Womens health and COVID 19

Since the start of the COVID-19 pandemic we have changed the way of working in general practice by continuing to deliver high quality care through initial remote consultation and triage aiming to reduce infection spread by unnecessary face to face contact. In women’s health there are opportunities to deliver quality care remotely provided there is a good understanding of the menstrual cycle, individualised holistic risk assessment and to support patient expectations. There are also many excellent on-line resources available which can empower patients with a better understanding of their concerns and management choices (self-care and medical interventions).

This section of the Women’s Health toolkit contains resources to help provide care during the COVID-19 pandemic, including when this can be offered remotely, including tips about applying recommendations to practice.

Guidance on:

Maternity

Coronavirus (COVID-19) infection in pregnancy published by RCOG and RCM.

This updated document aims to provide guidance to healthcare professionals who care for pregnant women during the COVID-19 pandemic.

The advice is not intended to replace existing clinical guidance but to use available evidence, good practice and expert consensus opinion to:

  • Reduce the transmission of SARS-CoV-2 to pregnant women
  • Provide safe, personalised and woman-centred care during pregnancy, birth and early postnatal period, during the COVID-19 pandemic
  • Provide safe, personalised and woman-centred care to pregnant and postnatal women with suspected/confirmed COVID-19

Supporting pregnant women using maternity services during the coronavirus pandemic: Actions for NHS providers.

In December 2020 guidance was published by NHSE to support women using maternity services during the coronavirus pandemic. This includes advice for maternity units to permit pregnant women in England to have one person beside them at all stages of the maternity journey and to be able to attend appointments (ante-natal, intra-partum and postnatal), as long as the support partner is not showing any COVID-19 symptoms. 

The Royal College of Psychiatrists advice on perinatal mental health during the COVID-19 pandemic

The recommendations identify the need to support pregnant women who may experience increased anxiety because of concerns about:

  • COVID-19 infection
  • impact of social isolation and reduced support from usual family and friends’ networks
  • financial worries
  • changes to usual face to face antenatal care

This is particularly important for those experiencing domestic violence or with safeguarding concerns.

The document includes information and signposts to a number of support services for women affected by:

  • postpartum psychosis
  • bipolar disorder
  • perinatal OCD
  • eating disorders
  • depression and other perinatal mental illnesses
  • perinatal anxiety

COVID-19 vaccination and pregnancy

Gov.UK have published COVID-19 vaccination: a guide for women of childbearing age, pregnant, planning a pregnancy or breastfeeding. 

Questions have been raised about COVID-19 vaccines in pregnancy, women who may become pregnant within the following 3 months and when breast feeding. Updated advice published by MHRA on 30 December 2020 recommended that both the Pfizer / BioNTech and Oxford University / AstraZeneca vaccines may be considered for use in pregnancy when the potential benefits outweigh any potential risks for the mother and baby. Women should discuss the benefits and risks of having the vaccine with their healthcare professional and reach a joint decision based on individual circumstances. Women who are breastfeeding can also be given the vaccine. 

Reproductive health

Faculty of Sexual and Reproductive Health Clinical Effectiveness Unit (FSRH CEU) recommendation on extended use of etonogestrel implant and 52mgs levonorgestrel-releasing intrauterine system during COVID restrictions.

The available evidence suggests that the risk of pregnancy in the 4th year of use of an etonogestrel implant and the 6th year of use of a 52mgs levonorgestrel-releasing intrauterine system (LNG-IUS) is likely to be very low. FSRH CEU suggest that in the current circumstances replacement of both devices can be delayed for up to a year although users should be made aware that the contraceptive efficacy cannot be guaranteed. Progestogen-only contraceptive pills can be taken in addition or use of condoms is an alternative option while waiting for the change of their contraceptive device.

When using Mirena for endometrial protection as part of HRT the LNG-IUS must be changed after 5 years or alternatively the HRT can be altered to a combined preparation.

The lower dose LNG-IUS devices require changing at their expiry time or additional contraception added as there is no evidence to support their extended use. 

Managing contraceptive provision during coronavirus pandemic.

Primary Care Women’s Health Forum (PCWHF) resource ‘How to manage contraceptive provision without face to face consultations’.

The resource is written by expert clinicians at the PCWHF and includes advice on:

  • Combined hormonal contraception
  • Progestogen only pill
  • Women due for a change of IUD/IUS/implant
  • Contraceptive injections
  • Emergency contraception 

Protocol for LARC fittings in primary care during COVID-19 restrictions

Since March 2020 there has been a reduction in LARC activity in specialist SRH services and primary care. To support clinicians to safely deliver services where possible the PCWHF resource explains how to minimise the risk of transmission of COVID-19 while providing LARC procedures. 

PCS COVID-19 Community Contraception Guide

A contraception guide flowchart for local use or adaptation. It covers oral contraception, repeat or new starter and long acting reversible contraception: Depo DMPA, implant, copper IUD and IUS. 

Guidelines in Practice article: Top Tips: contraception and COVID-19

Written by a practicing GP with an interest in sexual and reproductive health this article offers practical information on:

  • The impact of the COVID-19 pandemic on access to contraception
  • How to maintain the provision of contraception despite the reduction in face-to-face consultations
  • The efficacy and practicality of long-active reversible contraceptive methods, particularly during the pandemic

Webinar: Managing contraception in primary care remotely during COVID times and beyond

Case based presentation applying latest recommendations on providing contraception choices counselling using on line resources and remote consultation where appropriate, including management of any concerns aiming to improve contraceptive compliance and uptake of long-acting reversible contraception.

Menstrual wellbeing

Joint RCOG, BGSE, BGCS guidance for the management of abnormal uterine bleeding in the evolving Coronavirus (COVID-19) pandemic

A consensus statement providing a framework for the management of women presenting with abnormal uterine bleeding including:

  • Heavy menstrual bleeding
  • Intermenstrual bleeding
  • Postmenopausal bleeding
  • Post-coital bleeding 

How to manage women presenting with abnormal uterine bleeding in primary care without face to face contact during COVID-19

Advice published by PCWHF produced by clinical expert consensus and adapted for use in primary care from recommendations published by RCGO/BSGE/BGCS/BMS. The guidance includes advice on managing women presenting to primary care with:

  • Heavy menstrual bleeding
  • Intermenstrual bleeding
  • Postmenopausal bleeding (occurring in women not using HRT)
  • Post-coital bleeding
  • Unscheduled bleeding on HRT

Guidelines in Practice article:  Abnormal uterine bleeding: management in COVID-19 and beyond

Written by a GP with an interest in women’s health this article explains:

  • Types of abnormal uterine bleeding
  • When women with AUB need to be seen, examined and investigated and when management can be remote
  • How guidance on the management of AUB in the COVID-19 pandemic may provide future learning opportunities

Webinar: NICEr for women: managing bleeding problems in primary care

Case based presentation applying latest evidence and guidance to the management of women presenting to primary care with abnormal uterine bleeding. Including recommendations for when women can be managed remotely and when examination and investigations are required.

Menopause and beyond 

Webinar: Managing HRT and contraception remotely during COVID and beyond

Case based presentation applying latest evidence and guidance to the management of women presenting to primary care with menopausal concerns, including when prescribing hormone replacement therapy (HRT).  The discussions include tips about when management can be provided remotely and when examination and investigations are required.

The Personalised Care Podcast: Women's Health

In the first episode of The Personalised Care Podcast, brought to you by the Personalised Care Institute, you’ll hear a patient’s powerful description of what it was like to go through the menopause as we discuss the impact of a personalised care approach from healthcare professionals. We explore the importance of sensitive language in consultations and discover why the ‘one size fits all approach can be very damaging. This episode is all about helping healthcare professionals to empower women who seek help with the menopause, and we’ll be discussing the importance of appreciating the individual’s concerns and what matters to them.

How to manage HRT provision without face-to-face consultations during COVID-19 healthcare restrictions

PCWHF guide for primary care practitioners to support HRT provision during the COVID-19 pandemic, endorsed by BMS.

Includes tools for:

  • Initiating HRT by remote consultation
  • Reviewing HRT by remote consultations
  • HRT prescribing
  • Managing side effects and trouble shooting
  • Managing unscheduled vaginal bleeding and HRT
  • Individual assessment of long-term benefits and risks of HRT
  • Use of vaginal treatments 

Reflections and recommendations on the COVID-19 pandemic:  Should HRT be discontinued?

The board of the Italian Menopause Society has provided advice on the use of hormone therapy during the COVID-19 pandemic including the following recommendations:

  • Hormone therapy and hormonal contraceptives should be continued, unless the woman is severely ill
  • In cases of disease progression to severe symptoms, expert advice should be requested with consideration of the need to treat with heparin
  • Transferring from oral to transdermal oestrogen may be considered, but is not mandatory
  • If starting or restarting therapy it is probably useful to use transdermal instead of oral oestrogens
  • When hormone therapy is discontinued, it should be remembered that withdrawal bleeding may occur

BSUG guidance on management of urogynaecological conditions and vaginal pessary use during the COVID-19 pandemic

The recommendations include the assessment for timing and requirement for face to face review of women with urogynaecological conditions and when remote or delayed management is preferred when balancing the benefits and risks of COVID-19 transmission.  Recommendations also include vaginal pessary use for prolapse. 

Patient information

RCOG and RCM Coronavirus infection and pregnancy 

This resource provides information for pregnant women and their families, including videos and frequently asked questions.

This resource also includes information on:

  • Covid-19 vaccination during pregnancy and breast feeding
  • Women at higher risk of serious illness including from BAME communities
  • Early pregnancy
  • Antenatal care
  • Childbirth choices
  • Postnatal care
  • Occupational health guidance for pregnant women working in public facing roles

Sexwise - Help during COVID-19

Resource providing advice on contraception choices and sexual health including a section on Help during COVID-19.  This provides information on how to access sexual health services during the COVID pandemic, including:

  • Where to find the local sexual health services
  • How to access services which appear closed
  • Maintaining good sexual and reproductive health during COVID-19
  • Further specific information sites 

Endometriosis - COVID 19 and endometriosis

Endometriosis UK have added a page to their website containing the latest information and resources available on COVID-19 and endometrioisis. The resources include current recommendations on medical treatments and strategies for the management of associated symptoms including:

  • Coronavirus and endometriosis
  • Medical and self-care advice
  • Pelvic exercise programme
  • Webinars on endometrioisis and COVID-19 

Jo’s Trust - Coronavirus hub

Jo’s Trust have created guidance to help manage concerns for those due for cervical screening, have cell changes or are affected by cervical cancer. This includes information on:

  • Cervical cancer and coronavirus
  • Changes to screening and colposcopy
  • Blogs to include practical tips, other people’s experiences and support 

Target Ovarian cancer - wellbeing during the pandemic

In response to concerns raised about emotional distress caused by coronavirus pandemic Target Ovarian Cancer have produced a page on wellbeing during the pandemic including:

  • Q&A on mental health concerns and anxiety due to COVID-19
  • Support for women waiting for/undergoing cancer investigations and treatments
  • Signposting to on-line resources to help with mental health concerns 

Eve Appeal - cancer and coronavirus

Eve appeal have published a page on their website specifically for people living with gynae cancer, or experiencing any worrying symptoms. This includes information on coronavirus and:

  • Womb cancer
  • Ovarian cancer
  • Vulval cancer
  • Vaginal cancer
  • Cervical screening and colposcopy
  • BRCA testing during COVID-19
  • Reducing your risk.

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