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Nurse specialist in menopause

Introduction

  • The menopause happens to all women, however, the degree of its impact on a woman’s quality of life and the symptoms experienced are very individual
  • Menopausal women are seen in both primary and secondary care and by nurses of various disciplines, so the title of the nurse has been left deliberately broad to encompass all nurses who work at this advanced level of practice. It also acknowledges that nurses will be working at all levels within menopause services and this is aimed at nurses who are running services for women with more complex needs where there are limited national guidance available
  • The menopause naturally focuses on women, and women’s health, although it is acknowledged that consequences can also have an impact on men

Defining menopause

  • The menopause is defined as: ovarian failure due to loss of ovarian follicular function accompanied by oestrogen deficiency resulting in permanent cessation of menstruation and loss of reproductive function
  • NICE define menopause as: ‘Menopause is when a woman stops having periods as she reaches the end of her natural reproductive life. This is not usually abrupt, but a gradual process during which women experience perimenopause before reaching post-menopause
  • The transitional phase known as peri-menopause describes the time leading up to a woman’s final menstruation, along with the endocrinological, biological, and clinical features of the approaching menopause. The length of this transition is usually about four years, however, 10% of women may not experience this phase and menstruation may stop abruptly. The median age for menopause is 51–52 years, over an age range of 39–59 years
  • Terms used in the menopause are:
    • pre-menopause: the reproductive years prior to the last menstrual period
    • peri-menopause: the time immediately around the menopause, often accompanied by longer cycles and heavier and prolonged bleeding. These menstrual irregularities are due to decline in ovarian follicular function, but before 12 consecutive months of amenorrhoea (lack of menstruation) have yet occurred. This stage is often accompanied by hot flushes (vasomotor symptoms)
    • post-menopause: a period of time where no menstruation has occurred in 12 consecutive months. The median age for this to happen is 51–52 years. Women may continue to have symptoms beyond that time
  • The primary aim of menopause care is to provide women-centred assessment, advice and treatment which improves quality of life and promotes health into the years beyond menopause. This is achieved by using the NICE guidelines as well as adapting and building on them for a specialist service, including:
    • adopting an individualised approach at all stages of diagnosis, investigation and management
    • providing information in different ways, tailored to the individual
    • discussing treatment options, including an individualised risk assessment of each types and excluding contraindications
    • offering treatment as appropriate, monitoring and adjusting as necessary
    • adapting treatment as needed, based on a woman’s changing circumstances
    • taking into account fertility needs
    • considering and address psychological needs
    • seeing women at high risk of or with breast cancer
    • seeing women with other risk factors such as type 2 diabetes
    • seeing women with premature ovarian insufficiency
  • This is an important health issue for employment, including occupational health nursing. Women should be offered support and advice regarding their employment as well as their physical and mental wellbeing

The role of the nurse specialist in menopause

  • The role of the nurse specialist in managing and supporting women with menopause has been defined to take account of the need to:
    • facilitate a better understanding and the potential health implications of a well-managed menopause among all nurses coming in contact with women
    • lead and develop specialist menopause services
    • support these services and ensure they are linked with all areas of care
    • Following the publication of the NICE guidelines for the management of menopause the BMS has defined a specialist as:
    • A menopause specialist in the UK is defined as a health care professional who has obtained the British Menopause Society (BMS)/Faculty of Sexual Reproductive Health (FSRH) Advanced Menopause Certificate
    • is a member of the BMS
    • attends a National (BMS), European or International Menopause Society conference at least once every two years
    • provides a minimum of 100 menopause related consultations per year, of which at least 50 are new
    • has the responsibility documented as part of their job plan and discussed at their annual appraisal
  • Health professionals wishing to register as a specialist do so at: https://thebms.org.uk/nice-guideline/menopause-specialists

The Grandfather clause

  • In recognition of the number of specialists already working in the field of menopause, the BMS also included a clause, called the Grandfather clause, which enables those already working to this standard to apply retrospectively for recognition of the role. Nurses who wish to utilise this will need to apply to the BMS. Please refer to the full guideline for further details

Clinical context for women accessing services

  • Women can be seen in any area of health care (e.g. general practice, genetics, fertility services). They are seen for a variety of reasons and symptoms. It is important that nurses who specialise in supporting women with menopausal symptoms develop relationships with all these areas of practice, and understand the importance of effective multi-professional working and service provision
  • Women that may be seeking help in a specialist context may include women with:
    • women with suspected or confirmed premature ovarian insufficiency (POI)
    • women with hormone dependent cancers
    • women prior to risk-reducing surgery—bilateral salpingo oophorectomy for BRAC (BRCA1 and BRCA2 are human genes that produce tumour suppressor proteins)
    • women with contraindications to hormone replacement therapy (HRT)
    • women with a complex medical history
    • women with multiple treatment failures or side-effects on HRT
    • women with bleeding problems on HRT
  • The nurse specialist will see women who have a complex physiology and/or mental health needs. They will also be responsible for facilitating a better understanding of menopause amongst other nurses and women, men and their families

Different levels of complexity and practice

  • There are different levels of complexity and consequently different levels of practice required to best support women who present with menopausal symptoms that are causing concern or require specialist input with regard to hormone replacement therapy

Level one—registered nurse

  • Every registered nurse should have some understanding of the impact of the menopause on women, as women will present in a range of services as outlined above. An example of this could be seeing women for cervical screening, where they should be prepared to initiate discussions around issues such as vaginal dryness and menstrual periods and use this opportunity to provide further information about the menopause. Women may also raise the topic of menopause at other consultations, requiring all nurses to know where to signpost women for support and advice

Level 2—registered nurse with specialist knowledge

  • Nurses who have specialist knowledge of menopause will be seeing women in consultations specifically for menopause. They will be following NICE guidelines including discussing symptoms, medication and non-prescribed therapies. They would assess and monitor women with ongoing discussions of risk and benefits of medication, giving general health advice and have developed local pathways, knowing where to refer those who have more complex needs requiring a specialist menopause service

Level 3—registered nurse: specialist nurse menopause

  • The nurse specialist in menopause will have additional knowledge and skills, including formal education in menopause, as outlined above or for example, FSRH Special Skills Modules in Menopause. They would be responsible for assessing and treating women with more complex needs which is not detailed in NICE guidelines. These may be women with multiple treatment failures, women with POI and women with hormone dependent cancers. These specialist nurses will be responsible for developing pathways within their area of practice, and will be seen as a resource for those with less specialist knowledge. They will also actively engage in development and evaluation of local guidelines agreed within multidisciplinary teams and across specialties

Nurse specialist menopause responsibilities

  • The responsibilities of the nurse specialist in menopause could encompass:
    • development of pathways for women with specialist needs in menopause. This includes working with the multidisciplinary team and with other specialties
    • on their initial visit to the service, women could be seen by the nurse specialist and holistic history elicited to include a full review of symptoms including history, medical, menstrual and sexual history
    • where investigations are incomplete or additional ones are needed these can be performed or booked
    • detailed literature about treatments and likely next steps discussed
    • medications and treatment/therapies history
    • a risk assessment for cardiovascular disease, bone/osteoporosis and cancer risk
    • agree a plan of management with the woman, including prescribing and initiate treatment, if appropriate
    • ensure women have contact details of the nurse specialist and can make contact if problems develop or issues need clarified
    • a three-month review, including symptoms and side-effects of any medication, assessment of any bleeding, and then three-monthly checks until symptoms settle and annually thereafter—this care pattern may be referred back to general practice
  • This should include a quality of life assessment

Nurse specialist in menopause: skills and knowledge

  • The role of the nurse specialist is complex and will demand a range of practice skills, alongside management and leadership insightfulness. This advanced role will require the nurse to be able to:
    • be an inspiration and source of knowledge for others
    • reflect on own practice and use audit tools to assess effectiveness of own practice
    • enhance their own education
    • consider the need for research to further enhance practice
  • It is recognised that this is a developing role and that not all nurses will come with the full skills set required to fulfil all components outlined below

Clinical practice skills

  • Have an expert knowledge of the condition, all treatments options (including associated side-effects; complementary therapies), and be able to signpost patients to the appropriate services
  • See at least 100 patients per year, with 50 being new
  • Be able to communicate at all levels, with women and staff, both in primary and secondary care. Methods include written and verbal communications including good documentation
  • Be able to undertake consultations independently, which include assessment, history, physical and psychological assessment, and risk assessments for example, pelvic assessment where appropriate
  • Be competent in the use of ordering and interpreting diagnostic tools/tests DEXA (bone densitometry, also called dual energy x-ray absorptiometry) relevant haematology assessments, ultrasound and genetic tests
  • Work with women, giving pre-operative and post-operative advice for surgical menopause and HRT advice
  • Hold independent clinics both face-to-face and as a telephone service giving independent holistic consultations
  • Be a non-medical prescriber with knowledge of drug regimens and side-effects, including complementary therapies
  • Undertake counselling or be able to refer to the appropriate services
  • Undertake referrals—post-menopausal bleeding clinics, fertility, investigations, metabolic bone/osteoporosis, genetics, psycho sexual care/counselling, bladder and bowel care, counselling, mental health, and cognitive behavioural therapy
  • Advise on lifestyle and complementary therapies and medicine, and ensure that current and long-term health is optimised

Leadership skills

  • Be the woman’s advocate
  • Have the ability to work independently, as well as part of the multidisciplinary team, and to be organised
  • Be an autonomous practitioner while also working across and within multiple specialty teams
  • Be aware of the value and costing of the service by looking at the impact of the nurse specialist on service users; for example, by user satisfaction ratings, number of consultations, number of women seen and number contacted, audit of appointment cancellations and audit of pathway in conjunction with management teams

Service provision/pathway management/co-ordination

  • Team work—this includes working with the multidisciplinary team to co-ordinate the care of women with other specialities, e.g., fertility
  • Ensure a streamlined service in all areas of care
  • Be the central point of contact for women
  • Design and monitor care pathways
  • Provide emotional support to women
  • Ensure there is access to specialist care within either primary or secondary care

Data collection and management

  • Service evaluation and audit, including women’s views on the service and individual women in relation to quality of life and symptom relief
  • Informs research and uses research in practice
  • IT skills should incorporate database, protocols, literature searching, audit, questions, research, word processing and spreadsheets

Education and training delivery

  • Provide education to all health care professionals in relation to menopause
  • Develop educational materials for women and men, or be able to source them
  • Work with non-specialist menopause health care professionals to identify women who may need specialist help
  • Mentor and support health care professionals within menopause, as appropriate
  • Train and assess health care professionals within menopause, as appropriate

Menopause profile development

  • Raise awareness with women and men and within primary and secondary care to work with support groups to highlight the impact of menopause on women and especially with specialist menopause issues e.g., POI and menopause after cancer
  • Be aware of local support groups and charities
  • Understand the local and political landscape for providers
  • Actively find links in primary and secondary care and access to specialist services
  • Provoke interest and engage with others about menopause
  • Conduct audits and consider opportunities for research to enhance practice

Continuing professional development

  • The level of education needed for the role is at master’s level, with evidence of master’s level critical thinking and problem solving
  • A registered nurse who has obtained the BMS/FSRH Advanced Menopause Certificate
  • Be a member of the BMS
  • Attends a National (e.g. BMS) or International Menopause Society (e.g. IMS, EMAS) conference at least once every 2 years
  • Provides a minimum of 100 menopause-related consultations per year, of which at least 50 are new
  • Other education could include for example: non-medical prescribing, presentation skills, evidenced-based practice, advanced nursing practice, counselling, leadership enhancement, sexual health care, contraception, advanced physical assessment skills
  • Manages effective support for self-supervision, mentoring/buddies, using other nurse specialists and a menopause network
  • Ensures the responsibilities of the role are documented as part of their job plan and discussed at their annual appraisal
  • Maintains skills and knowledge in line with NMC requirements for revalidation
  • Considers using the RCN Credentialing process to enhance career development opportunities

Conclusion

  • The NICE guidelines reference a specialist health care practitioner from any discipline and this development should be welcomed and celebrated as an attractive career opportunity for nurses. The nurse specialist in menopause represents an exciting opportunity for nurses to develop into a leadership role in a collaborative environment, where they can facilitate high quality care for women who are experiencing challenges with this life event, and require expert advice and good menopause management to improve their personal experience and prevent long-term negative consequences (such as osteoporosis). It is being recognised as a strategic leadership opportunity for nurses who specialise in an important aspect of woman’s health care

full guideline available from…

www.rcn.org.uk/professional-development/publications/pub-005701

Royal College of Nursing. Nurse specialist in menopause. March 2017.

First included: April 2018.