Women's health plan 2021 to 2024: final report

Women’s Health Champion

Professor Anna Glasier was appointed as Scotland’s first Women’s Health Champion in January 2023. Below, she reflects on her time in post to date.

Introduction

I was honoured and thrilled to be offered the role of Women’s Health Champion and have thoroughly enjoyed being in post. As Scotland’s first Women’s Health Champion I did not know what was expected of me and I imagine that the Scottish Government was also not entirely sure how best to use me. As a clinician (albeit retired) and still an active researcher, simply being a figurehead was never going to be my style and I have taken quite a ‘hands-on’ approach. While this suits me, I suspect that it also leads to more frustrations in trying to effect change. Writing this report gives me an opportunity to review broadly what I have been doing, to express my thoughts on the totality of the Plan and to give some thought to the next phase.

Where to focus

It was suggested that, while being involved in every aspect of the Plan, I should focus on specific areas. Given my expertise as a gynaecologist, as well as the vocal public demand for more information and better services, it made sense to choose the menopause as one area of interest.

Menopause:

Over the last couple of years media interest in the menopause has been huge. Sometimes this interest increases confusion about the nature of the menopause and the place of hormone replacement therapy (HRT). I think we could do better in finding a balance between over-medicalising the menopause and giving the public accurate information about menopausal symptoms, HRT and the alternatives. Giving women accurate, personalised information should enable them to choose for themselves whether a trial of HRT would be worthwhile if symptoms are troublesome and, importantly, to have realistic expectations as to the benefits and the risks.

Group counselling sessions on the menopause have proven very efficient in providing high quality information with, reportedly, a significant proportion of women apparently finding information alone sufficient to reassure them. Years ago, group counselling sessions for men considering vasectomy in Lothian proved to be a very efficient use of staff time and ensured that everyone received the same accurate information. I encourage GPs to consider such sessions for women in their practice who would like to know more about the menopause.

The Women’s Health Plan has done much to provide accurate information about the menopause to the public through NHS Inform. But we know that most people still use Google when looking for health information and we need to do more to make everyone in Scotland aware of NHS Inform. Importantly too, many people living in the more deprived areas of Scotland may not have access to the internet so we rely on organisations such as The Health and Social Care Alliance Scotland and groups such as the Menopause Warriors Scotland to get information on women’s health in general and on the menopause in particular, to women who find it hard to access and navigate the NHS. We know that women living in deprived areas of Scotland are less likely to be prescribed HRT than women living in affluent areas, and we need to find innovative ways to give all women the same choices about menopause management.

Arguably the biggest problem with menopause services throughout Scotland is the long waiting times for referral to specialist menopause clinics.

Over 51% of Scotland’s population is female and every woman will go through the menopause. It is my view that most women needing advice could be managed within general practice and that there should be at least one clinician in every practice well informed and confident in providing standard HRT. To this end NES have been developing a comprehensive menopause education module for general practice, which will be available on TURAS later this year. We have also worked closely with the Menopause Clinical Reference Group to try to improve relevant referral pathways; write guidance for management of the menopause for women with cardiovascular disease and, through the National Menopause Specialist Network, provide an additional source of updating and clinical advice.

Polycystic Ovarian Syndrome:

My second priority area has been menstrual health and within that I wanted to include Polycystic Ovarian Syndrome (PCOS) since this particular condition is common, has significant implications beyond reproductive health and, arguably, could do with more advocacy.

As with menopause, the Women’s Health Plan is concentrating on educating clinicians and the public. Recognising the value and popularity of the Menopause Specialist Network we have established a Menstrual Health Clinical Network for healthcare professionals which is going from strength to strength. I am aware that many young women with heavy menstrual bleeding and/or painful periods simply put up with their symptoms, unaware that there are simple remedies which can help them. Once again, I think we could do better at informing women, particularly young women, about the nature of menstruation and what to expect. Menstrual dysfunction can be helped by simple non-steroidal anti-inflammatory medication or by tranexamic acid, both of which need only be taken on days when symptoms are bad. I am working with colleagues from Edinburgh University on making the case for tranexamic acid to be added to the medicines available through Pharmacy First when funding becomes available.

It would also be extremely helpful, both for women with menstrual dysfunction, including PCOS, and for contraceptive users, to dispel the negative image that presently characterises hormonal contraception (HC), particularly among young people. This problem is widespread. Colleagues in Europe and the US note increasing reluctance among women and girls, influenced by social media, to consider using hormonal methods. In the UK we need to make an effort to explain better how HC works (both as a contraceptive but also as a means to improve a range of gynaecological problems) and to provide realistic and accurate information about side effects and risks. Importantly, we need to find a way to get this message across using the same social media platforms that the public use. This is not going to be easy. This is a project for which we should be working across the UK.

Heart Health:

A recent commentary in the Lancet^[2] reviewing the English Women’s Health Strategy argued that it is important to address women’s health across non-reproductive conditions, such as mental health, cardiovascular diseases (CVD), and cancer. The third area of priority for me as the Scottish Women’s Health Champion has been heart health. While most women are terrified of breast cancer, in fact they are much more likely to die from heart disease. I have been paying attention to specific reproductive health issues faced by women who have heart disease as well as considering how to improve CVD prevention in the female population.

For women with heart disease, contraceptive options, the management of menstrual dysfunction and the menopause present particular difficulties since many of the therapeutic options are based on estrogen. There are few data on the safety of estrogen treatment in women with heart disease, and so, erring on the side of caution, many clinicians are reluctant to prescribe hormonal preparations. Gynaecologists, Sexual and Reproductive Health (SRH) specialists and cardiologists have been working to prepare practical, evidence-based guidance which should allow more women living with CVD to have access to the more effective methods of contraception, to menopausal hormone replacement therapy and effective treatments for menstrual dysfunction.

I have been highlighting to clinicians working in obstetrics and gynaecology and SRH to pay more attention to risk factors for CVD, particularly those which become apparent during reproductive health consultations.

We need to recognise that women with conditions such as premature menopause, PCOS, recurrent miscarriage and pregnancy induced hypertension (PIH) are all at increased risk of CVD in later life when compared with women without these conditions. We not only need to recognise the association, but we need to think of ways to do something about it. To this end I have been working with colleagues to look at reinstating, among women diagnosed with PIH, the system of self-monitoring of blood pressure and proteinuria (protein in the urine) which was put in place during the covid pandemic.

Most health boards in Scotland stopped using the system after the end of the pandemic despite good evidence that it is both effective and cost-effective for both the NHS and for women with PIH. However, I should like to take self-monitoring a step further and to encourage women with conditions which pre-dispose them to CVD to monitor their own blood pressure for the remainder of their lives linking into a system such as Connect-me BP which would ensure that their hypertension was not only diagnosed but also appropriately treated. I realise that this is a tall order, but it is perfectly in line with the CMO led programme of work to improve the identification and management of clinical risk factors for cardiovascular disease.

Contraception and Abortion:

Contraception and abortion are important aspects of the Women’s Health Plan.

I have been working closely with the relevant policy teams and am chairing the Expert Group charged with reviewing the abortion law with the aim that abortion is seen as a health issue and managed in the same way as all other health issues with clinicians providing information on the risks, benefits and alternatives, empowering women to decide for themselves.

With respect to contraception, I have focused on trying to improve access to the long-acting methods of contraception (intra-uterine devices (IUDs) and contraceptive implants) which have been proven to reduce unintended pregnancies at a public health level.

The Health of Women and Girls in Scotland:

The overall aim of the Women’s Health Plan is to improve the health of women and girls throughout Scotland. It covers issues, such as menstrual health, which are not dealt with elsewhere, but it is primarily concerned with the health of women in every sphere. Recognising the causes of the gender health gap, such as the many socio-economic factors that disadvantage women, I should like to see the next phase of the Plan aiming to make the health of women central to every area of healthcare so that in the future we have no need for a plan specifically focusing on women and girls.

Professor Anna Glasier OBE, Women’s Health Champion