Nurse Specialist in Menopause

Overview

The role of a specialist in menopause was included in the 2015 NICE guidelines on managing menopause; however, the detail of how this role might be implemented in practice was less clear and subsequently the British Menopause Society (BMS) produced a guide for all healthcare professionals.

This Guidelines summary of the Royal College of Nursing (RCN) guidance for nurse specialist in menopause builds on the BMS agreed standards, focusing on the options for nurses who may choose a career pathway towards becoming a specialist practitioner in menopause.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Defining Menopause Care

Facts and Figures About the Menopause

• The average age for a woman in the UK to reach the menopause is 51–52 years
• There is no definite single blood test to diagnose menopause
• Early menopause is when menopause occurs in a woman under the age of 45 years, and premature ovarian insufficiency is when the menopause occurs in women aged under 40 years. An estimated 1% of women under 40 years, and 0.1% of women under 30 years, are affected by premature ovarian insufficiency
• Around eight out of 10 women in the UK experience symptoms of the menopause. Of those, 45% find their symptoms difficult to deal with
• Around 70% of women experience the most common menopausal symptoms: hot flushes and night sweats
• Many women experience vaginal dryness and painful sex due to lack of oestrogen
• Women need to use contraception for 1 year after the last menstrual period if they are over 50 years old, and 2 years if under 50 years old
• Hormone replacement therapy (HRT) is not a contraceptive.

Menopause Care

• The primary aim of menopause care is to provide women-centred assessment, advice, and treatment that 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 type and excluding contraindications
  • offering treatment as appropriate, monitoring and adjusting as necessary
  • adapting treatment as needed, based on a woman’s changing circumstances; including being sensitive to gender-specific issues and sexual differences
  • 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 (POI)
• 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 menopause is defined to take into account 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 British Menopause Society (BMS) has defined a specialist as:
  • a healthcare professional who has obtained the BMS/Faculty of Sexual Reproductive Health (FSRH) Advanced Menopause Certificate, or completed the Royal College of Obstetricians and Gynaecologists/BMS Advanced Training Skills Module^[A] in Menopause Care (or equivalent, for example, the menopause and premature ovarian failure module of the subspecialty training programme in reproductive medicine) and who: 
    • is a member of the BMS
    • attends a national (BMS), European, or International Menopause Society (IMS) conference at least once every 3 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 the BMS website
• Recertification with BMS is required every 3 years, when specialists will be asked to confirm that they still fulfil the criteria
• This summary provides further details for nurses who wish to develop their expertise towards becoming a nurse specialist in menopause, and encompasses the care of all women with menopause
• Nurses who wish to advance their practice to within the specialty of menopause will have:
  • extensive experience working within a women’s health setting
  • been educated to master’s level and display masters level critical thinking and decision making
  • an insight into the menopause and all of the areas of management, including the wider social and political dimensions of the menopause
• There are currently no commissioned services for women with menopausal symptoms; however, the direction of travel is that specialist service requirements will change this as this important area of women’s health care is being better recognised.

Clinical Context for Women Accessing Services

• Women can be seen in any area of healthcare (for example, oncology services, genetics, fertility services, general gynaecology, mental health, medical clinics [renal, lupus, osteoporosis, and orthopaedics], general practice, and sexual and reproductive healthcare). 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 suspected or confirmed premature POI
  • women with hormone-dependent cancers
  • women pre-risk-reducing surgery—bilateral salpingo oophorectomy for BRCA (BRCA₁ and BRCA₂ are human gene mutations that produce tumour suppressor proteins)
  • women with contraindications to 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 healthcare professionals 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 HRT.

Level One—Registered Nurse

• Every registered nurse and registered nursing associate 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 Two—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 and knowing where to refer those who have more complex needs requiring a specialist menopause service. This can be nurses in any area and they are likely to need further training—see BMS education pages at: thebms.org.uk.

Level Three—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 complex needs that are 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, as well as actively engaging in professional and political engagement.

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 a 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 3-month review, including symptoms and side-effects of any medication, assessment of any bleeding, and then 3-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

• To have an expert knowledge of the condition, all treatments options (including associated side effects; complementary therapies), and be able to signpost if needed
• 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, for example, dual energy X-ray absorptiometry,  relevant haematology assessments, ultrasound, and genetic tests
• Work with women, giving preoperative and postoperative advice for surgical menopause and HRT advice
• Hold independent clinics both face-to-face and as a telephone/virtual 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—postmenopausal bleeding clinics, fertility, investigations, metabolic bone/osteoporosis, genetics, psychosexual 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/Coordination

• Team work—this includes working with the multidisciplinary team to cohttps://www.rcn.org.uk/Professional-Development/publications/nurse-specialist-in-menopause-uk-pub-010-335ordinate the care of women with other specialities, such as fertility
• Ensure a streamlined service in all areas of care
• Refer women to the multidisciplinary team meeting, and be a key member of the case discussion by using expert clinical knowledge to inform management and act as an advocate for patients
• Be the central point of contact
• Design and monitor care pathways
• Provide emotional support
• Ensure there is access to specialist care within either primary or secondary care
• Advise on and support women in the workplace with menopausal issues.

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 (such as Microsoft Word and Excel).

Education and Training Delivery

• Provide education to all healthcare professionals in relation to menopause
• Develop educational materials for women and men, or be able to source them
• Work with non-specialist menopause healthcare professionals to identify women who may need specialist help
• Mentor and support healthcare professionals within menopause, as appropriate
• Train and assess healthcare 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, such as 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 (BMS) or international menopause society (IMS, European Menopause and Andropause Society) conference at least once every 3 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.

Footnote

[A] Please note the Advanced Training Skills Module is only available currently to medical staff.