I read the article[1] by Mehigan and Burnett in the July 2012 issue of this Journal about training for nurses working in the field of sexual and reproductive health (SRH) with interest.

This is certainly a challenge faced by many, and one which we are trying to work on in Solihull at the moment. We have a significant number of nurses who are shining stars in the world of SRH and are waiting for funding to attend a university-based course that is currently being run in Coventry. We have an excellent relationship with our commissioner here and luckily have managed to secure two or three places this year, which is great news! However, some general practitioners are asking for a payment to backfill the nurse's post whilst they are out of the practice.

All of our practice nurses have access to SHIP Training (http://www.ship.bham.nhs.uk/), which provides an excellent foundation of knowledge at entry level, with the course at Coventry being the next level.

I agree and support the authors' thinking for nurses to have access to the Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) with equal accreditation. This would certainly overcome the need to invest large amounts of money into a university-based course and would give nurses an even footing within our field. It also provides an established and structured programme of learning that has certainly been tried and tested.

Over the coming months we will be making some decisions around the type of training offered to our nurses, both within our CASH and GUM services as well as within primary care. Taking on board the authors' comments about "wobbly wheels" has really helped to clarify where we'll be heading with our discussions.

Journal readers will probably gather that training and development within the field is close to my heart as I am sure it is to Mehigan and Burnett. Consequently, I would be willing to offer my assistance and support to the worthy cause of improving training and accreditation for nurses working within SRH.

Reference 1. Mehigan S, Burnett J. An innovative training for nurses in sexual and reproductive health. J Fam Plann Reprod Health Care 2012;38:194-195.

Conflict of Interest:

None declared

I have just read and would like to congratulate the authors on their excellent article "An innovative training for nurses in sexual reproductive health" in the July 2012 issue of this Journal [1]. I totally agree with the five benefits of their methods of training. The most important one is matched multidisciplinary skills, this being so necessary for nurses to undertake further training to fit implants and intrauterine devices/systems. I was a founder member of the Faculty Associate Members Working Group (established in 2005) that has been trying to resolve the problem of opening up the Faculty's medical Diploma to nurses. Some 7 years on, surely now the time is appropriate to permit this for the future training of nurses in sexual reproductive health? The Faculty now has 16 nurses training doctors in subdermal implants and has nationally recognised their competence and skills. Please could the Faculty produce an accreditation mechanism for nurses in sexual reproductive health? Reference 1. Mehighan S, Burnett J. An innovative training for nurses in sexual and reproductive health. J Fam Plann Reprod Health Care 2012;38:194-195.

Conflict of Interest:

None declared

I was very pleased to see the article by Shapiro and colleagues[1] that was recently published online in the Journal of Family Planning and Reproductive Health Care but dismayed to see the emotional response from epidemiologists.[2] This reanalysis of data from the so-called 'Million Women' study[3] raises important clinical concerns about the original strongly stated conclusions. I think it is essential that we see continuing debate about these complex epidemiological studies, where results are open to different interpretations.

Putting emotions aside, there are some problems with the original analysis of the Million Women Study (MWS). This type of study cannot make allowances for every possible bias, and as we are all aware 'big is not necessarily better' when biases are present. The statistically significant differences seen in the MWS are still very small, and potential biases could considerably change the final statistics.

It is the traditional scientific way to have debate about the findings of controversial studies, and, to me, it seems appropriate that the epidemiologists should set aside emotion and address the legitimate questions and criticisms of other scientists in the original journal to which the article was submitted.

The epidemiologists have managed to raise fear among women in the general community about use of hormone replacement preparations, yet these therapies have an enormous impact on many aspects of wellbeing, such that the benefit-risk ratio for most individual women is very positive. I would really like to show the epidemiologists I know (who do not see any patients) the dramatic impact that hormone replacement therapy (HRT) can have on the quality of the lives of many menopausal women.

We should not forget that the much vaunted and highly criticised Women's Health Initiative study showed a significant reduction in risk of breast cancer for women using oestrogen-alone HRT.[4] I do not hear the epidemiologists trumpeting this!

Everything we do in this life carries risk. Please can we look realistically at what are the many potential benefits of HRT and put them in perspective with individual risk. Let the debate continue - without emotion!

References 1. Shapiro S, Farmer RDT, Stevenson JC, Burger HG, Mueck AO. Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies. Part 4. The Million Women Study. J Fam Plann Reprod Health Care 2012;doi:10.1136/jfprhc-2011-100229. 2. Kmietowicz Z. Articles disputing link between HRT and breast cancer are "ridiculous" BMJ 2012;344:e513. 3. Million Women Study Collaborators. Breast cancer and hormone replacement therapy in the Million Women Study. Lancet 2003;362:419-427. 4. The Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA 2004;291:1701-1712.

Conflict of Interest:

None declared

Yet again scientists and epidemiologists are publicly debating the controversies around the previously reported risks of HRT (hormone replacement therapy). Is this further publicity deserved? The impact of studies such as the Million Women Study (MWS)[1] and Women's Health Initiative (WHI)[2] has been profound leading to significant reductions in the use of HRT. This has understandably affected millions of menopausal women globally who deserve to be fully informed of any doubts that may exist concerning the studies and should be aware of the debate.[3-4]

Ever since these publications were published the headlines in the popular press have been biased towards the 'bad news' messages, resulting in our patients feeling confused and under pressure to stop HRT. Following a recent web-based survey 70% of women who came off their HRT were below the age of 50. More importantly had these women known what we know today, 45% would have stayed on treatment.[5]

Many patients have been advised by their doctors to stop HRT and in some cases have had their prescriptions unilaterally withdrawn. These women have sought additional, poorly researched products with unproven safety and efficacy - often sold as food supplements to circumvent regulatory authorities.

Which risk is greatest? Taking a treatment which has little evidence of effectiveness or safety, or taking a product with the enormous research base that applies to HRT? Do we really know the answer? Is there enough information to allow carers or patients to be fully informed? We believe that the risk, if any is small and it is the view of the British Menopause Society (BMS) that, when used appropriately, any risks are outweighed by the benefits for the majority of women.

We must not forget that at the centre of the current published arguments there are millions of women who want to be properly informed about whether they should be taking HRT. Further, there are likely to be thousands of doctors and nurses who want to be more knowledgeable and confident about prescribing HRT.

In recognition of the menopause having diverse consequences and in an attempt to improve the provision of essential information for women, the BMS has recently submitted recommendations to the Department of Health. The key recommendation is that women should, around the time of the menopause transition, have a formal assessment of their needs, including advice concerning lifestyle, diet and individualised discussion of the risks and benefits of any suitable hormonal therapies. The BMS also suggested that whilst this would require additional resources, the potential long-term health gains would make this consultation highly cost effective in disease prevention terms.[6]

The two main areas that require addressing urgently are:

1) A robust understanding of the benefits and risks of HRT for patients and carers.

Most women who have been taking HRT since the publication of WHI and MWS will have been doing so having weighed up the pros and cons of treatment. Many women, even if there were genuinely a small increased risk of breast cancer, would accept this, if they could have a good quality of life through relief of the debilitating symptoms that invariably affect personal, social and wider quality of life.

The clear benefits in osteoporosis treatment and prevention have recently been included in a recommendation from the National Osteoporosis Society that recommends HRT for the treatment and prevention of osteoporosis in women under 60.[7]

2) HRT is not a single drug as the press and our patients seem to have derived from the publicity.

HRT is a comprehensive suite of preparations and delivery routes produced by the pharmaceutical industry in response to women's needs over more than 20 years of development, refinement and research. This research continues, even though research funding is a fraction of what it once was.[8]

Recently completed trials not only suggest that natural progesterone may not affect the risk of breast cancer and have a neutral effect,[9] but also that soon to be released small studies of lower dose, endogenous-type hormone treatments given to recently menopausal women show great promise.[10]

The BMS feels that the research must continue. As the female population lives longer after the menopause we need to establish safe ways to prevent disease and maintain a high quality of life. This requires a trial to establish definitively the correct indications, patients and hormones for optimal postmenopausal health.[11] We should harness the wealth of knowledge from the debates around WHI and MWS to design this study rather than watch the arguments from the sidelines.

The BMS is dedicated to advancing education in all matters relating to the menopause and to the primary prevention of the burden of preventable chronic disease.

Nick Panay, Chairman, British Menopause Society; Consultant Gynaecologist, Queen Charlotte's and Chelsea & Westminster Hospitals, Honorary Lecturer, Imperial College London, London, UK

Heather Currie, Medical Advisory Council Member, British Menopause Society; Associate Specialist Gynaecologist, Dumfries and Galloway Royal Infirmary, Dumfries, UK; Medical Director "Menopause Matters Ltd"

Edward Morris, Medical Advisory Council Member, British Menopause Society; Consultant, Obstetrics & Gynaecology, Norfolk & Norwich University Hospital, Norwich, UK

References

[1] Million Women Study Collaborators. Breast cancer and HRT in the Million Women Study. Lancet 2003; 362: 419-427.

[2] Writing group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's health initiative randomised controlled trial JAMA 2002; 288(3): 321-333.

[3] Shapiro S, Farmer RD, Stevenson JC, Burger H, Mueck AO. Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies Part 4: The Million Women Study J Fam Plann Reprod Health Care 2012. Jan 16 (ahead of print)

[4] Shapiro S, Farmer RD, Mueck AO, Seaman H, Stevenson JC. Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies: part 2. The Women's Health Initiative: estrogen plus progestogen. J Fam Plann Reprod Health Care 2011 Jul;37(3):165-172.

[5] Cumming GP, Currie HD, Panay N, Moncur R, Lee AJ. Stopping hormone replacement therapy: were women ill advised? Menopause Int 2011; 17(3): 82-87.

[6] British Menopause Society Council. Modernizing the NHS: observations and recommendations from the British Menopause Society. Menopause Int 2011 Jun;17(2):41-43.

[7] Bowring CE, Francis RM. National Osteoporosis Society's Position Statement on hormone replacement therapy in the prevention and treatment of osteoporosis. Menopause Int 2011; 17: 63-65.

[8] Panay N, Ylikorkala O, Archer DF, Rakov V, Gut R, Lang E. Ultra low-dose estradiol and norethisterone acetate: Effective menopausal symptom relief. Climacteric 2007; 10(2): 120-131.

[9] Fournier A, Fabre A, Mesrine S, Boutron-Ruault MC, Berrino F, Clavel-Chapelon F. Use of different postmenopausal hormone therapies and risk of histology- and hormone receptor-defined invasive breast cancer. J Clin Oncol 2008; 26(8):1260-1268.

[10] Harman SM, Brinton EA, Cedars M, Lobo R, Manson JE, Merriam GR, Miller VM, Naftolin F, Santoro N. KEEPS: The Kronos Early Estrogen Prevention Study. Climacteric 2005 Mar;8(1):3-12.

[11] Panay N, Fenton A. Has the time for the definitive, randomized, placebo-controlled HRT trial arrived? Climacteric 2011 Apr;14(2):195-196.

Conflict of Interest:

Nick Panay (NP), Eddie Morris (EM) and Heather Currie (HC) have received sponsorship for lectures and advisory work performed for pharmaceutical companies. NP and HC have received educational grants for meetings and NP has received funding for pharmaceutical trials. NP is co-editor in chief of Climacteric (International Menopause Society Journal) and EM/HC are co-editors in chief of Menopause International (British Menopause Society Journal).