Evidence
Collection

Women’s Health

Women's health is a broad branch of medicine covering the diagnosis, treatment and management of health concerns that are often unique to women. Many of the health issues relate to reproductive health and childbirth, including fertility, contraception, pregnancy and menstruation.

This Collection brings together NIHR research on several areas of women’s health. We asked a number of healthcare professionals and service users to comment on selected Alerts that are relevant and important to them. Their commentary highlights what we can learn from the research summarised in the Alerts to better understand current approaches to women’s health issues.

The Alerts included in this collection are:


Women with womb cancer are to be offered a genetic test for Lynch syndrome

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Dr. Christina Founta - Consultant Gynaecologist

“I very often diagnose patients with endometrial cancer and treat the ones with early/low-grade disease. I have also been doing regular clinics for women with genetic predisposition to gynaecological malignancies in the past. I am genuinely glad that the offer for Lynch syndrome testing has officially been introduced for all women with endometrial cancer in the UK.

“The outcome of this research will benefit both the patients and their families. I would echo Professor Crosbie's comment alongside the Alert, that patients are highly likely to feel psychologically relieved by having an answer to the question ‘is there a genetic reason for my disease?’ Furthermore, ‘is there something I need to be checked for in the future and is my family likely to be affected?’

“I appreciate the burden for genetic counseling clinics may increase. However, this is without doubt a major step forward. It helps replace diagnosis and treatment with prevention, with the multi-level advantages such an improvement brings along. I would like to congratulate the authors for their achievement.”

Dr. Robin Crawford - Gynaecological Oncologist

“This is a very important alert. We are seeing an epidemic of womb cancer and it is better to offer management for patients without cancer at a high risk of cancer. Identifying patients with Lynch syndrome leads to management, screening and risk reduction changes which are important. In addition, identification of a new Lynch syndrome patient leads typically to the identification of three further relatives at risk who will then benefit. Reflex testing following endometrial cancer will identify twice as many women with the present risk scoring approaches. This reflex testing also mirrors the management of patients with colorectal cancer and genetic testing.”

Davida Hamilton - Service user living with secondary breast cancer

“The Alert is introduced by a useful video that sets the scene for the paper effectively. Like a good illustration, a change in presentation format with appropriate content can aid comprehension and navigation of the text.

“The Alert includes a clear recommendation based on a very clear result. 98% of UK women womb cancer patients want to know if their cancer is inheritable for the sake of their families.

“While this may seem obvious from a UK patient point of view, the paper points out that a US study showed a much lower rate of testing assent, possibly attributable to health insurance risks (one of my US-based relatives has declined BRCA screening for the same reason). This indicates that communications needs are system- and potentially culturally-dependent and need to be moderated accordingly.”

Antenatal MRI can aid ultrasound when fetal brain abnormality is suspected

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Dr. Pensee Wu - Consultant Obstetrician and Maternal Fetal Medicine Subspecialist 

“In the UK, following identification of a suspected fetal brain anomaly on routine mid-trimester ultrasound screening, women are referred for fetal neurosonography by a fetal medicine specialist. The parents are then counselled regarding the prognosis based on fetal neurosonography findings. It is of paramount importance to ensure that the parents have accurate information so that they can make informed choices during pregnancy. This research reinforces my practice of using in utero MRI (iuMRI) as an adjunct to fetal neurosonography in order to improve the diagnostic accuracy of antenatally suspected fetal brain abnormalities. This new evidence will help to provide a more uniform approach for the management of this condition across the country.”

Jenny Hall - Service user and experience of immune-related recurrent miscarriage

“This was an interesting alert and demonstrates the benefit of in utero MRI (iuMRI) in cases of suspected foetal brain abnormality.

“The accuracy of iuMRI is higher than ultrasound, which gives pregnant women a better idea of what they are facing and allows them to make an informed decision about their pregnancy. I also understand that iuMRI is a non-invasive and safe procedure, since it does not use ionising radiation - it would have been useful for the Alert to point that out.

“I am sure that iuMRI is more expensive than ultrasound, but it seems to be worth the additional cost and is an important diagnostic tool for women in the uncertain and distressing position of carrying a child which may have abnormal brain development.”

Routine use of progesterone does not prevent miscarriage

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Barbara Hepworth-Jones - Vice chair of the Miscarriage Association and has experienced recurrent miscarriage

“This is very useful evidence for doctors to consider when they are seeing women with bleeding in the first 12 weeks of pregnancy. For women with a history of recurrent miscarriage especially, the improved outcome for those treated with progesterone in those early weeks makes a strong case for treatment. It would be equally understandable if doctors were also to treat those with one or two previous miscarriages in the same way, despite the very small improvement in outcome that the trial showed. Prescribing progesterone suppositories to women with a history of miscarriage presenting with bleeding in early pregnancy would be relatively quick and cheap.

“We know that supportive care in early pregnancy confers a significant beneficial effect on pregnancy outcome for women who have experienced unexplained recurrent miscarriage. Adding in progesterone would provide much needed reassurance that everything possible had been done to ensure a successful pregnancy and so enhance supportive care for those with bleeding in early pregnancy, which is a very frightening time. This applies even for women who have not had a previous loss in view of the safety profile and cost of progesterone. As miscarriage is sadly very common, treatments with even modest effectiveness may potentially prevent an important number of miscarriages. Progesterone treatment would be welcomed by all women who experience bleeding in early pregnancy and particularly those who have experienced miscarriage for no known reason and bleed in a subsequent pregnancy.”

Jenny Hall - Service user and experience of immune-related recurrent miscarriage

“I found this an interesting Alert, which demonstrates that routine progesterone supplementation does not prevent miscarriage in women without a history of recurrent miscarriage.

“It would have been extremely interesting to understand the reasons for miscarriage in the women who took part in the trial. From other research I know that the majority of cases of stand-alone miscarriage are caused by random genetic abnormalities in the foetus. It would therefore make sense that progesterone would not be able to save a pregnancy if the foetus had genetic abnormalities..

“However, it is very interesting to note that in women with a history of recurrent miscarriage, progesterone does reduce the rate of miscarriage. This suggests that it is more likely that women with recurrent miscarriage have an underlying problem, such as a hormone imbalance, which can be rectified by the use of supplemental progesterone - whereas the women in this trial without a history of recurrent miscarriage are likely to have been pregnant with a genetically abnormal foetus - a random unfortunate event - which cannot be rectified by supplementing with progesterone.

“It would therefore have been very useful to understand the cause of miscarriage in each of these cases, and to differentiate between women with a one-off miscarriage and women who have an underlying problem - otherwise, the research is not as meaningful as it could be, and women who might actually benefit from progesterone may not be offered it.”

Marie Buckleygray - Long-standing therapist, fertility teacher, perinatal support and now student midwife 

“One in five  women experience bleeding within the first 24 weeks of pregnancy. This circumstance is more common than people might think, often experienced in private before employers and wider social networks are told about the pregnancy. This issue matters a great deal to prospective parents, impacting many lives. Research aiming to assess a potential pathway to prolong pregnancy to at least viable gestation is particularly welcome.

“This NIHR Alert concerns research into how effective administering progesterone, a pregnancy sustaining hormone, is in these circumstances. Progesterone is ordinarily produced naturally by the woman initially at the ovum eruption site following ovulating at the ovary then through to around 12 weeks thereafter the developing placenta takes over as a source of the hormone. Progesterone, amongst other pregnancy sustaining attributes, naturally suppresses contractions.

“Although this research has shown a slight overall increase (2% difference) in pregnancies continuing within the group who were administered progesterone, this increase is not large enough to be considered statistically significant. There was however a potential gem within one of the subgroups: women who had experienced three or more miscarriages did notice a significant improvement with administration of progesterone. The live birth rate was 72% for those who had been administered progesterone in comparison to 57% for those who had been given a placebo. There was a small number of women within this subgroup (285), so further research with a larger cohort would be of great interest. This research might lead to a conversation between a woman and her Midwife or Obstetrician in order to come to a supported and informed decision about administering progesterone in these circumstances.

“After the age of around 30 years old women’s baseline levels of progesterone begin to decrease, given that the average age of women birthing in the UK is increasing it would be reasonable to anticipate that further research in this field will be all the more vital in the future.”

Dr. Robin Crawford - Gynaecological Oncologist

“Good evidence to advise patients and caregivers during the early months of pregnancy about the value of taking medication is important. This will save many mothers and babies being subjected to unnecessary medication at a critical time of the process. This is a useful piece of evidence.”

Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study

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Davida Hamilton - Service user living with secondary breast cancer

“This Alert highlights the need to treat breast cancer patients according to individual need and health and not according to age, ‘reaffirming that surgery for breast cancer in the older population is safe’. With a 2% surgical complication rate and no deaths in nearly 2800 women between 70 and 95, I find this study remarkable and heartening.

“Having experienced surgical complications myself at the tender age of 57, I now value comfort much more than looks. Quality of Life (QoL) issues are more age-independent and may result from the mortality-focus of discussion and discussion tools (including those cited in the Alert). Lymphoedema was discussed with me, but is not universal to all patients. Post-mastectomy neuropathy in the breast (and often in the axillary lymph node dissection (ALND) area is universal and is barely discussed because it is not treatable, so is an ongoing distress to the patient, possibly impacting QoL scores in the study.

“Expectation management is very important. This Alert, like many in the women's health area, highlights the need for clear communication tools relating to the patient rather than the clinical experience”.

Professor Zoe Winters - Professor of Breast Surgery

“This study brings real life big data to clinical decision-making in this group of women in whom it is crucial to individualise biological age versus breast cancer stage and therefore percentage benefits in using gold standards of care.

“It is timely that multidisciplinary meetings standardise measures of frailty and co-morbidity such as the Charlson co-morbidity Index on which to base treatment recommendations for surgery. This study reported 20% improved survival in older women correctly selected for surgery. The risks of surgery were low and likewise recent advances such as no axillary treatment as per the currently recruiting POSNOC (low burden positive lymph node trial) randomised trial is important. Furthermore, the omission of whole breast radiotherapy (PRIME 2) in older women supports the increased recommendation of breast conserving surgery rather than mastectomy in eligible women. Accelerated radiotherapy as per the FAST FORWARD randomised trial allows delivery of therapeutic doses within 5 days and further supports lumpectomy and breast conservation in older women.”

Dr. Robin Crawford - Gynaecological Oncologist

“In gynaecological oncology we have tried to offer the appropriate treatment to patients regardless of their age. The importance of this alert is that there is now more evidence that we should offer patients the appropriate surgery depending on their clinical state and not restrict management purely on age.”

Decision aids including leaflets and computer programs help patients make treatment choices

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Marie Buckleygray - Long-standing therapist, fertility teacher, perinatal support and now student midwife

“Women and other service users often have to make complex choices within obstetrics and gynecology, impacting upon their entire lives. Informed decision making regarding these choices can be difficult due to time pressure or lack of access to suitable evidence. This perceived lack of autonomy and lack of good quality information during life changing events can lead to decisional conflict or even psychological trauma. Following on from the case of Montgomery vs. NHS Lanarkshire, the concept of legal consent has been further clarified alongside highlighting areas for improvement in the communication of health care professionals. Shared decision making is seen as best practice within NICE guidelines and forms part of professional regulator guidelines such as at the General Medical Council (GMC) and Nursing and Midwifery Council (NMC).

“This NIHR Alert points to research indicating that patient decision aids (PDAs) improve the patient’s knowledge of their conditions and treatment options thereby assisting with making an informed choice. There were some concerns raised by health professionals about the amount of time that the PDAs would require to facilitate.

“A system can only be successful if it contains high quality appropriate information that is delivered within a reasonable time frame. If birth choices were explored via digital PDA earlier in the antenatal period for instance then it would be reasonable to hope that the process would require less overall staff time, a more considered decision from the service user and more straightforward intrapartum experience. The recent advancements within communication technology and ubiquity of access make PDAs a potentially transformative area of improvement in health care.”

Davida Hamilton - Service user living with secondary breast cancer

“Whether or not clinicians think it will take more time, patients and their carers must make an informed treatment choice. Twenty minutes in a consulting room is unlikely to facilitate this unless the patient has prior knowledge of the situation. ‘Sign here please’ after a medi-speak Situation Report (SITREP) and the gift of a leaflet outlining the recommended option is common and is not informed consent. Contact details for follow up questions are very rarely given; patients and their carers (who may not be well informed at all) know resources are in very short supply, so rarely try to get back in touch.

“After eight years navigating various clinical disciplines on my own and relatives' behalf I can still be caught out by a consultant I do not know and delighted by therapists who get it right.

“Good decision tools based on patient need will reduce patient and carer anxiety, time wasted in indecision and inappropriate treatments undertaken. Medical communications should also cater for those who need more or less detailed information to be comfortable and some clinicians need training in how to communicate risk effectively.”

Surgery to fix the womb in position after prolapse is an alternative to hysterectomy

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Dr. Robin Crawford - Gynaecological Oncologist

“This is an interesting report and has relevance as we have an ageing population. With an increase in the incidence in uterine cancer, the preservation of the womb in the postmenopausal age group as suggested by this alert may lead to unexpected consequences such as subsequent endometrial cancer.”

Planned earlier delivery for late pre-eclampsia may be better for mothers

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Professor Asma Khalil - Professor of Obstetrics and Maternal Fetal Medicine

“In a sense, when managing severe pre-eclampsia, which carries significant risks to the mother and sometimes her baby, the decisions are easy. Delivery is the definitive cure so must be expedited even if the baby is very premature. But decision making in late pre-eclampsia (between 34 and 37 weeks’ gestation) is often more nuanced. This is far more common, often not severe and is evolving slowly, leading to the dilemma whether to expedite delivery in order to ‘cure’ the woman’s pre-eclampsia, or delay delivery so the baby gains maturity but risking more severe pre-eclampsia in the mother. The PHOENIX randomised trial addresses this common scenario.

“These findings do not change current management; the advice remains ‘if considering a planned birth, it is important to take into account the woman’s and baby’s condition’. But this trial does provide reassurance that current management is now supported by the evidence, and provides figures around the different outcomes that can be used to guide clinicians and counsel women. It is possible that the longer term follow-up of the babies from this trial may provide further evidence that tilts the balance in favour of one course of action or the other.”

Dr. Pensee Wu - Consultant Obstetrician and Maternal Fetal Medicine Subspecialist

“The PHOENIX trial is important for women with late onset pre-eclampsia as there is no consensus on its optimal management. This is because the potential benefit to maternal health is offset by the potential harm to neonatal health in planned early delivery.

“This research provides evidence that earlier delivery may be beneficial for mothers, without causing significant neonatal morbidity. The study findings are helpful for counselling women in making informed choices regarding their management plan. However, as longer-term data are not yet available, there are knowledge gaps which make it difficult to change current clinical practice. Therefore, the results from the follow-up study of this trial will be important in fully implementing the findings of this research.”

Dr. Robin Crawford - Gynaecological Oncologist

“Notwithstanding my lack of active practice in obstetrics for over 26 years, this study and learning point suggests earlier intervention then previously recommended. Mothers will benefit from the earlier intervention. The increased requirement for neonatal care may be a limit to introduction for some hospitals. This is likely to be an important milestone in modern obstetrics.”

Updated evidence on progesterone to prevent preterm birth in at-risk pregnancies

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Lisa McDonald - Independent Midwife

“This study concludes that the best management for preterm birth is the use of progesterone administered via any route.

“However, as the evidence to support this is of low to moderate quality and there is limited data on alternative methods, this indicates a need for further high quality studies, specifically for alternative interventions in order to make reliable comparisons.

“Based on the findings of the reviewed evidence, the pregnant client should be given a choice about their preferred intervention, with a frank discussion about the limited benefits reflected in the research. This may be determined by the success or failure of any previous treatment option they have experienced and the clinician’s previous success of a particular intervention.

“In obstetric units where the clinicians favour cerclage or pessary strategies over progesterone to manage the risk of preterm birth, the evidence in this review is not persuasive enough to change practice and further research is needed to ensure clients are offered the most appropriate and least invasive treatments to improve outcomes for them.”

Jenny Hall - Service user and experience of immune-related recurrent miscarriage

“Interesting to learn that progesterone supplementation may prevent preterm birth, although it appears there is some debate on the best treatment options for women at risk.

“I wonder why in these cases both progesterone and a cervical stitch can't be routinely used? It seems that further research in this area is needed.”

Keyhole hysterectomy is effective for women with heavy menstrual bleeding

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Dr. Christina Founta - Consultant Gynaecologist

“Working in gynae cancer diagnostics, I am not the clinician to counsel these patients regarding treatment modalities and/or perform them. I am however seeing them often when they are first referred to exclude malignancy as a reason for their bleeding and definitely if/when they present in the future with either vaginal bleeding following previous endometrial ablation or abnormal smears following a subtotal hysterectomy.

“Regarding the second group, colposcopy of the cervical stump is often unsatisfactory and a diagnostic loop and /or large loop excision of the transformation zone (LLETZ) is technically challenging. Trachelectomy post subtotal hysterectomy, should one be needed, is highly likely to come with intra-operative complexity and high morbidity risks. Luckily, we don't often come across such diagnostic challenges as patients with a history of subtotal hysterectomy are not common at present. However, if it becomes a more frequent choice as a result of this study, its occurrence will likely change.

“Regarding the first group, patients who present with bleeding post ablation to the rapid access gynaecology clinic (RAC) have indeed been a significant group during the recent years. An ultrasound scan (USS) is not likely to be helpful, hysteroscopy is very rarely possible and the same applies for endometrial biopsies. Different services have attempted structured protocols for the management of this group with the aim of auditing outcomes and proposing research to identify preferable management, quantify the risk of underlying pathology and the frequency of the problem etc. The suggested ways forward would be expectant management, MRI scan of the uterus and diagnostic hysterectomy. This is definitely an area we need good quality studies/evidence for. In everyday practice, it is representing a reasonable chunk of referrals in a RAC/Postmenopausal Bleeding (PMB) clinic in hospitals which perform endometrial ablations.”

Dr. Robin Crawford - Gynaecological Oncologist

“This study adds to the options for women with heavy menstrual bleeding that is not improved by the use of the hormonal intrauterine device. However, there is still the requirement for general anaesthesia for the supracervical hysterectomy with the resources and issues that carries with it. Both endometrial ablation and supracervical hysterectomy require the continued involvement by the woman in the national cervical cancer screening programme. There is also a training aspect in laparoscopic surgery required. Recently, we as a professional group have been minded to use less power morcellation (disruption) of the uterine specimen to reduce the likelihood of inadvertently spreading a malignancy from within the uterus. This change has happened since the beginning of the study presented and surgical behaviour and practice has changed.”

Antibiotics reduce complications after assisted vaginal delivery

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Lisa McDonald - Independent Midwife

“ANODE is a large multi-centre randomised controlled trial and demonstrates the use of antibiotics prophylaxis for instrumental births, reducing maternal infection rates up to 6 weeks of birth by 50%.

“The evidence appears to strongly support the use of intravenous antibiotic prophylaxis, in terms of reduced pain, improved healing, less follow up care and reduced impact on breastfeeding.

“However, due to the growing concern regarding antibiotic resistance, there is still further research to be done before rolling out in national guidance, looking in more detail at the differences in infection rates between forceps and ventouse births. Episiotomies are routinely used during forceps births, but not always used with ventouse and the perineal trauma appears to be a significant factor in levels of infection.

“The data collected in the placebo group is based on the numbers of antibiotic prescriptions written, not confirmed cases of infection. It is important to note that 24% of the data was also not included as the data was not complete. Both of these factors could have impacted on the results seen. Further research to reduce these limitations is needed to ensure change in practice is based on the highest level of evidence.”

Dr. Robin Crawford - Gynaecological Oncologist

“In this era of increasing antibiotic resistance when the need for evidence to use drugs and especially antibiotics in the puerperium is important, this study is important. It is recognised that antibiotic prophylaxis is required at caesarean section to reduce maternal surgical site infection and this evidence extends the benefit to operative vaginal deliveries. This is a simple yet important intervention to implement and should be done so without delay.”


Learn more about our contributors


Dr. Christina Founta

Christina is a Consultant Gynaecologist and Colposcopy Lead with a special interest in cancer diagnostics at Guy’s & St Thomas’ NHS Foundation Trust (GSTT). She has been training as part of gynaecological oncology teams exclusively since 2013. During this time, and before joining GSTT, she has worked as a clinical research fellow at the Queen Elizabeth Hospital, Gateshead and as a clinical fellow and consultant diagnostic lead at Musgrove Park Hospital, Taunton. Christina’s main interests are colposcopy, gynaecological endoscopy but also complex open and laparoscopic gynaecological surgery for diagnosis and early stage gynaecological cancers.


Dr. Robin Crawford

Robin is a Gynaecological Oncologist at Addenbrooke’s Hospital, specialising in the surgical management of gynaecological cancers. He also provides care and research into precancer via screening and symptoms suspicious for cancer via the two week wait referral or rapid referral system. Robin provides clinical care and contributes to clinical research in cancer genetics in relation to gynaecological cancer.


Davida Hamilton

Davida comments from a patient and carer point of view. She trained as an architect before completing an MSc in Computer-Aided Building Design. This led to a 30 year career in workplace strategy researching user needs in corporate, public sector, higher education and healthcare organisations and directing major workspace change and relocation projects.

After a diagnosis of secondary breast cancer, Davida retired in 2018. Her own experience of the oncology and other disciplines supporting her has provided a stark and sometimes poignant contrast.

Davida is keenly interested in science and educated in statistics, so is not afraid of medical jargon and is comfortable with her health situation.


Dr. Pensee Wu

Pensee is a Clinical Academic and Consultant Obstetrician and Maternal Fetal Medicine Subspecialist at Keele University and University Hospital of North Midlands NHS Trust. She has research interests in maternal and fetal outcomes following high-risk pregnancies.


Jenny Hall

Jenny has a history of immune-related recurrent miscarriage and is currently an IVF patient. She is therefore particularly interested in fertility and reproductive health, and the effects of reproductive health problems on mental health.


Barbara Hepworth-Jones

Barbara Hepworth-Jones is vice chair of the Miscarriage Association national charity and has experienced recurrent miscarriage. She has a PhD in physiology and pharmacology and is Director of Clinical Operations at a large pharmaceutical company.


Marie Bucklegray

Marie Buckleygray is a long-standing therapist, fertility teacher and perinatal support, who is now training to be a midwife. She has been a teacher for various women’s services organisations remaining a peer reviewer and mentor. She is based in Scotland where she also manages a Birth Support Group and Birth Pool Service.


Professor Zoe Winters

Professor Zoe Winters is a Professor of Breast Surgery at UCL in the Division of Surgery and Interventional Science.  She is a Chief Investigator for NIHR Randomised clinical trials in breast surgery and the CEO of London Breast Health.  She works at Kingston Hospital NHS Foundation Trust to support the NHS.


Professor Asma Khalil 

Asma Khalil is a Professor of Obstetrics and Maternal Fetal Medicine at St George’s Hospital, University of London. She is the Lead of the Twins Trust Centre for Research and Clinical Excellence. She is the Senior Obstetric Lead of the National Perinatal Mortality Audit and is an Expert Advisor to the NICE Centre for Clinical guidelines.


Lisa McDonald

Lisa is an independent midwife based in South London.