Cervical cancer is a particularly virulent and nasty cancer that most commonly affects women aged 30 to 35 years. Treatment is usually total hysterectomy (removal of the womb) in combination with  chemotherapy plus radiotherapy to the pelvis. Both chemotherapy and radiotherapy affect the ovaries, effectively shutting them down. This means that the periods stop and full blown menopause kicks off. This is termed Premature Ovarian Insufficiency (POI) if the woman is under 40 and early menopause if she is aged 40 to 45. 

If under 40, a small number of women can start to menstruate again, sometimes several years after her cancer treatment has ended. Fertility, however, rarely returns. Irradiation of the pelvis can have catastrophic longterm effects if strategies are not put in place by the cancer survivor’s healthcare professionals. Pelvic Radiation Disease (PRD) is a term used to describe a collection of symptoms that can arise in non-cancerous body tissues after radiotherapy treatment. The effect of radiotherapy on the pelvic area can be immediate with six-to-eight in 10 people undergoing radiotherapy experiencing acute side effects, which generally start two weeks into radiotherapy and can settle two to six months after the treatment. Nine in 10 patients will have chronic symptoms that persist for more than six months or develop afterwards. Symptoms can affect the bowels with frequent motions or rectal bleeding, the bladder giving painful or frequent urination or the pelvic floor resulting in difficulty passing urine or incontinence. Pelvic radiation can cause chronic  pelvic pain, and sexual dysfunction such as pain during intercourse, reduced sexual pleasure and inability to achieve orgasm.

Unlike breast. womb and ovary cancers, cervical cancer is not driven by oestrogen or hormones. Oestrogen replacement with HRT and vaginal oestrogen is completely safe to use after cervical cancer. This is not generally well known. Timely oestrogen therapy, both systemic HRT and vaginal oestrogen plus pelvic floor physiotherapy can prevent many of the symptoms of PRD.  

I work in CUMH Complex Menopause Clinic and have seen firsthand the consequences of late or no oestrogen therapy for cancer survivors who have had chemotherapy and pelvic radiotherapy. 

What causes cervical Cancer?

The human papillomavirus (HPV) causes almost all of the main types of cervical cancer.

There are more than 100 HPV types but only 14 are considered high risk. Two of these; HPV 16 and HPV 18 cause 70 per cent of all cervical cancer cases.

HPV is a common bug and anyone who has been sexually active is at risk of HPV infection, Infection can be passed on through oral sex, touching in the genital area, vaginal or anal sex or sharing sex toys. Using condoms will not completely stop you catching HPV but will greatly reduce the risk.

For many of us, HPV causes no harm and  our immune system clears about half of HPV infections within six to 12 months. But sometimes this doesn’t happen and the infection persists. If that happens with one of the high risk types of HPV,  the virus can cause changes to the cells in the cervix. These changes are sometimes called pre-cancers as they could develop into cervical cancer. These pre-cancer cells  can be treated and completely removed.    

Can we prevent Cervical cancer? And how? 

Yes! Cervical cancer is entirely preventable and curable, as long as it is detected early and managed effectively. Yet it is the fourth most common form of cancer among women worldwide, with the disease claiming the lives of almost 350 000 women in 2022. 

Vaccination

The HPV vaccination programme in Ireland officially began in September 2010, initially targeting 12-13 year-old-girls. The programme expanded to include boys in 2019. The vaccine is safe, free and school-based. 

Screening

Ireland’s national cervical screening programme, known as CervicalCheck, officially started in September 2008, a little later than other countries. In 2008, the cervical screening test was cytology based, which meant taking a sample of cells from the cervix and having these analysed. Research published in 2014 showed that HPV screening was better at detecting cervical abnormalities before they developed into cancer. In simple terms, cytology picked up about 15 out of 20 abnormalities in every 1,000 women screened. HPV testing detects 18 of those 20. The chance of a false negative test is lower with HPV testing. In 2020, Ireland made the switch from cytology to HPV testing and we were one of the first countries to adopt this more advanced screening method. The screening interval is every three years for women aged 25 to 29, and every five years for women aged 30 to 65.

So your smear test is not a cancer test; it is a test for HPV. If  you have one of the high risk HPV types, you go for an examination called a colposcopy; essentially a closer look at the cervix. If anything abnormal is found a biopsy is taken. Pre-cancer changes can be treated there and then  with what is a simple zapping or cautery type procedure, so you nip it in the bud and no cancer develops. If  you have had one of these pre-cancer changes detected, your doctors will keep a closer eye on you and do annual smear tests until you have had a few years of negative smears.  

Treatment

Without screening and treatment, women with high-grade abnormalities would have a 31 per cent or one in three chance  of developing cancer. With treatment, that risk drops to 0.5 per cent  or one in 200. It’s an incredible reduction, demonstrating the effectiveness of cervical screening.

So can we get rid of Cervical Cancer altogether? 

That is the aim! In August 2020 the World Health Organisation (WHO) adopted the Global Strategy for Cervical Cancer elimination.  

In order to eliminate cervical cancer,  an incidence rate of below four per 100 000 women needs to be reached. To achieve that goal  the following three targets need to be met:

Vaccination: 90 per cent of girls fully vaccinated with the HPV vaccine by the age of 15.

Screening: 70 per cent of women screened using a high-performance test by the age of 35 and again by the age of 45.

Treatment: 90 per cent of women with pre-cancer treated and 90 per cent of women with invasive cancer managed.

This is known as the 90/70/90 target.

How are we doing? 

Ireland formally committed to the WHO global initiative to eliminate cervical cancer  in January 2023 and  Ireland’s Cervical Cancer Elimination Action Plan was launched November 2024. 

Ireland’s current cervical cancer annual incidence rate is 11 per 100,000 women, based on 2021-2023 data. Despite temporary fluctuations during the COVID-19 pandemic years, the long-term trend since 2009 continues to decline. 

We are performing strongly against WHO’s 90-70-90 targets and remain on track to actually eliminate cervical cancer by 2040; 

Vaccination: HPV vaccination coverage: In 2025, 82.7pc of girls by the age of 15 years were vaccinated and  2022/23 data showed 76.6 per cent of boys in first year had received the vaccine.

Screening: At the end of 2025, 76pc of women aged 25 to 65 have had a smear test in the last five years. 

Treatment: 2025 data showed that 97.2pc of cervical cancers treated within one year of diagnosis.

Get a smear test…It might save your life

All the above is great and really positive but the sad reality is that most cervical cancers are found in women who have not had smear tests and sometimes it is detected after it has spread to other organs, resulting in a poorer prognosis. Cervical cancer can be completely asymptomatic.  

Ladies, none of us like having our vagina rummaged around in with what looks like a dodgy set of salad tongues. Yes, it can be uncomfortable; yes, it can be embarrassing having your bits out on display to your nurse or GP but, if you have not had a smear in the last three to five years, get over yourself and get one done. Plus, in the near future it is going to be possible to do your own test at home. 

When I see a patient who is avoiding smears, I always ask her why? Often the reason is that she has previously had a painful, sometimes brutal and insensitive vaginal examination in the past and is understandably reluctant to repeat it. Sometimes previous childhood sexual abuse or rape in adulthood comes to light. I always thank my patient for sharing such sensitive, painful information. I assure her that I can use a very small instrument and take as much time as she needs. Most importantly if she wants me to stop, we stop. 

If this article has raised any questions for you about the HPV vaccine, your smear test or perhaps you are a cervical cancer survivor and not on oestrogen therapy, please go and discuss your concerns with your GP.

Unfortunately, Ireland like other European countries, is experiencing an increase in STIs over the last five years.

The most commonly notified STIs in Ireland in 2024 were chlamydia (n=11,534) and gonorrhoea (n=5,961). 

HSE Health Protection Surveillance Centre data to the end of 2023 showed that notification rates for all STIs in Ireland increased by 30.7 per cent compared to 2022. Worryingly, in females aged 15-24 years, Gonorrhoea notifications increased by152 per cent and Chlamydia by 28 per cent in that same time period. 

One explanation for this might be that we are picking up previously undetected STIs because confidential, free STI testing at home was introduced in Ireland in 2021. In 2024 the HSE Home Testing accounted for 48 per cent of chlamydia and 29 per cent of gonorrhoea notifications nationally. The remainder were diagnosed by GPs or in a hospital setting. 

Another reality is that condom use has fallen off since the arrival of effective HIV drugs. Because a  new diagnosis of  HIV is no longer a death sentence, the fear has gone. The resulting reduced condom use has caused a surge in all STI infections including syphilis.

HSE June 2025 stats do, however, show a slight reduction in notifications for chlamydia and gonorrhoea, by 12 per cent and 16 per cent respectively.

Chlamydia

Chlamydia is a curable STI caused by the bacteria Chlamydia trachomatis. 

It can infect the urethra or wee pipe, womb, cervix or Fallopian tubes. In men, it can infect the urethra, testicles and rectum. In both sexes, the throat and eyes can be involved.  

Chlamydia cannot be caught by kissing, hugging, sharing baths or towels, using swimming pools or from toilet seats, only through unprotected sex. Chlamydia can also be passed to a newborn if the mother is infected at the time of  birth. Chlamydia is very infectious; if one partner has it, guaranteed you both do. 

Symptoms: Up to 70 per cent of men and 50 per cent of women have absolutely no symptoms.

This makes the blame game difficult, as it is possible for a chlamydia infection to be present for some time, say from a previous relationship. So if you get a positive chlamydia test it does not necessarily mean your partner has been playing away. I know; it’s complicated. 

Lower genital tract infections can cause a change in vaginal discharge, bleeding after sex or bleeding in between the periods. If the wee pipe or urethra is involved it can cause cystitis or a burning sensation when you pee as well as increased frequency of urination and can be mistaken and for a urine infection. If the womb is infected it causes pain that feels like period pain and can cause very heavy, painful periods. It can also cause pain during sex. Again, most men have no symptoms, but there may be a discharge from the penis or burning when passing urine.  

Complications: Prompt diagnosis and treatment is needed to  prevent  serious complications. Chlamydia affecting the womb causes PID, pelvic inflammatory disease. This results in severe pelvic pain, which can become chronic. Infected tubes can become scarred causing tubal infertility and ectopic pregnancy. In rare cases, joints or the liver can be involved. For menchlamydia infection of the testicles can cause chronic pain and swelling. 

Gonorrhoea

Caused by the bacteria Neisseria gonorrhoeae, Gonorrhoea, unlike Chlamydia, usually causes   symptoms within a few days of the offending sexual encounter making the blame game much easier. 

Symptoms: Fifty per cent of women get a change to their vaginal discharge, which may become heavier or change colour. Twenty-five per cent of women get low abdominal pain. Gonorrhoea  does not cause  bleeding problems like chlamydia. If the urethra is infected it causes cystitis and urinary frequency and again can be mistaken for a urine infection. Up to 20 per cent of women infected with gonorrhoea end up with serious womb infection, PID, which can make you quite unwell with high temperature and  affect fertility down the line. 

Ninety per cent of men with a gonorrhoea will develop a yellow/green discharge from the penis. Gonorrhoea can infect the throat in both men and women. That usually does not cause any symptoms or sore throat. Men can end up with spread to the testicles causing chronic pain, tenderness and swelling. 

Complications: Again, for women, even one gonorrhoea infection can lead to problems conceiving down the line. In men, infection can lead to chronic testicular pain or chronic inflammation of the prostate gland.

Diagnosis: There is no need for an embarrassing examination. A self swab of the skin of the vulva is the most accurate way of diagnosing chlamydia and gonorrhoea for women. For men, it is a urine sample and tests can be done confidentially, for free and in the privacy of your own home (www.sexualwellbeiing.ie).

However, if you do have any of these  symptoms: change in  your vaginal discharge, increase in heaviness or pain of your periods, a new problem with pain when having sex or cystitis with dashing to the loo, it is very important to see your GP for an examination.

Treatment

Chlamydia is treated with a one-week course of antibiotic called doxycycline, which is free for all. 

We recommend a woman’s sexual partner is  treated at the same time to avoid reinfection. It is not absolutely necessary but it is good practice to have the swab repeated six weeks after treatment to ensure that the infection has cleared. 

It’s a little more complicated with gonorrhoea as, over the last 10 years, it has become resistant to many antibiotics. Therefore your doctor needs to take a second swab to send to the lab to test for  antibiotic sensitivity in order to know what antibiotic to give you. Again, both sexual partners need treatment at the same time and test of clearance is recommended. 

Sexual Health Services Ireland

In the UK, STI diagnosis and management guidelines recommend that gonococcal, as well as most other STIs, are managed in specialist Sexual Health Clinics.These are free, self-access clinics that men or women can just book in to for a contraception or sexual health consultation. In Ireland HSE does run similar clinics but they are few and far between with none in rural communities. 

Key HSE clinic locations and contacts (check for updates):

• Dublin: Mater Hospital STI Clinic (01 803 2063).

• Cork: South Infirmary Victoria University Hospital (SIVUH) GUM/STI Clinic (021 496 6844).

• Galway: Galway HSE STI Screening (091 525 200).

• Waterford: University Hospital Waterford (051 842 646).

• Mullingar (Westmeath): Midland Regional Hospital (087 710 4152).

• Portlaoise (Laois): Midlands Regional Hospital (086 859 1273).

• Enniscorthy (Wexford): Enniscorthy Health Centre (051 842 646). 

But, I’m a 42-year-old woman living in West Cork; how will I pick up an STI?

Many women, especially the over-40s, feel that an STI is something that happens to someone else, to a frisky under-25-year-old perhaps, but not to her. She assumes that an STI will give her a funky discharge or pain, so because she has no symptoms, she is alright. 

All not true.  

What the stats show us is that although STIs are less prevalent in the over-40s versus the under-25-year-olds, rates in this age group are slowly increasing. There are probably a few factors at play here.

A woman over 40 might feel there is no need to use a condom because she already uses another form of contraception or perhaps the new fella has had a vasectomy. Either way, STIs just don’t cross her mind.

My advice to women of all ages is, if you have a new squeeze, use a condom, even if you already use contraception. 

Yes they are expensive, but you can get free condoms (www.sexualwellbeing.ie).

Then, once sex is on the table, have the conversation. Yes, I know; STIs are the least sexy, least romantic topic for a fourth date. Many women worry he will assume you are accusing him of having a ‘mucky willy’! Put a romantic spin on the conversation; say you plan to get a home STI screen yourself, as you would like to be more intimate with your new beau, to have sex without condoms… and that can happen once you both have negative STI screens.

This article is not exhaustive and there are many other STIs that can affect women; genital warts, syphilis, HPV, Hepatitis B and C, as well as HIV. 

As always, I hope this is useful and if any readers have a female health topic they would like to see covered, please email the editor, mary@westcorkpeople.ie.

Women of all ages come under huge pressure to achieve unrealistic levels of perfection; personal, professional, physical, sexual, spiritual and psychological. I wanted to write a piece about how amazing women are, well, because we are. 

I have an opinion that may horrify many; I don’t think our 1970s feminist sisters did us 2025 women a huge favour.

Don’t get me wrong; I am a militant feminist. I understand that the misbeliefs held by a patriarchal society with regard to women needed to be torn down. It was believed for centuries that women were less intelligent, less organised and were incapable of logic, math and problem solving. We were described as flighty, silly – in fact hysteria was an actual female medical diagnosis for many years. We were thought less able than men to do any particular work task so thus should be paid less. Etc, etc, etc. 

The rhetoric of late 60s and 70s feminists was that women are able to do every thing. A cohort of feminists went further, opining that we do not need men. I understand the need at that time to direct this loud, oppositional argument to a patriarchal society. 

And I agree entirely; women CAN do anything. We are intelligent enough to go to university and get a degree; we can compete for and get a high profile, high pressure, well-paying job to pay the rent/mortgage. We are creative enough to paint, design and build. We can grow human beings in our body, feed them, nurture them, teach them. We can manage money, shop, clean, and co-ordinate the logistics associated with running a household and home. 

Has anyone spotted the flaw with 1970s feminism yet? 

In modern society, women have ended up doing it all. 

Most of us work and rear kids and run a household, plus end up in middle life being the main carers for ageing parents and relatives.

There was a benefit associated with the old societal attitude that women are frail beings prone to illogical thought processes and fainting fits; that we should be looked after, cared for. That concept has disappeared. The Red Tent – gone. Women and baby communal homes, places for women to  rest, breastfeed, bond with baby, and recover from the bone-shattering trauma of childbirth for a few weeks – a thing of the past.  Living in London, I was pleased to see this is still part of the Orthodox Jewish community. 

 The concept of  society looking after women seems to have been lost; our status changed from frail shrinking violet needing looking after, to Wonder Woman.

In addition, over the last 10 years, with the arrival of social media, not only are we doing everything but we are being told that we are doing it all wrong.

 Constantly we are told we are not the right shape; too thin, too curvy, too tall, too short, too much nipple showing, too much body hair, too sexy, not sexy enough. 

The ideal body type seems to be a prepubescent, hairless, curve-free stick with large boobs. We are told that the natural signs of ageing are ugly and should be covered up or surgically changed. Oh, and your vagina is too loose/ugly. 

We are told we are doing the wrong kind of exercise and are bombarded with advice by social media and celebrity ‘experts’ on what the ‘right’ diet or exercise is. No carbs, low carbs, no fat, good fat, intermittent fasting.

We are supposed to be the perfect working professional with an impeccably well-organised home, pristine children with 16 after-school activities each per week, have the perfect body and also be spiritually zen.

Oh, yes, and also deal with the maelstrom that is perimenopause, and menopause transition when that comes along.  

There is a is a constant barrage of criticism that I do not see society directing towards men.

In fact the latest trend seems to be that our feminism and independence is emasculating our men and making them feel unvalued. 

So I wanted to talk about self care for women.

Self care has become a bit of a buzz phase and most of us twitch and grind teeth when we hear it, as our inner She Wolf roars; Just where the fe*k am I supposed to fit that in?!

Women’s physical health – facts:

• One in two women over the age of 50 will suffer an osteoporotic fracture.

• One in three women, age 75, will die of a heart attack or stoke.

 • One in two women over 60 years have high blood pressure and most are unaware. This is the lead cause of heart attack and stroke in women in later life, if left untreated.

• Women’s cholesterol changes  through menopause transition, with total, as well as the bad LDL cholesterol, going up. High LDL is thought to be the strongest predictor of heart problems in women. 

• A high BMI, 30 or over, increases a woman’s risk of heart attack by three. Unfortunately menopause transition results in weight gain; an average of 7kg according to studies, but in reality it is more. That weight, as we all know, sits around the belly; what is known as central obesity and is incredibly difficult to shift. 

This combination of central obesity and lipid changes is called metabolic syndrome and is associated with much higher risk of developing diabetes. 

The physiological changes that occur in our body as a result of falling, then low, oestrogen levels through menopause transition, cause these medical conditions, but they are not inevitable. 

So, what can you do about it? Take control!

When I talk about self care I mean; stand up and take control of your body, your destiny. No one else can do it for you.

That, unfortunately does not happen by going for cupping, taking supplements, having a massage or  Reiki session or wafting some crystals and incense around. Don’t get me wrong; I am not one of those alternative therapy-bashing doctors; there are huge benefits, but they will not prevent a heart attack or hip fracture. 

The stuff you don’t want to hear:

If you read on social media that there are four simple changes you can make to your life that have been proven in studies to massively reduce your risk of heart attack, stroke, Alzheimer’s, diabetes,  breast cancer, colon cancer  and lung cancer, you would be all over it, right? We are talking evidence-based medicine here. Those four things are:

• Don’t smoke.

• Drink less alcohol – No harm in the odd beer or glass of wine, in fact small amounts of alcohol is beneficial to the heart.

• Eat a healthy diet – nothing weird; there is no ‘right’ diet. Eat  more veg, fruit, nuts pulses and beans; eat less red meat, less trans fats. Be aware that over the age of 50, we get higher glycaemic spikes after eating, which then triggers more dramatic sugar swings over the day, causing cravings. So try go for less refined carbs/sugars. Aim for a slow carb in the mornings to avoid big swings in sugar. Yes eat cake; we all love cake! Just not every day. The timing of eating seems to be important. Don’t skip breakfast, it’s bad for your microbiome. Check you are eating enough calcium – 1200mg/ day if you are 50 or over or have gone through an early menopause (www.osteoporosis.foundation).

• Exercise – don’t kill yourself; it has been proven that benefits are gained from Exercise Snacking. This is a new phrase meaning short spurts of exercise. You don’t need to spend an hour in the gym or run 10K. Twenty minutes of fast walking, fast enough to get very out of breath, four or five times per week. If you can jog, great, if not, just walk fast. Regular weights exercise to prevent osteoporosis. Doing low-weight, free weights impact exercises – for 20 reps per exercise for 10 minutes every day – has been proven to increase muscle mass and strength in studies.  

I did warn it’s not easy, but little changes will have a huge impact. 

And I cannot finish an article emphasising what we, as women, can do to take control and prevent that heart attack, stroke or hip fracture, without adding a #5 to my essential things for overall good  female health –consider using HRT for a few years. Evidence from recent studies and Cochrane analysis suggests that HRT started under the age of 60 or within 10 years of the last menstrual period is associated with a reduction in atherosclerosis progression, coronary heart disease and death from CVD causes, as well as all causing mortality.

In addition, four to five years HRT use is associated with almost halving of risk of osteoporotic hip fracture by the age of 65. 

Current evidence around HRT use and risk of breast cancer suggests that oestrogen alone is associated with little or no change in risk of breast cancer while combined HRT can be associated with an increased risk of breast cancer, which appears to be duration, not oestrogen dose, dependent and may vary, depending on the type of progestogen used.

However, this risk is low, both in medical and statistical terms, particularly when compared with other modifiable risk factors such as obesity, alcohol intake and lack of exercise.  

Current evidence suggests that being on HRT for four to five years does not significantly increase the risk of breast cancer over background population risk. However, longer term use may increase the risk. 

Using oestrogen through the skin rather than in tablet form, will not increase the background risk of leg or lung clots,  heart attacks or stroke, and will not affect blood pressure. 

New Year, New You? 

Give yourself a break; none of us are going out running marathons on January 1. 

Enjoy your Christmas! Then…Decide you are going to start looking after yourself better in the New Year. 

A good start is to book in and see your GP for a women’s health check. I suggest you ask for a longer, 20- or 30-minute appointment so the GP has time for a full check-up: Bloods, BP and BMI measurement. Cardiovascular risk assessment to calculate your Q3 risk score, which tells you your chances of having a heart attack of stroke in the next 10 years. You can work it out yourself on www.qrisk.org. Evidence base is rsk > 20pc or one in five should take statins. Many cardiologists would like to start a statin if LDL is  two or more. 

Do an osteoporotic fracture risk assessment on fraxplus.org.

You don’t automatically need a DEXA, and a normal DEXA can be falsely reassuring, as most of osteoporotic fractures happen to women with normal or near normal DEXA.

However if you are over 40 and have fallen over and broken a bone in the last few years or, have a female relative that had a hip fracture under the age of 65, you should have a DEXA . 

That GP check will rule out existing problems like high blood pressure or pre-diabetes.

The rest is down to you: The hard work part – see the four life changes mentioned above. 

In addition, if you are 50-plus, or under 50 and your periods have stopped, please book a separate appointment with your GP to discuss the pros and cons of HRT use for you.

I work alongside Dr Helps in Bantry, and this allows for more patients to be seen, resulting in a waiting time of only two to three months. 

 Gynaecology procedures such as a pelvic scan and hysteroscopy are undertaken in Bantry. Hysteroscopy is an investigation, done by the consultant, to look up inside the womb. Unfortunately, West Cork GPs are currently not able to access a pelvic scan in Bantry directly; they need to refer to Gynaecology in Bantry and we will arrange the scan for you. 

My periods have changed, doctor, should I worry? 

A change to a woman’s periods can mean nothing or can be a sign of an underlying problem. Rarely, it is an early warning symptom of  cancer. What women want to know is when to worry: how abnormal is abnormal? Hence I’m going to run through the kinds of changes that might happen to the menstrual cycle and what they may signify. 

What is normal? 

Periods usually start between ages of 12- and 13-years and can take a year or so to settle into a pattern. Not every woman has a bang-on four-week cycle. Your period will arrive if the egg you produced that month was not fertilised. A woman will shed the blood and endometrium, or womb lining that is not needed to nurture a foetus. This results in a bleed of a certain duration; some women bleed two or three days, others from seven to 10 days. When that bleed finishes, there should be no more bleeding until the next period begins. The interval between periods is counted from the first day of one period to the first day of the next. This is usually the same, give or take; one to three days for a woman throughout her reproductive years. This interval is classically 28 days or four weeks but can be 21 days or 35 days. Whatever the interval, that is what is normal for that woman.

Changes to menstrual pattern Flow: In the absence of a recent pregnancy, if your periods become heavier for a duration of three months or more, you should see your GP as this may need investigation.   

Intermenstrual bleeding (IMB) – Bleeding in-between periods: It can be normal to have spotting or a very light bleed at the time of ovulation, which usually happens two weeks after the first day of your last period. However, if you start to bleed or spot in-between your periods and this lasts for three or more months, see your GP. The bleeding might be unprovoked and random or only after sex and can occur at any time in the cycle. 

Interval between periods changing: Whatever the number of days in between your periods, that is what is normal for you. If you notice a change to  the interval going on for more than three months, you need to go see your GP. 

Oligomenorrhoea: If your periods become more spaced-out with a cycle length of seven or more days longer than usual for more than three months, this is called oligomenorrhoea and is a significant change that needs investigation.  

 Polymenorrhoea: Periods might begin to come closer together than usual; this is called polymenorrhoea. If your periods have been closer together for  more than three months, see your GP.

Premenstrual Syndrome (PMS): PMS has been the topic of one of my previous West Cork People articles, which can be accessed online. Changes to a woman’s cycle are not only about the bleeding. PMS can start to occur for the first time or become very severe over the age of 40. If you are noticing cyclical emotional and or physical symptoms occurring in the week or so before your period starts, which completely disappear once the bleeding starts, this is PMS; go see your GP. 

What check-ups do I need? 

History, history, history… Most gynaecological problems can be diagnosed by your doctor taking a careful history.

The number of times I have asked: “Are there any problems with your periods?” and get the answer: “No, they’re normal, doctor” only for careful questioning to reveal that the woman is flooding for 10 days a month, changing tampons every one to two hours for the first three days. What is normal for one woman is not always normal. 

If you feel your periods are different in any way for more than three months, your GP needs to know the following:

• How many days do you bleed for?

• How heavy? Do you get clots or  flood through sometimes? How often do you change your tampon/sanitary pad on a heavy day

• Is there pain and has that changed? 

• Once your period has finished and that includes the last bit when the tail end of a period can be just some brown spotting; when that is all done: how many days until the next one starts again? Has that gap between your periods changed? 

• After one finishes and before the next one starts; is there any pink, brown or red spotting in-between? 

• Is there bleeding; even pink spotting, after sex?

• Do you have any new urinary symptoms of cystitis or are you passing urine very often?

• Are there any changes to your vaginal discharge? 

Examination

• Internal as well as speculum examination. 

• Infection screen. Genital infection with Chlamydia can cause IMB, as well as bleeding after sex.

• Blood test. If you have very heavy bleeding your GP will want to check you are not anaemic. 

• Pelvic scan to rule out problems in the womb, the ovaries and the endometrium or womb lining. 

• If the pelvic scan is abnormal, your GP may refer you to see a gynaecologist. You can choose to be seen in Bantry.

• Smear test. Abnormal cervical cells can result in IMB or bleeding after sex. However if you are within the usual recall time since your last smear; within three years for women under 45 and five years for women over 45, then there is no point taking a smear, as HSE screening labs will not analyse it. 

If your examination shows that your cervix looks abnormal in any way, your GP will refer you for a procedure called a colposcopy, which looks at the cervix in detail. This will be in CUH in Cork city.

What might be wrong, doctor?

• Sexually transmitted disease: Chlamydia can cause IMB or bleeding after sex.

• Ovarian cysts: Certain types of ovarian cysts can cause changes to your bleeding.

• Premature Ovarian Insufficiency (POI): POI was the  topic of one of my  previous articles, which can be accessed online. POI means that menopause occurs under the age of 40 and has significant health implications. POI is often diagnosed late and that can have catastrophic implications, not just for that woman’s fertility but for her overall health and longevity. The European Society of Human Reproduction and Embryology, ESHRE, 2024 updated guidance on the diagnosis and management of POI contains the  amended diagnostic criteria of; menstrual disturbance {amenorrhoea or oligomenorrhoea} for at least four months and an FSH (follocle stimulating hormone) over 25IU/L on one occasion only, taken at any time in the cycle, under the age of 40 years. It is vital to diagnose and treat POI early in order to avoid  the health sequelae of osteoporotic fractures, heart attacks, stroke and early dementia.

• Cervical cancer: Abnormal cervical cells can cause IMB and bleeding after sex.

• Fibroids: This is a completely benign condition involving the muscle layer of the womb, the myometrium. This can become thickened or knotty occurring in either a diffuse way, throughout the wall of the womb, called adenomyosis, or in a more localised way, which is called a fibroid. This condition can be seen on a pelvic scan. Fibroids and adenomyosis can result in very heavy bleeding. They do not, however turn into cancer and do not necessarily need to be removed.

Endometrial polyps

Benign polyps will cause

• IMB: These are easily treated by removing at hysterocopy, which can be done for you in Bantry. Having an endometrial poly does not put you at increased risk for endometrial cancer. 

• Endometrial cancer: The incidence of cancer of the womb lining or endometrium has increased 50-fold in the last 25 years. In the past, it was mainly seen in women over 60. We are now seeing  women diagnosed at younger ages. Now, being aged 45 years or over is regarded as a risk factor. The increase in prevalence is thought to be driven by the obesity epidemic because obesity is a major risk factor for endometrial cancer. Other risk factors include a history of polycystic ovary syndrome, not having children, Type 2 diabetes and a family history of endometrial cancer. Overstimulation of the endometrium is also a risk factor and this will occur if you use the oestrogen component of your HRT but not the progestogen. Caught early, endometrial cancer has a very good prognosis with up to 95 per cent of women being alive, well and disease-free five years after hysterectomy plus removal of ovaries following a diagnosis of endometrial cancer. If the diagnosis is made later, after the cancer has spread outside the womb, the prognosis is much worse. 

If you have a change to your periods – perhaps they are heavier or you get some bleeding in-between, please do not assume that this is just a sign of getting older or put it down to perimenopause.

Yes, women in perimenopause often get much heavier periods because of the hormone fluctuations occurring at this time and sometimes the bleeding becomes completely chaotic but it can also be an early sign of endometrial cancer; do not ignore.

If your GP feels it necessary for you to see a gynaecologist, you can choose to be seen in Bantry rather than CUMH. Your GP, when doing the gynaecology referral, must select consultant Dr Aenne Helps in order to ensure you are seen in Bantry. 

I hope this has been helpful.

Sex is an important and  wonderful part of our lives and wellbeing and we don’t talk about it enough. It is sometimes assumed that sex is either not important or not happening in the lives of  older women but I am here to set the record straight. Women over 40 have sex, orgasms…and they even enjoy it!

There is much I can write on the topic of female sexual health and wellbeing but today I wanted to focus on the requirements for contraception and hormone stability in the over 40s. 

When I talk sex and contraception with women in their 20s and 30s it’s a conversation about what she prefers to use in order to not get pregnant. Occasionally there are issues like migraines, acne, heavy periods or PMS that guide choice but on the whole it is a straightforward consultation. Seeing women between the ages of 40 and 50 is a whole other ballgame because there is so much going on physiologically, hormonally and emotionally at that time. 

Consensus guidelines advise that contraception is needed for women up to the age of 55 years. What contraception a woman decides to use is a matter of choice, but for me, as a menopause doctor, where she is in her perimenopause/menopause journey very much dictates what I will recommend. 

The Pill

Unfortunately the good old-fashioned Pill has come under attack in recent times on social media, often by young women who dub it unnatural and harmful without evidence to back this up. It can be nasty stuff critiquing other women for not being real, natural women. I want to make a strong case here for the Pill and indeed for all  hormonal contraceptives. 

Yes, using hormones is not 100 per cent natural but can we please all agree that mother nature is a bit of a bitch to ladies over 40? Besides the obvious disaster of an unplanned pregnancy at this age,  we get hormone chaos and can have horrendous heavy, painful periods, all on top of managing the life joys  of teenage kids, ageing parents and a career. 

So I will completely defend allowing a woman to take power into her own hands to counter what mother nature intended her to endure in her 40s. And I would request that women under 30 please keep their pontificating, criticism and lecturing of other women’s use of hormones to themselves, thank you very much.

Oestrogen-containing contraception

What you know of as The Pill is actually a combined oral contraceptive pill or COC containing an oestrogen and a progestogen, two hormones that naturally occur in a woman’s body. The COC works by inhibiting ovulation and therefore prevents pregnancy. But there are also incredible non-contraceptive benefits of taking The Pill. It treats heavy, painful periods, is first line in the management of endometriosis symptoms and treats premenstrual syndrome as well as acne.

The oestrogen in many of these pills is ethinyl estradiol. This synthetic oestrogen is metabolised by the liver and  the chemicals or end-metabolites generated as a result of this process cause a slightly increased risk of venous thromboembolism; ie a leg or lung clot and can cause a rise in blood pressure.

As the risk for both these issues is negligible in women under the age of 40, the risks of taking an ethinyl estradiol containing COC pill far outweighs the benefits for this age group. 

Women over 40, however, will have a raised risk of thrombosis if they are very overweight, with a BMI over 30, or are smokers. Similarly, they might be more prone to the blood pressure effects of this sort of pill if BMI is over 30 or they have pre-existing Hypertension or high blood pressure.

In the past doctors would have told the 44-year-old woman who smokes, has hypertension and a BMI of 32 that she cannot have the COC Pill. Finally Big Pharma has put time and money into developing something other than different flavours of easy to swallow viagra! 

New COC Pills 

Drovelis is a COC that contains Estetrol an  estrogen that is effectively an end-metabolite. That means it does not undergo the same metabolism in the liver as its sister ethinyl estradiol. In plain English; it is safer in the over-40s, as studies to-date have shown that its use is not associated with any increased risk of leg clots or raised blood pressure.

Another relatively new COC is Zoely. This contains estradiol hemihydrate, which is an estrogen that is body identical or the same as the oestrogen in our body. This is the same  oestrogen contained in HRT products.

Perimenopause

I cannot talk about oestrogen containing contraception for the over 40-year-old and not mention perimenopause.  

As early as age 42 or 43, women can experience perimenopause symptoms. These are many and varied, ranging from hot flushes, which might be intermittent, dry, sore vagina and painful sex to the emotional turmoil of low mood, tears, anxiety, raging anger and irritability; often all of the above happening in one day. Then there are weird burning, itchy skin symptoms, dry eyes and libido goes out the window. Helpfully, all this happens at a time when life has become very stressful with teenagers at home, ageing parents and career, work and possibly financial worries.

Symptoms happen because the twin engines that are our ovaries do not work as well as they did during the previous 30 years when they ovulated or produced an egg every month. Ovulation becomes erratic. Some months it skips, resulting in dropping oestrogen levels and oestrogen deficiency symptoms of flushes and dry vagina. A cycle without ovulation will have a prolonged phase of progestogen dominance, our angry, cranky hormone. Other months a woman will ovulate twice, giving very high oestrogen levels and relatively lower progestogen levels, a combination, which results in the oestrogen-dominant symptoms of long, heavy, painful periods, bloating, swollen painful tender breasts and headaches. It is not uncommon for women to start getting migraines for the first time at this age. 

So my consultation with a 45-year-old to talk about contraception is also a consultation about stabilising hormones and how best to manage this hormone helter-skelter. I have encountered the gallows humour of the  perimenopausal patient who finds it funny to be in the oxymoronic situation of needing contraception whilst having absolutely no interest in sex.

Contraceptive hormone therapy

So using any COC will steady that hormone chaos but some are better than others. I favour Zoely, a COC introduced recently, which contains oestradiol, a body identical oestrogen. This is the same oestrogen contained in HRT products. Therefore this COC  will not only prevent pregnancy but also stabilise hormones, treat perimenopause symptoms and provide a little oestrogen hormone therapy in the same way HRT would. This will treat oestrogen deficiency symptoms of hot flushes and dry sore vagina. I always ask about sex and at that point in a consultation offer vagifem, an oestradiol pessary that goes into the vagina. 

Drovelis, mentioned earlier, will have the same effects and is my go-to if a woman has elevated clot  or blood pressure risks. 

For this reason  Zoely and Drovelis have been dubbed contraceptive HRT. To clarify: HRT products are not contraceptive.  

So we have lots of options now to offer our over-40-year-old and COC pills can be safely up to the age of 50.

What if I can’t use oestrogen-containing contraception?

The COC pill, because of its oral oestrogen component, may be contraindicated, such as if there is a history leg clot, certain type of migraines, or if there is poorly-controlled hypertension. In this situation it is safe to use progestogen-only contraceptives such as the Mini Pill, the Depot, an injectable progestogen given every three months, the Implant, a tiny device inserted under the skin of the upper arm, changed every three years and The Mirena coil – more later. These forms of contraception can be also effective at managing perimenopause symptoms. 

Can I have oestrogen HRT as well as my progestogen contraception when I start to get perimenopause symptoms? 

Short answer is yes but it gets very complicated. The progestogens in contraceptives have not been proven to provide the endometrial protecting that progestogens in HRT do and therefore are not licensed for that. So, if your GP gives you oestrogen therapy as patch gel or tablet on top of your Mini pill, Depo or Implant, they will need to give you a second form of progestogen as well. 

Did I mention that a GP’s consultation for contraception with a 46-year-old is a lot more complicated than that for a 26- or 36-year-old?​

If I  get to this complicated scenario, I  strongly recommend my patient go for the Mirena progestogen contraceptive coil, as this IS licensed as part of HRT. 

The Mirena Coil

Over the age of 40 many women develop heavy, painful periods. The Mirena coil contains a small amount of a progestogen,  Levonorgestrel. The function of progestogen is to suppress the stimulant effect of oestrogen on the womb lining or endometrium. The Mirena coil constantly releases tiny amounts of progestogen in the womb resulting in suppression of the endometrium and very light, short, pain free periods. It is the most effective contraceptive  treatment for heavy, painful periods. Many women stop bleeding altogether with the Mirena, It is licensed for contraception for eight-years but if fitted over the age of 45-years is effective until age 55.

A great advantage of having The Mirena in place over the age of 45 is that at some point peri-menopause will move into menopause and women start to have more pronounced oestrogen deficiency symptoms of hot flushes, dry vagina and brain fog, as well as emotional symptoms.

The Mirena makes managing that bridge from menopause to post-menopause so much easier. When  a patient gets to the time of needing oestrogen therapy, it is a simple matter of adding in oestrogen as patch, gel or tablet because the Mirena will serve as the progestogen part of a HRT regimen. It is licensed for this for five years. 

I hope this is helpful. If this article brought up any issues for you please book an appointment with your GP. 

If you are suffering from heavy painful, chaotic bleeding over the age of 40 or you are struggling with contraceptive choices at that age, your GP can refer you to Bantry Gynaecology Clinic where I work alongside the consultant there, Dr Aenne Helps.

While I specialise in menopause health, which we encounter later in life, in this article I’m focusing on teenage female health issues.

In my opinion, teenagers get a really bad press. They’re slated to the point of ridicule for being rude, grumpy, lazy, and argumentative. What needs to be appreciated are the enormous hormone-driven physiological changes that are going on during these years. Yes, we were all teenagers once, but let’s be honest; how many of us really  remember what it felt like? 

Let me explain in terms many of you may understand; stop and think about your menopause transition, in particular those perimenopause years from 45 to 50. Remember the maelstrom of physical, emotional, psychological, neurological, dermatological, sexual and urinary symptoms as a result of  hormone fluctuations at that time​?  Some of us felt like we were going mad. 

Now imagine that multiplied by 100 – that’s what being a female teenager feels like.

It is a transition from child to young woman and goes on for several years, exactly like perimenopause. 

Remember, this is a child, oestrogen-naive who, over a period of a few months, begins to have oestrogen, progestogen and testosterone circulating in her body for the first time, acting on pretty much every part of her; skin,  breasts,  genitals, internal organs, and, most importantly, her brain, affecting her emotions. Then she starts to bleed from her vagina! This is usually accompanied by pain like she has never experienced before. It is chaotic, painful, emotionally-overwhelming and very frightening. Yet, teenage girls get criticised and laughed at for their hormone-driven behaviour.

What is normal?

Onset of puberty in girls occurs between the ages of 11- and 13-years-of-age. Any signs of puberty starting under the age of eight is abnormal. This is called precocious puberty and should be investigated.  

Breasts: Often the breasts initially develop in an uneven way. Benign breast cysts are also common in early puberty. Normal breast development can be painful and tender. It is important to reassure both the teen and her mother that this is all normal, that she is not going to end up with one boob much bigger than the other, and watchful waiting is recommended. I will see, examine, reassure, but ensure that she comes back with mum again in three to six months to review breast development. Rarely are scans or review by breast specialist needed. However, any leaking from the breasts in teenage or pre-teen girls needs investigation. It may be as a result of abnormalities of prolactin or thyroid hormones. 

Menstruation: Menarche is the medical term for onset of menstruation. This usually occurs between the ages of 12 and 13. Bleeding under the age of eight requires investigation. Similarly, if a girl has turned 14 and not started her period, you need to see the GP, as investigation with blood tests and pelvic scan may be warranted. Outside of when the periods start, there is no normal; every girl is different. Periods often stop and start over the first one to two years and may take up to five years to become regular. Once they have settled into a regular pattern, not every teenager has a four-week cycle. 

Talk to the girl!

What is important, as with all aspects of puberty, is to talk to the teen and ask about her periods. How heavy are they? How painful? What are her preferences for sanitary products? Ensure she has decent painkillers – paracetamol will not touch the sides and chemically ibuprofen is a better medicine for womb contractions, which is what period pain is. If ibuprofen 400mg does not help pain, go see your GP.

I have come across many teens who, when asked how their periods are, simply reply; “normal” only to find out on closer questioning that she is changing her pad or tampon every two hours for the first two days and, in spite of using tampon plus a pad at night, she wakes to a mess in the bed. That is not normal and needs managing; see your GP. 

 And please do not assume your daughter knows what is going on just because she is on social media or because she grunts: “Yes, Mum! I know all about it!”  

That is just avoidance because she is scared, mortified, and doesn’t want to talk about it. It may be that she won’t talk to you but might talk to a favourite auntie or family friend. Always signpost to age-appropriate literature, such as: www.healthforteens.co.uk – a teen appropriate source for information on all things puberty-related. 

Heavy painful periods

If the bleeding and/or pain is so bad she is missing school, you need to see the GP. Non-hormonal medications like mefenamic and tranexamic acid are very effective at reducing both pain and heaviness of flow but she will need to take 12 tablets a day through her period, which is a bit of a task. Definitive and kinder treatment is to actually prevent the painful heavy periods in the first place by using the oral contraceptive pill. 

Just moody or is it Pre-menstrual Syndrome (PMS)?  

I wrote on the topic of PMS in November 2023. For anyone with a teen suffering marked symptoms occurring during the week before her period, please access this online. The second half of the menstrual cycle, the one to two weeks before the period, is a time of crashing oestrogen and rising progestogen levels. That combination results in a whole collection of symptoms; sore, tender boobs, nausea, sometimes vomiting, food cravings and ravenous appetite, headaches, sometimes migraines, bowel symptoms of diarrhoea and marked emotional symptoms. What happens with PMS is that the young woman experiences feelings and emotions that are out of proportion to whatever is going on and impossible to control, be it anger, irritability or low mood and crying. There is great variation with PMS, from moodiness and slamming doors, to not being able to leave the bedroom for two days. It is important to validate the symptoms and resist the urge to criticise.

If any symptoms a teen is having in the week before her period  stop her getting out to do what she would usually do, go see your GP. Again, the oral contraceptive is a life-changer here, as its job is to suppress ovulation and eradicate the premenstrual phase of her cycle. When used for treatment of PMS and heavy painful periods, I recommend using back to back for three months, then four days off, and start again on this three month cycle. If she does not want to take tablets, the same medication is available in patch form called Evra. 

She’s a bit spotty; isn’t that normal for a teenager?

Do not underestimate how crippling even moderate acne can be for a teenage girl. 

It is a time of massive body changes all happening at the same time. She is changing  shape, growing boobs, growing armpit and genital hair, starting to have weird feelings that can be impossible to control, is thinking about boys or girls, whichever, for the first time in “that way”, is having  painful vaginal bleeding and to top it all off her face breaks out in pustules. Acne can be there all the time or only appear for the week before your period. What breaks my heart as a GP and a mum is that acne scarring is preventable. Whatever about the damage to her self-esteem, any teen with large spots and boils is likely to end up with scarring, which may persist for life.  Treatment is easy; again, oestrogen in the contraceptive pill or patch usually eradicates acne. If the contraceptive pill or patch is not appropriate, a once-a-day low dose oral antibiotic is also very effective.

For all those mums, aunties and grannies out there with a teenage girl in their lives, be kind; remember, when we were teenagers we didn’t have to deal with the cesspool that is the internet and social media. 

I’m 58 and can recall the comments and jibes at hockey practice when I was a teen (aka; ginger, spotty, freckled, flat-chested and a bit of a swot). Imagine all that multiplied by 1000 with reminders and pictorial examples of how not pretty or perfect you are, constantly shoved in your face on a device on your person at all times.

Very last word

Be kind to our teenage girls; they’re the ones who will be kicking ass and sorting out the world’s problems when we are in our 90s. 

This month I’m running through the common sorts of lumps anyone can get, before getting into lumps that affect women only.

If you notice a lump anywhere on your body for the first time, the best thing to do is go see your GP to figure out what it is. If a lump is new, red, hot, throbbing and tender; it is infected, and you should see a GP in the next one to two days, as it is likely antibiotics are needed. If it is not painful, then this is not an urgent issue and will wait one to three weeks for a routine GP appointment. 

Common things are common…

Lymph nodes: When we have any flu-like infection or sore throat, you will notice that your glands in your neck swell up and become painful; this is a good thing. 

Lymph nodes or glands are small bean-shaped nodules that contain millions of infection-fighting lymphocyte cells. They are found at intervals along the lymphatic vessels, like beads on a string. The lymph nodes filter out harmful organisms and abnormal cells before the lymph reaches the blood stream. 

These often worry patients who assume it is a sign they need antibiotics. Not true and invariably the opposite is true: The lymphocytes in the glands multiply like mad in response to an infection, resulting in a huge increase in the size of that gland. This happens quickly, often overnight, causing pain and tenderness in the enlarged glands. So, the sudden appearance of large painful lymph nodes is a sign that your body is doing a good job dealing with an infection. Your glands will remain enlarged for seven to 10 days. Glands can come up on one side only and are found in different sites around the body: the neck, the arm pit, along the clavicle, and in the groin. 

When should I worry about an enlarged gland? If a gland remains enlarged for more than six weeks, see your GP.

The exception to that rule is a lymph gland in the armpit; it is advisable to see your GP for a chest and breast exam rather than wait the six weeks.

Lipomas: A lipoma is a lump of fatty tissue that grows just under the skin. Lipomas move easily when you touch them and feel rubbery, not hard. Most lipomas aren’t painful and don’t cause health problems, so they rarely need treatment.  It is advisable to see your GP only to log that you have a lipoma. However, will need to have the lipoma reviewed if it starts to grow or if larger than 7cm.  

Sebaceous cysts: Sebaceous cysts are non-cancerous, slow-growing bumps that develop in the skin. They often occur due to blocked sebaceous glands and can be uncomfortable or unsightly; they tend to look like a small, firm egg attached to the skin. They are usually not painful and are completely benign. Generally, if it is not bothering you – leave it alone. Resist the temptation to squeeze it, as this might cause infection. 

Hernias: A hernia usually happens in your abdomen or groin, when one of your organs pushes through the muscle or tissue that contains it usually due to a weakness in that muscle layer. It may look like an odd bulge that comes and goes during different activities or in different positions. It may or may not cause symptoms, such as discomfort or pain. Some hernias may need surgical repair.

Women’s lumps

Breast lumps: Finding a lump in your breast is one of the scariest things a woman can encounter. She instantly assumes cancer. It needs to be emphasised that most breast lumps turn out to be benign in women under the age of 45 years.  

Types of benign breast lumps:

The size and shape of breasts vary, and everyone’s breasts are different. They’re mostly made up of fatty tissue and glandular tissue. The glandular tissue produces milk when you’re breastfeeding. Tiny milk ducts carry milk from the glandular tissue to the nipple. A tail of breast tissue goes up into your armpit; breasts are pear not apple-shaped. 

In women, breasts are affected by hormones. They change size and shape throughout your monthly cycle and when you’re pregnant. This means breasts can feel tender, heavy, and lumpy. This usually happens just before your period and goes back to normal once it starts. It’s normal for many women to feel lumpy areas in their breasts, which come and go, as their hormones change. 

Fibroadenomas are solid, benign growths of tissue and do not ever transform into cancer. They are painless and not tender. They usually feel firm to touch and may move underneath your fingers when you check your breast. This resulted in the old-school term of ‘breast mice’, as they seem to ping away from your touch when self-examining. Fibroadenomas are the most common type of benign breast lump and you’re most likely to get one when you’re under 30. These do not need to be surgically removed and do not increase the risk of breast cancer.  

Breast Cysts are round sacs of fluid that can build up in your breast tissue. You can have one or more cysts, and they vary in size. You’re most likely to get them after 35 and they can come and go. These tend to appear in the week or two before your period then completely resolve. They can be sore and tender to touch. They are completely benign and do not increase the chances of getting breast cancer later in life. 

I found a breast lump! I recommend the following three steps if you are under 45, having regular periods and you notice a breast lump:

1. DO NOT PANIC!  – most breast lumps are benign Make a note of where you are in your cycle; nine times out of 10 a new breast lump appears during the week before your period. If, however, you are breastfeeding and find a painful tender breast lump, this is likely to be an infection called mastitis and does require an urgent GP appointment. 

2. Leave it alone – then re-examine yourself again at a different time in the following cycle.

3. If the lump persists book a routine appointment to see your GP. 

Of course, many women will choose to book a GP appointment straight away. Try to remember, most breast lumps felt under the age of 45 are benign.

How can I tell if the lump is breast cancer? Breast cancer is a very common cancer with a one in eight lifetime risk.

It is more common in older women with only one in 2000 prevalence in women under 30 but it will affect one in 15 women over the age of 70.  However, most women do not die of their breast cancer; strokes and heart attacks are the big killers. This is because advances in breast cancer treatment plus early detection through screening programmes mean that 85 per cent of women will be alive, well, and disease-free, five years after a diagnosis of breast cancer. 

What is a dodgy lump?  If a breast lump feels very hard; is fixed, or hard to waggle around when you examine yourself, is associated with any changes to the overlying skin  – don’t ignore it:  these are features more often seen with a cancerous lump. 

In Cork the HSE system for getting a woman checked out with a worrying breast lump is excellent: most are seen in two weeks or less. 

Down-below lumps

Sebaceous cysts can occur in the skin of the external genital area.

Bartholin’s cysts: Bartholin’s glands are small pea-sized glands located at the entrance of the vagina, behind the lips (labia minora). Secretions of these glands provide some of the lubrication during sexual intercourse. A Bartholin’s cyst is formed when the duct of these Bartholin’s gland is blocked, and the secretions collect behind the blocked duct forming a cyst.

What you notice is a non-painful lump at or just inside the opening of the vagina. This is usually on one side only. 

The cyst can become infected and then will get much bigger and become painful and tender – walking can be an issue. This generally settles with antibiotics. Rarely, infections become recurrent and require referral to a gynaecologist for surgery.  This is an entirely benign condition. 

I found a lump that comes out my vagina! 

This invariably turns out to be a prolapse, a topic of a previous article but one I am happy to revisit again. 

In summary; If you find a new lump anywhere go see your GP.

Your GP can usually tell you from the history and examination findings what the lump is. Blood tests are rarely required. If your GP is uncertain as to the nature of the lump they may arrange a soft tissue ultrasound. 

Any woman wishing to see me in the Gynaecology Clinic in Bantry needs to ask her GP for a referral to CUMH Cork Gynaecology outpatients, then choose the consultant ‘Dr Aenne Helps’ who runs the clinic in Bantry hospital. 

I also see patients in Bantry gynaecology clinic two days per month. However, because of HSE IT and other issues, the system does not allow for direct referral to myself, a GP; your GP needs to choose the named gynaecology consultant for Bantry, Dr Aenne Helps. 

Acne

Acne is a common problem in the week before a woman’s period related to the background hormonal changes at that time. Acne can also be a problem for the first time during the perimenopause. The combined oral contraceptive pill is a very effective treatment for acne and many of the newer pills are very safe to use over the age of 40.   

Dry skin

More common during perimenopause and menopause are skin issues related to dryness and sensitivity.

As women, our skin generally becomes a little dryer as we age. But what you might not know is that when skin gets very dry, it gets very unhappy. Dry skin can result in micro splits in the epidermis or top layer of our skin, which then facilitates the skin layers underneath drying out even more. When those layers get very dried out, an inflammatory response occurs; yes – you literally break out in a rash because your skin is so dry.  

The first line is buckets of emollient! Emollient is another word for a moisturiser, describing a good heavy cream, usually free from  colours  or scent. Unless you have particularly oily skin, you should be getting through a 500ml tub of emollient in two to three weeks. That means just rubbing a pea size blob onto a dry or itchy patch of skin will not work; you need to slather it on all over. 

Which cream, doctor?

There is no magic cure-all cream for dry, menopausal skin; do not listen to the guff on social media! It will be someone flogging a product. As a general rule, avoid fancy expensive products; invariably they contain more additives; colours and scent. Stick to a basic gloop-type emollient; typically used for eczema-dry skin. If any product feels like it irritates your skin then you may be sensitive to one or more of the ingredients. 

Lanolin, a sheep protein commonly present in emollients, is a fantastic moisturising agent but some people are sensitive to it.

Other irritant ingredients in moisturisers can be parabens, petroleum products and SLS or sodium laurel sulphate. Generally, SLS is only an issue when the skin is already quite inflamed such as in active eczema in kids. 

I am not advocating one brand over another; if it moisturises your skin, it’s a great cream. Always ask your pharmacist for a generic or non-brand emollient; why give even more money to the pharmaceutical companies? Bottom line – read the ingredients. 

As a ginger and a woman of a certain age…I remember the sock-full of oats hung into the bath and having your mam slather the gloop that came out of the sock all over you before she would let you out. Not an old wives tale: coarse oatmeal contains compounds known as avenanthramides. Avenanthramides have anti-inflammatory and antioxidant properties, which can help reduce skin inflammation and relieve itching. Additionally, oatmeal forms a protective barrier on the skin, locking in moisture and promoting skin healing. 

An old-fashioned remedy for dry skin is Vaseline; this actually acts as a barrier to the skin, not a moisturiser, and the petroleum ingredient can be irritant. 

Antihistamines

If you have itchy, burning rashes on your skin; as well as emollients, use a  non-sedating antihistamine tablet like cetirizine or loratadine – both can be bought over the counter. 

Perimenopause and menopause skin symptoms can be quite odd and seem unrelated to simple dryness, as they don’t always resolve with moisturisers alone. I have had women describe burning of the skin or a feeling like ants crawling under the skin. These symptoms generally completely resolve with hormone therapy. 

Down below…GSM

The skin of your external genital area is very sensitive. We are all used to moisturising the rest of our body but how many women out there purposefully moisturise the skin of the vulva and surrounds? 

GSM or Genitourinary Syndrome of Menopause is the term for the collection of symptoms that occur as a result of fluctuating and falling  oestrogen levels. GSM symptoms involve the external genital skin, the vagina and the urinary tract.

Skin: itching, dryness, burning and irritation of the skin of the external genital area are common in perimenopause and menopause.

This can be focal, with one particular spot itching and burning like mad or more diffuse. Often women itch in the night and can wake up very sore with scratch marks and sometimes splits in the skin. 

Vagina: The vagina feels dry and intercourse can be uncomfortable or even painful as a result. Obviously, this has knock-on effect on libido, as well as our relationships. 

Urinary: Fluctuating and falling oestrogen levels commonly result in increased urinary frequency; dashing to the loo 10 times a day and needing to get up at night two or three times. Passing urine can be uncomfortable and feel like low grade cystitis. It can cause or worsen pre-existing stress incontinence; meaning we leak more easily when we laugh or sneeze. Lack of oestrogen in the years following our menopause can result in  recurrent urinary infections, as well as incontinence in later life.  

Treatment: Vaginal moisturisers and lubricants are readily available over the counter. 

Lubricants are just that; you pop it in the vagina before you have sex; it has a short-term effect on lubrication. Vaginal moisturisers are longer acting so using two or three times a week can result in the skin outside as well as the mucosa inside the vagina feeling comfortable and sex stops being painful.  Again, no one product is better than the other. 

Look for the ingredients; moisturisers can be water, oil or silicone-based. Studies have shown the oil and silicone-based ones are more effective. There are a few brands out there women may have heard of such as YES and Replens. Each brand usually has a number of different products in their range; ie water, oil or silicone based. Be aware that silicone and oil-based products can affect condom integrity.

Newer vaginal moisturiser products such as Hyalo Gyn and Hyalofemme contain hyaluronic acid, and studies show these to be really effective. Moisturisers and lubricants are not available on prescription so you need to buy these yourself. 

Vaginal Oestrogen: The gold standard treatment for any GSM symptom is local oestrogen therapy; and skin and vaginal symptoms tend to completely resolve within a week or two. GSM urinary symptoms of peeing very often, discomfort when you pee, leaking and UTIs do not resolve with moisturisers and lubricants alone.

Therapy can be in the form of a cream, Ovestin, which can be applied to the skin externally, as well as used up inside the vagina with an applicator. Vaginal pessaries, such as Vagifem, are also available. The product you use is a matter of choice; they both contain the same ingredient.

Vaginal oestrogen is NOT Hormone replacement therapy, despite what information sheets in the packaging says. Using vaginal oestrogen does not increase your risk of breast cancer. Its use has been studied in breast cancer survivors and there is no increased risk of cancer recurrence. 

Vaginal oestrogen can be started at any age; I have seen many 75-plus-year-old women having recurrent UTIs, which completely resolve with vaginal oestrogen – it is safe at any age. Furthermore, studies have shown that using vaginal oestrogen lifelong will treat, as well as prevent UTIs, and support your pelvic floor strength, to minimise and prevent incontinence issues in our 80s. 

And good news – all vaginal oestrogen products are available free on prescription if you have a medical card and are covered under the DPS, drug prepayment scheme. 

Not tonight, darling! Men do not have a cliff-face drop in their testosterone levels at 50 like we do with our oestrogen through the menopause. So, they just don’t get it when we try to explain that it just does not feel right down there;  we have an urge to pee every 30 minutes, sometimes leak, it’s burning and uncomfortable in the area, intercourse felt like razorblades the last time we tried so the last thing on your mind is letting him anywhere near that department! If he had issues with really sore, burning, itching willie and scrotal skin, it hurt when he peed, he’d had two urine infections in the last six months and leaked a bit when he laughed, he  might not be feeling very sexy either. 

On a more serious note there are certain skin conditions that affect the genital area that it is vital to diagnose and treat early such as Lichen Sclerosis and Lichen Planus. 

Lichen Sclerosis is an inflammatory skin condition, confined to the genital area and can affect the skin of the perineum and anus. It carries an increased risk of vulval skin cancer. 

Lichen Planus is also an inflammatory condition but can also affect other parts of the body like inside the mouth or more rarely inside the ears or around the eyes. 

Both conditions can result in deformation and scarring of the external genital area and vaginal opening or even closure of the vagina if left untreated.  

These conditions can present in the same way as menopausal skin issues with burning, itching and soreness of the skin of the external genital area but the examination findings are completely different.

Examination by a doctor is vital to establish a correct diagnosis and treatment plan.  

In my roles as Gynaecology GP in Bantry hospital and as Menopause doctor in CUMH Complex Menopause Clinic, I see women who reluctantly admit to genital area symptoms only after I have specifically asked about them. Unfortunately, examination sometimes reveals significant abnormalities. It usually turns out that woman has never told her GP or asked for an examination. I cannot help but wonder how many  of the doctors that have seen her over the years asked her about genital area symptoms?  

Show your doctor your bits. So vitally, if you are having any symptoms involving the skin of your external genital area, around or inside your vagina, of the vulva, labia, flaps, lady curtains, whatever you call them, or any discomfort down there, you must tell your GP; you must have an examination. 

If you have a male GP or would like to see me about any of the GSM symptoms mentioned in this article, ask your GP to refer you to Gynaecology outpatients in Bantry. To ensure you are seen in Bantry not Cork, your GP needs to select the Bantry  gynaecologist, Dr Aenne Helps in the dropdown on the referral form.

“My sex drive has gone out the window, doctor; can you let me have testosterone?”

I’ve been writing for West Cork People since September 2023 and those who read my articles may have noticed that I have left the topic of testosterone therapy for women until now.  

Over the last year, I have seen a surge in demand for testosterone therapy, sometimes coming from women as young as 40-years. For a long time doctors have been concerned about the fear-mongering and damage wrought by certain health assertions on social media.  Unfortunately, these days an opinion spouted by an influencer with 100,000 or more followers is taken as fact by some women.

Rather satisfyingly, this very phenomenon has recently been scrutinised scientifically.

A global University of Sydney-led study has been published in February 2025  in JAMA Network Open. 

Researchers analysed almost 1000 posts about five controversial medical screening tests that had been promoted by social media influencers to almost 200 million followers. They found most posts had no reference to scientific evidence, were promotional, had explicit financial interests and failed to mention potential harms. One of the interventions looked at was testosterone blood tests. This article is worth a read: my favourite quote: “One of the underlying themes being used by influencers promoting these tests is that knowledge is power, but most information is cherry-picked. When it comes to health, getting the full picture is so important, and half-truths are often lies.”

Get your information from credible sources like the website menopause matters.co.uk or www.womens-health-concern.org.

So, let’s look at the facts about testosterone therapy for women.

Is testosterone a female
hormone?

Yes, premenopausal women produce both testosterone and oestrogen. The main sources are ovaries and adrenal glands, small glands located near the kidneys. The amount of testosterone produced in a woman’s body is less than in a man’s. 

What happens my testosterone levels with age? 

Testosterone levels in women fall a little between ages of 20 and 40 and reach a steady level at menopause.

There is no dramatic cliff face fall-off in testosterone through the menopause as happens with oestrogen. A dramatic fall-off will occur, however, if a woman’s ovaries are removed surgically. What a lot of people are unaware of is that our testosterone levels start to rise again a little over the age of 60.  

Mythbusting

I need my testosterone blood test done; Testosterone will help my fatigue and brain fog; I don’t want HRT, doc, I just want to have testosterone. 

All of the above statements are not true or are flawed. 

So, what will it do for me, doctor? 

Testosterone use in the postmenopausal woman has been studied extensively. There s no evidence that it helps with brain fog or improves cognition. Similarly, studies have not shown it to be helpful for fatigue or aches and pains in this group. The only symptoms that have been repeatedly shown to be improved by testosterone is low sexual desire or libido; defined as a loss of interest in sex, and/or inability to become aroused and attain orgasm that is impacting on a woman’s psychological wellbeing or impacting her life in some way such as causing issues with her relationship. 

The level of your testosterone in the blood does not tell us anything, as studies again have failed to show any links between testosterone levels and symptoms. Put simply; a woman’s  testosterone can be lower than the usual female range and she may feel absolutely fine.

We also lack data on the possible negative effects of long-term testosterone use on increasing cardiovascular risks such as heart attacks and strokes as it is known that oral testosterone increases our blood lipids. There is also concern that longer term use may increase risk of breast or other cancers. 

Evidence based guidelines on testosterone use in post-menopausal women have been  published by the  British Menopause Society( BMS) and National Institute for Clinical Excellence ( NICE) UK.

There is very little information and practically no studies done looking at testosterone use in women before the menopause so we just do not know if it is safe. 

When can I have it? 

The place of testosterone is as an add-on to hormone replacement therapy, HRT. Patients come with multiple menopause symptoms; low libido is only one of them. 

For women, libido is a complex and multifactorial issue and therefore the approach needs to be holistic. You are going to have a rubbish sex drive if you are worried sick about one/all of the kids, your mum has recently passed away, there are money problems in the household, your husband is ill, you are exhausted as not sleeping for the hot flushes and everything down below is dry/itchy/burning/on fire; all of the above.

The initial approach is to deal with all the menopause symptoms and, unless contraindicated, start systemic HRT in the form of patches or tablets. It is vital to identify and treat vulval and vaginal symptoms of soreness, itching and dryness. This will require oestrogen as a cream and or pessary, in addition to HRT. 

I see the patient three months later for a review. Depending on her symptoms, a slight increase in her oestrogen dose might be needed. In that case, I will see her again after another three months.

Only once I have established that her oestrogen deficiency symptoms have resolved do we talk about testosterone gel. In other words; the hot flushes are gone, she has seen improvement in mood and brain fog, sleep is better and her vulvo-vaginal symptoms have completely settled; specifically that sex is no longer painful or uncomfortable. 

Then we talk about sex and what else can be done do to improve her libido and sexual enjoyment. 

If libido is low and sex is not happening; is that a problem for her? I have met women who told me it’s not something they want any treatment for. Other women are distraught that they used to feel sexy and have regular sex with their partner and want to get that intimacy back.

What first? 

Now we do a blood test; not because the result will influence my treatment plan but in order to ensure that her baseline level is low or within normal female range.  

Three months after starting testosterone gel we do another blood test to ensure the level remains within the female range; we are not aiming for high levels. 

How do I take it? 

Testosterone for women comes as a gel but there are currently no licensed formulations for women outside of Australia. 

This is mainly because Big Pharma do not see this as a therapeutic area worth investing in.

The dose is 0.5mg per day for a post-menopausal woman. Because these products have been manufactured and licensed for men who need higher doses, the dosing for women is fiddly: Testogel  comes in a sachet that should last eight days. Testim gel comes in a sachet that should last 10 days so about half pea size blob per day. Tostran is a pump canister slightly easier to use; one pump equals 10mg alternate days.  

Side effects? 

Even at normal female testosterone levels, some women experience excessive hair growth, in particular on the face, acne, and sometimes weight gain. These side effects are reversible and subside on stopping therapy. Other side effects, more commonly associated with testosterone levels outside the female range but not exclusively, are male pattern baldness, deepening of voice and enlargement of the clitoris. Unfortunately, these side effects can be irreversible. 

Monitoring

After your three-month blood test you should see your doctor to ensure your testosterone level remains in the female range and to review your symptoms. If you feel your libido and sexual enjoyment are benefitting from the testosterone you can continue but must have a blood tests, to keep an eye on testosterone levels, every six to 12 months. Importantly if I see a woman on testosterone gel for six months who feels it is doing absolutely nothing for her, I would recommend she stops. 

Who should never have
testosterone therapy? 

If you are pregnant or breastfeeding, have active liver disease or a history of breast cancer, or if your baseline testosterone level is elevated, testosterone therapy is not for you.

I finish this article as I always do by recommending that anyone experiencing symptoms related to menopause, perimenopause, or indeed issues with sex drive and enjoyment at any age, book an appointment to talk to your GP.  

I emphasise again that doing blood tests for any female hormones, including testosterone  under the age of 45 is rarely of any clinical use.

Because of the drop in oestrogen hormone levels that occurs throughout the menopause, women over the age of 50 are much more likely to develop high blood pressure, diabetes, obesity, high cholesterol, have a heart attack or stroke and one in three will have an osteoporotic fracture. 

 All of these conditions are preventable. 

 A Menopause Health Check or, as I like to call it: ‘You are Fab and 50 Health Check’, needs to be a holistic, patient-centred health check, looking to prevent conditions like high blood pressure, diabetes, heart disease and osteoporosis. 

High Blood Pressure

Up to one in three women over 50 have hypertension or high blood pressure and most are unaware because they do not come to have it checked. The problem with high blood pressure is you feel absolutely fine up to the moment you have your heart attack, stroke, or your kidneys fail. This Health Check is an opportunity to pick up hypertension before it does any damage. Review of a woman’s personal, as well as family history, will tell if she is high risk for developing hypertension, heart disease and stroke. 

Diabetes

If there is a family history of diabetes or a woman’s BMI is over 30, we do a blood test that will pick up pre-diabetes. Advice about lifestyle and diet changes empowers that woman to actually avoid developing diabetes. 

Heart Attack and Stroke

We use the Q3Risk assessment tool that tells us how high a woman’s risk is of having a heart attack or stroke in the next 10 years, which guides advice on whether a statin medication should be started in order to reduce that risk by up to 50 per cent. www.qrisk.org

Osteoporotic fractures

We have an osteoporosis risk assessment tool, FRAX, that  tells us if a woman is at high risk of osteoporotic fracture and might benefit from an early DEXA scan. www.frax.shef.ac.uk

We advise on regular exercise in combination with weight bearing exercise with calcium and vitamin D supplements to prevent osteoporosis. Smoking cessation advice is vital as this impacts risk of heart attack stroke as well as osteoporosis. 

A Menopause Health Check is about disease prevention and supporting women to live long and healthy lives. At Bantry Bay Medical Centre, we have started inviting patients in for a 50-plus Health Check. 

Have you noticed that so far, I have not even mentioned HRT?  

So, what is your government doing to get you access to a Menopause Health Check?  

Yes, it is admirable that this government has generated The Women’s Health Action Plan 2024-25 (gov.ie). It means that your government is actually thinking about Women’s Health Service provision.

The document mentions HSE-funded Menopause Clinics in secondary care, eight across the Republic. This is good. However, as a GP working in West Cork, I know these are not bread and butter menopause services. They are intended for patients that GPs do not feel confident in managing, as is the case for The Complex Menopause Clinic in CUMH, and referral criteria are very strict. 

I naively assumed The Women’s Health Action Plan might contain details of funding going into Primary Care so that high quality Menopause Health Checks can be delivered; that is not the case.

The expectation is that a woman goes to her GP for her Menopause Health Check and treatment. I completely agree; GPs in Ireland are more than qualified to do this. 

That’s not the point.  

So, Mr Stephen Donnelly, Health Minister; you are promising free HRT medications for all?

HRT is only a small part of a Menopause Health Check. Promising to fund HRT medications  without funding the consultation is an insult both to women and to their GPs. 

The fact that this is suggested as a fix for current poor access to high quality Menopause Consultations for women across Ireland means, Stephen, that you haven’t a clue. 

Government needs to start listening to what women, as well as their GPs in Ireland, have to say: 

My 50-plus female patient wants enough time in her GP appointment to discuss all aspects of her health, disease prevention as mentioned above, as well as her many and myriad menopause symptoms. The appointment needs to allow time for necessary intimate examinations and; subsequent discussion on what management plan suits her best. 

GPs know that a minimum 30-minute appointment is needed for the type of quality Menopause Health Check I describe.

I have emailed Stephen Donnelly’s office in the Oireachtas on this very point and just received a reply to the effect that the free HRT medications that is planned will solve everything.

It made me so angry. 

It is an insult to the women of Ireland to suggest that something as complex, personal and sensitive as Menopause can be adequately dealt with in a 10- to 15-minute routine GP appointment in the same way as a cough, sore throat or back pain. 

So what would work?

If the funding was there, GPs would be able to set up a dedicated Women’s Health Clinic with the required 30-minute appointments, as we have done in Bantry Bay Medical Centre. 

There is a funding system in place for Women’s Health checks for women of childbearing age, the Free Contraception Scheme. Many GP lists are closed because of work pressure so women who don’t have a female GP cannot get in to see a female doctor. Most of the women I have seen over the last year would not dream of going to discuss their menopause, vaginal or incontinence issues with a male GP.

The Free Contraception Scheme allows for a patient to see a GP that is not her usual doctor for contraception consultation or a coil fitting. This is a fair system that recognises that not all GPs are contraception specialists, as I am. 

The same needs to be acknowledged when it comes to Menopause consultations; not all GPs feel confident, or indeed have the time to have those conversations, undertake required intimate examinations, investigations, then generate the management plan that is right for that patient. 

HRT is only a small part of a Menopause Health Check. Promising to fund HRT medications without funding a Menopause Consultation is an insult both to women and to their GPs. 

I would go further and say that it is downright ageist that HSE does not fund a Health Check for women in their post-reproductive years in the same way they do for women of childbearing age. 

westcorkmenopauseclinic.ie 

West Cork Menopause and Women’s Health Clinic

It is with great pride that I report my completion of the final hurdle of The British Menopause Society (BMS) qualification process: I am now officially a BMS Menopause Specialist. 

I run The West Cork Menopause and Women’s Health Clinic, located in Bantry Bay Medical Centre. This service was set up in March 2024 and  would not be possible were it not for the fantastic support of Bantry Bay Medical Centre’s lead GP, Dr Michael Kingston, who agreed to host the clinic. While women of all ages may phone to book an appointment to see me for 30-45-minute appointments, most consultations are for menopause, perimenopause and continence issues. I also work as a regular GP at the surgery, three clinics per week. 

For high quality patient information on all menopause issues go to www.womens-health-concern.org and www.westcorkmenopauseclinic.ie

Menopause in Ireland: How are we doing? 

In May 2021, RTÉ’s Joe Duffy devoted 10 days of his radio show, Liveline, to the subject of menopause. Most women I now see will remember where they were when what is described as the Irish Menopause explosion occurred. It somehow gave women permission to talk about menopause and resulted in a rise in patient demand for menopause consultations.

Readers will know that I worked as an NHS GP in the UK for 28 years before returning to my native Cork in February 2023. I was saddened at that time to learn how far behind Ireland was with regard to Menopause care provision:

Ireland did not have its own structured Menopause Society, like the British or International Menopause Society, which provides evidence-based menopause learning to members.  

Your GP is your first port of call for any health issues including menopause. However, in my time at UCC, there was no education or training on menopause for medical students and I am not aware that this has changed. I trained as a GP in the UK and again I did not receive any training specific to menopause. So how do GPs attain the knowledge and skills needed to manage menopause for their patients? Is there an Irish qualification process for GPs to become a Menopause Specialist such as exists with the BMS? Not currently. 

If a GP lacks the knowledge or skills, is there a menopause service in their area they can refer to?  Not a publicly-funded general menopause service, no. 

Then and now

We might have started at the back of the group when it comes to menopause but, since 2021, Ireland has been positively sprinting: 

The Irish College of GPs set up online learning modules for GPs on menopause and urogynaecology, the latter dealing with continence and prolapse issues. This went live in 2022 and this has now also been made available to practice nurses. 

In addition, any Irish doctor can become a member of the British Menopause Society and avail of the fantastic BMS online learning and training resources. Many GPs I have met are unaware of this.

This year we should be proud to learn of the establishment of The Menopause Society of Ireland (www.menopausesocietyireland.ie).

In terms of resources for clinicians and information for patients, it is looking at bit sparse at the moment, but it is a great start. The Society’s inaugural meeting will be held in Dublin on September 14.   

Cork University Maternity Hospital, CUMH, set up a Menopause Clinic in September 2023, which is fantastic. 

However, it is only for what they describe as complex menopause cases, and referral criteria are very stringent. They will only accept patients they deem need the input of their BMS Advanced Care Practitioners. It is expected that GPs will manage everything else.

We do not yet have a HSE funded menopause clinic to refer to for those Cork GPs who do not possess the necessary skills and time required to manage menopause.

What next?

The groundswell of public interest in menopause care provision in Ireland continues to rise. A question we need to all be asking is: The HSE provides free contraception consultations and  medicines – why not  free menopause checks and HRT?

I put this very question to The Leader of the Social Democrats, Holly Cairns’ team and she directed the following parliamentary question to Stephen Donnelly in July in The Oireachtas:  

• 2366;  Holly Cairns asked the Minister for Health if he would consider the implementation of a free menopause scheme, similar to the contraception scheme and the maternity and infant care scheme; and if he will make a statement on the matter.

Another parliamentary question was raised on the dearth of HSE funded menopause clinics nationally in July by deputy Niamh Smyth when she asked the Minister for Health for an update on the provision of menopause services; the number of clinics available through the public health service; the contact details for each clinic and the waiting times for a first appointment. 

We welcome reports from Stephen Donnelly that he plans to introduce a publicly funded hormone replacement therapy (HRT) scheme. 

The proposed scheme only mentions free HRT prescriptions. HRT is only a tiny part of a Menopause Health Check. What we need to see is HSE funded Menopause Health Checks for all women aged 45 and over. 

As per the core principles of SláinteCare, these checks need to be delivered close to home and be independent of a woman’s ability to pay.  

Have we reached a tipping point nationally and politically with regard to the provision of Free Menopause Care in Ireland or is this politicians  giving pre-election and pre-budget lip service to a popular hot-topic? 

The Contraceptive Train was a women’s rights activism event, which took place on May 22, 1971. Members of the Irish Women’s Liberation Movement (IWLM), in protest against the law prohibiting the importation and sale of contraceptives in the Republic of Ireland, travelled to Belfast to purchase contraceptives. In 1979, the Irish Family Planning Act was introduced, allowing contraceptives to be sold under prescription. Finally, in 1985 the laws relaxed to allow the sale of condoms and spermicides without a prescription. Contraception did not, however, become free until 2022.

Ireland has been a trailblazer on a number of issues such as the smoking ban and same-sex marriage.  

Ladies, make some noise: let’s make Free Menopause Health Checks  happen.

Menopause and Perimenopause are normal, physiological stages of female health. 

Today I want to talk about what is abnormal so I will revisit some definitions.

Menopause is a retrospective diagnosis. This means that we can only say that a woman is menopausal if it has been 12 months since her last period. 

The Perimenopause is the time between the first onset of any menopause symptoms and 12 months after a woman’s last period.

This lasts from four to eight years. In my experience as a Menopause Specialist this can span from age 45 to 55 years. 

Menopause onset at age 40 to 45 is called Early Menopause. Menopause occurring under the age of 40 is regarded as premature and the medical term for this is Premature Ovarian Insufficiency or POI. 

This occurs in one per cent or one in a 100 females, so it is not that rare. Menopause under the age of 30 years has a prevalence of 0.01 per cent or one in 1000 women. 

Diagnosis

This first sign is usually a change to periods; they start to be further apart or skip a month. 

While pregnancy needs to be ruled out, there are a few conditions that can cause changes to periods. These include problems with thyroid hormone, as well as prolactin, a hormone secreted by the hypothalamus in the brain. Dramatic weight loss causing a woman to be severely underweight can also switch off periods.  

Eighty per cent of women with POI will have symptoms. Some 50 per cent will get vaginal symptoms of dryness and soreness and might complain that sex has become  uncomfortable. Hot flushes may occur. 

A woman who finds that her periods have become further apart, for a duration of more than three months, needs full investigation. This should include blood tests for full blood count, thyroid and prolactin hormones, as well as for female hormone follicle stimulating hormone,  FSH.

While female hormone blood tests have no place in diagnosing the normal menopause process, an FSH level over 25-30iu on two occasions, separated by six weeks, in a woman under the age of 40 years, confirms the diagnosis of POI. 

Causes

In 80 per cent of women a cause is not found. There is definitely a family history component. Chromosomal abnormalities are found in about 10 per cent and autoimmune issues in five per cent of cases.

POI can be iatrogenic, the term used  to describe a condition caused by medical procedure or medication. Chemotherapy and radiotherapy used to treat young female cancer patients can knock out the ovaries. Women sometimes need to have the ovaries removed because of cancer. This is called a surgical menopause but has the same implications as POI.

So does it mean I can’t have children, doctor?   

POI means that the ovaries are slowing down and not producing enough oestrogen so women will not ovulate or produce an egg every month. It does not mean that the patients will never ovulate. Spontaneous natural pregnancy will occur in five to ten per cent of patients. This occurs most commonly in the first one to two years following onset of symptoms. Early diagnosis is therefore vital if a woman wishes to conceive naturally. Unfortunately many women are diagnosed several years after onset of symptoms when, studies have shown, spontaneous pregnancy is much less likely.

Because of increasingly better treatments, many young patients are surviving cancer and will want a family later. The younger the woman is at age of treatment, the more likely her ovaries are to recover naturally. However, it is vital that cancer specialists talk to all young female cancer patients about preserving their future fertility by harvesting eggs and freezing before treatment is started. 

The most successful fertility treatment for patients with POI wishing to have children is with egg donation.

Alternatively, if my patient does not wish to fall pregnant it is essential that I provide her with contraception. 

But I don’t want kids, doctor, so it’s not a big deal, right? Wrong!

Women with POI are at high risk of developing osteoporosis and studies indicate almost 15 per cent prevalence. Risk of heart disease and stroke are also greatly increased. It is vital that a DEXA or bone density scan is done once diagnosis confirmed. Then I need to have a discussion with my patient about what treatment is needed to prevent osteoporosis, heart attacks and stroke.

A side benefit of POI is a much lower risk of breast cancer.  

Treatment

Women with POI need to have the hormones that they are missing, oestrogen and progestogen, replaced; it’s that simple.  

This can be in the form of HRT or a combined oestrogen/progestogen contraception, in the form of the pill, the EVRA patch or NuvaRing. 

If a pregnancy is not wanted, contraception is the obvious choice, as HRT is not a contraceptive. However, some studies have indicated that the pill is less effective than HRT in preventing osteoporosis and heart disease. There is an ongoing study to look at this. So it may be necessary to give a patient top up oestrogen with her pill. 

Using hormones in this way, even in the form of HRT, up to the natural age of menopause, does not increase the risk of breast cancer; studies have proven this. 

Women of all ages, with any female health issues can book an appointment to see me in the Women’s Health Clinic in Bantry Bay Medical Centre by phoning: 027 20022.

Following on from my article last month on the value our government places on female health, I have been in conversation with Holly Cairns TD. She has agreed to put to the government as a Parliamentary Question; 

When does the government plan to provide free Menopause Checks to all women? Contraception is free why not a Menopause Check?  

We are pre-election, ladies. The louder we shout about this, the more likely it is to happen!