statement-V2-March-2021.pdf · In addition, the BMS introduced in 2020 an innovative and sustainable programme of virtual educational meetings for healthcare professionals on various aspects of women's health to meet current educational demands during the pandemic. In addition, as part of supporting the training of healthcare professionals, in 2020 the BMS launched its training programme to further the provision of menopause training, and adapted this to allow for the constraints on training caused by the pandemic. All forthcoming BMS meetings and study days in 2021 are being delivered virtually to allow continuity in delivering education in the current climate. · The BMS has noted that virtual educational meetings have allowed some healthcare professionals to attend who may otherwise not have been able to attend an in-person meeting and opened the door to a wider audience who rather than being constrained by whether a meeting is local to them or the practicalities of travelling to it, could attend a meeting virtually regardless of location.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Contributorship
Contributorship: HH wrote the manuscript. SM wrote the manuscript.