Category: Test Flyers

Symptoms

The main symptoms are abnormal bleeding:

• Bleeding after the menopause
• Bleeding between periods
• Bleeding that is unusually heavy
• Blood stained discharge – from light to dark brown

If you have ovaries, you may still have monthly bleeding with your cycle. If you are taking testosterone, it is likely you may have a change in periods or they may stop completely. Every person is different and bodies react differently to hormones. It is important to know your normal, and if anything changes, speak to a doctor.

Risk factors

Obesity

Obesity can increase the risk of womb cancer by tenfold, as fat cells produce oestrogen. Oestrogen, if not balanced by a second reproductive hormone, progesterone, can lead to abnormal growth of the cells lining the womb and increase the risk of cancer, so the risk remains even if you have had your ovaries removed.

Testosterone

There is currently not much research out there around the effects of testosterone on gynaecological cancer risk. Some studies have indicated that if you have been taking testosterone and have a womb, you may have an increased risk of womb cancer due to the effect of testosterone on the womb lining (endometrium). The current recommendation is for trans men and non-binary people who have a womb and have been taking testosterone for more than two years, to have a pelvic ultrasound every two years.

Hereditary cancer risk

A very small percentage of people develop womb cancer because of an inherited genetic condition called Lynch Syndrome. If one of your immediate family members knows they have Lynch syndrome you will be eligible for testing. You should also consider being tested if several members of your family have suffered from bowel, womb or breast cancer. You can find out more about Lynch Syndrome here.

Symptoms:

• Increased abdominal size and persistent bloating (not bloating that comes and goes)
• Persistent pelvic and abdominal pain
• Unexplained change in bowel habits

Difficulty eating and feeling full quickly, or feeling nauseous

Risk factors:

Family history

If you have two or more close relatives who developed ovarian cancer or breast cancer, your risk of also developing the condition may be increased.

If your relatives developed cancer before the age of 50, it’s more likely it was the result of an inherited faulty gene. BRCA1 and BRCA2 are genes that when altered are linked to ovarian cancer, breast cancer, prostate and pancreatic cancers.

You may be at a high risk of having a faulty gene if you have:

• One relative diagnosed with ovarian cancer at any age and at least two close relatives with breast cancer whose average age is under 60; or alternatively at least one close relative with breast cancer under the age of 50. All of these relatives should be on the same side of your family (either your mother’s OR father’s side)
• Two relatives from the same side of the family diagnosed with ovarian cancer at any age.

If you’re at a higher risk of having the BRCA gene alteration, your GP can refer you for tests to check for faulty BRCA1 and BRCA2 genes.

Hormones

If you are on hormone treatment, it may alter your risk. There is a small reduction in risk if you are on or have taken a combined contraceptive pill. There may be a slight increase in risk on certain types of HRT. There is currently very little research into the effects of testosterone on ovarian cancer risk.

This may be relevant to you if have not had a total hysterectomy (removal of the womb and cervix).

Most cervical cancers are caused by a common sexually transmitted infection called human papillomavirus (HPV). HPV is a group of viruses, of which there are more than 100 different types and are responsible for skin warts, genital warts and verrucae. A number of these viruses , known as High Risk HPV can infect the cervix and cause no visible symptoms If the body is unable to clear High Risk HPV, there is a risk of abnormal cells developing, which could become cancerous over time. High Risk HPV is spread during sexual skin-to-skin contact, which is why it is important to get vaccinated if applicable, and go for your cervical screening, if applicable, even if you have not had penetrative sex. The UK government offers a HPV vaccination to all children at 11-12 years old.

It is currently the only gynaecological cancer with a national screening prevention programme, which is estimated to save around 4000 lives a year. In the UK, from the age of 25 everyone with a cervix is eligible for screening every 3-5 years, depending on their age. You can find out more about screening HERE.

Symptoms:

• Abnormal bleeding
• Bleeding between periods
• Bleeding after penetrative sex
• Bleeding that is unusually heavy
• Discharge – unpleasant smelling or blood stained
• Bleeding after the menopause
• Pain

Risk factors:

Smoking

People who smoke are twice as likely to develop cervical cancer as those who don’t; this may be caused by the harmful effects of chemicals found in tobacco on the cells, which make the immune system less effective, and less able to clear the HPV virus from your body and more vulnerable to the effects of the virus.

Immunosuppression drugs

People who are on immunosuppression drugs long term (organ transplant recipients), can be at increased risk of retaining the HPV virus and developing cervical cancer.

Further information about cervical screening for trans men, non-binary and intersex people is available.

This is relevant to you if you’ve not undergone genital surgery, or if you’ve had a phalloplasty or a metoidioplasty (both sometimes referred to as bottom surgery), as part or all of the vulva is kept and remodelled. The vulva describes the external genitals, including the soft tissue (labia minora and labia majora), the clitoris, and the Bartholin’s glands.

Symptoms:

• A lasting itch on the external genitalia
• Pain or soreness on the external genitalia
• Thickened, raised, red, white or dark patches on the skin of the external genitalia
• An open sore or growth visible on the genital skin
• A mole on the external genitalia that changes shape or colour
• A lump or swelling on the external genitalia

All these symptoms can be caused by other more common conditions, such as infection, but if you have any of these, you should see your GP. It is unlikely that your symptoms are caused by a serious problem but it is important to be checked out… remember non- cancerous conditions can be uncomfortable and so much better when treated!

Risk Factors:

Skin conditions that cause inflammation may sometimes develop into an early cancer. The two most common of these being vulval intraepithelial neoplasia (VIN) and Lichen Sclerosus. Some of these cell changes will go away without the need for any treatment; however, finding these abnormal cells early can help to prevent cancer.

Smoking

Smoking increases your risk of developing VIN and vulval cancer. This may be because smoking makes the immune system less effective, and less able to clear the HPV virus from your body and more vulnerable to the effects of the virus.

Vulval intraepithelial neoplasia (VIN)

VIN is potentially a pre-cancerous condition. This means there are changes to certain cells that aren’t cancerous, but could become a cancer at a later date if left untreated. This is a gradual process that usually takes well over 10 years.

There are two types of VIN:

• Usual or undifferentiated VIN – this typically affects people under 50 and is thought to be caused by an HPV infection
• Differentiated VIN (dVIN) – this is a rarer type, usually affecting people over 60, associated with skin conditions that affect the area, and is more likely to be associated with cancer.

Human papilloma virus (HPV)

HPV is present in at least 40% of cases, which suggests it may increase your risk of developing the condition. HPV is known to cause changes in the cells, which is known as VIN.

This is relevant to you if you’ve not undergone genital surgery, or some of your vaginal wall was remodelled during a metoidioplasty or if some vaginal tissues was left or remodelled during a phalloplasty procedure (both procedures are sometimes referred to as ‘bottom surgery’).

Symptoms:

• Abnormal bleeding, eg. between periods, after menopause
• Discharge with an unpleasant smell or blood stained
• Pain during penetrative sex
• An internal lump or growth that you or your doctor can feel
• An internal itch that won’t go away and pain when urinating
• Persistent pelvic and internal pain

Risk Factors:

Human papilloma virus

HPV is present in more than two-thirds of cases, which suggests that it may increase your risk of developing the condition.

Abnormal cells

Vaginal intraepithelial neoplasia (VAIN). VAIN is a term used to describe cells that are abnormal, which are thought of as a pre-cancerous condition. It is thought to be closely linked to having a persistent HPV infection. If left untreated it can turn into cancer.

Everyone with a cervix should be able to access the NHS cervical screening programme, and we want to provide helpful information for every community. Here we have answered some frequently asked questions:

When am I due to go for my first cervical screening?

Cervical screening (also known as a smear test) begins at the age of 25 in the UK. Around the time of your 25th birthday you may receive a letter inviting you to book your first screening appointment. If you are registered as male on your records, you will not get a letter asking you to book your appointment, but at the age of 25 you can contact your GP, or specialist clinic, and book your screening test.

You will be eligible for your next screening test every three years until the age of 50, and then every five years until the age of 64, if your screening tests are normal.

Although you will no longer receive screening invitations after the age of 64 as the risk of developing cervical cancer is low, you can still request cervical screening.

If you are 65 or over and feel you would benefit from a cervical screening appointment, please contact your GP.

What is a cervical screening test and how does it work?

The cervical screening programme is designed to protect against cervical cancer. This is because it can detect precancerous changes to the cells of the cervix, which if left untreated, could potentially develop into cervical cancer in the future. These changes give no symptoms which is why it is important to attend for screening. Please don’t be scared that this is a cancer test, it is designed to be preventative and reduce your risk.

The doctor or nurse will take a sample of cells from your cervix. They will do this by inserting a speculum (small plastic instrument) into the vagina, which holds the vaginal walls apart and allows the nurse or doctor to clearly see your cervix. They will then sweep the cervix with a soft plastic brush to collect the cells. Your sample will be sent to a laboratory for testing, where they will look first of all for high-risk HPV (human papillomavirus), a virus that causes almost all cervical cell changes. If high-risk HPV is present, your cells will then be tested for any abnormalities. It is important to remember that most people who have high-risk HPV will not have any cervical cell changes.

HPV is a common virus passed on through skin to skin sexual contact that causes over 99% of all cervical abnormalities. Your changes will be categorised into mild, moderate or severe dyskaryosis.

Will the cervical screening test hurt?

For some people, a cervical screening test can be uncomfortable. If you’re someone who doesn’t typically experience vaginal penetration, then there may be a higher chance of an internal examination causing you some discomfort.

If you are taking an oestrogen suppressant i.e. something that is stopping your ovaries from oestrogen, you will have less natural lubrication.

Using a natural vaginal moisturiser before your appointment will help to make the screening test more comfortable, and asking the doctor or nurse to use the smallest speculum can help minimise discomfort.

I’m a trans-man. Do I need to go for a cervical screening test?

Anyone with a cervix is at risk of developing cervical cancer. If you are a trans man who has a cervix, we understand that attending a cervical screening appointment may be emotionally and physically difficult for you. It can be helpful to have a separate appointment your nurse or doctor beforehand, and talk through the process with them. We have created a list of tips for helping with your screening, HERE. If you have any worries or concerns about going for your screening, do speak to your nurse, doctor or our Ask Eve information service.

I am a non-binary, do I need to go for a cervical screening test?

If you have a cervix, you will still be at risk of cervical cancer and we encourage you to attend your cervical screening appointment. This can understandably be something that is difficult to navigate, but your nurse and doctor are there to help you make the experience as positive as possible. Speak to them beforehand, go through what the appointment will involve and do check our list of tips on cervical screening, HERE. If you have any worries or concerns about going for your screening, do speak to your nurse, doctor or our Ask Eve information service.

I am intersex, do I need to go for a cervical screening test?

Not everyone who is intersex will need a cervical screening test. If you are intersex, it will depend on your combination of internal reproductive organs, i.e. whether or not you have a cervix, as to whether or not you need the screening test.

Your nurse or doctor will want to make you feel comfortable and reassured during this procedure, and good communication between the two of you is really important. Take your time, ask the questions you need answers to in order to feel as in control and relaxed as possible. Our tips on screening for trans men, non-binary and intersex people with a cervix can be found HERE, and our Ask Eve information service team are here to help you.

I have had the HPV vaccine, do I need my screening test?

Yes. The HPV vaccine available on the NHS works against four strains of HPV: 6, 11, 16 and 18. Types 16 and 18 cause around 70% of all cervical cancers. There are 11 other strains of high-risk HPV (HPV that can cause precancerous abnormalities) that are not currently included in the vaccination. It is still important to go for your screening test to pick up on any abnormal changes to your cervix. Together, the vaccination (typically given to children age 12-13) and screening programme in the UK prevent thousands of cases of cervical cancer a year. We encourage people to have both the vaccine and regular screening tests if applicable to you.

I haven’t had penetrative sex. Do I need to go for my screening test?

If you have never had penetrative sex, it is not a guarantee that you do not have any cervical abnormalities. Remember that sexual contact, without full intercourse can still transmit HPV. If you have never had any type of sexual contact then you are at a lower risk of cervical cancer, but as a small number of cervical cancers are not caused by HPV, so we would still recommend that you attend your screening appointment.

Jo’s Cervical Cancer Trust also has information and advice on their website which you might find helpful.

• Get booked in: if you’re registered as male at your GP surgery, you may not receive an invitation letter to go for your cervical screening. If you are 25 or over and have a cervix do call your GP and find out if you are due and get an appointment booked.

• Expectations: There is no pressure to actually have your screening test done in your first appointment. Sometimes multiple appointments are needed so that trust is built up between you and your nurse or doctor. If you are finding your screening difficult for whatever reason, it’s absolutely fine to need extra time in order to feel ready and prepared.

• Ask questions: Try not to be afraid to ask questions, or talk through any concerns you may have. Knowing what to expect can help make things seem less scary. It can be useful to see the equipment first and talk through the procedure step by step. If your nurse or doctor doesn’t ask for your pronouns, if you have had any genital gender transition surgeries or if you have a preferred term for your body parts, then try and tell them as early on in the appointment as possible, to avoid any communication that makes you feel triggered or uneasy.

• Start small: A speculum is the plastic instrument inserted in order to give the nurse or doctor a good view of the cervix. Speculums come in different sizes, so if you think you might find the screening test painful, ask for the smallest speculum and for it to be well lubricated.

• Ask Eve: Our nurse led information service, Ask Eve, is also here to help you. You can contact Ask Eve with any of your questions around gynae health and screening. You can email them on nurse@eveappeal.org.uk or call 0808 802 0019. The service is completely free and confidential, so please do get in touch if you want to talk to someone before (or after) your appointment.

• Relaxation is key: As humans, when we hear the words ‘just relax’, we often do the exact opposite! But try to relax in whatever way you can. What normally relaxes you? Whether it’s playing your favourite music or having a friend or partner with you for support, then use these tools to help you during your screening. Whatever you can do to try and feel as calm as possible. Control: Remember, you are in control of this situation! You can tell your nurse or doctor to stop and change your mind at any time for any reason.

• Lubricate: If you are post-menopausal or taking testosterone, you will have less natural lubrication, which can make a cervical screening test more uncomfortable. Try using a natural internal moisturiser before the appointment to make using a speculum easier and more comfortable. An oestrogen cream is also something that is helpful in this situation, but understandably using an oestrogen-based product can be off-putting, even if it is a localised product, i.e. won’t do anything to the body other than create more natural lubrication.

• You first: If you are finding the appointment really difficult, or taking the sample is causing a lot of discomfort or pain, it may be better for you to not go through with the screening test at this point in time. There might be a time in the future where it might be better for you. Sometimes, after thinking about your risk of having HPV, i.e. your sexual activity/history, you may decide against screening. Your overall wellbeing is a priority, particularly if the risk of cervical cancer is low. Your doctor or nurse will be able to discuss your risk with you and help you make the decision which is best for you and your overall health. You can also speak to Ask Eve.

• Plan B: If your GP/practice nurse finds it difficult to take your screening test, you can ask to be referred to your local colposcopy clinic where there is often a wider variety of equipment to make the process as comfortable as possible. There are some specialist LGBTQ+ clinics across the country too, which if possible, you can book into for your screening.

• Plan C: Sometimes it just isn’t possible to finish the test or you would prefer not to go ahead with the appointment. If you think it is a better option for you, you might want to consider a self-testing kit that can be done at home. It will come at a financial cost, and the chances of a poor sample or inaccurate result are higher, but it may be a better option if you would really like to be screened but are finding it too difficult.

If you still have any worries or concerns ahead of your appointment, you can contact our nurse-led information service, Ask Eve, by emailing nurse@eveappeal.org.uk, or calling the freephone number 0808 802 0019.

Preparation

1. Make the offer: Trans men will not receive an invitation letter to go to a cervical screening so do keep in mind when seeing them whether they may need a screening test, make them aware they are due and chat them through what the test is and why they might want to have one.
2. Don’t assume: If you don’t already know, check with your patients what their pronouns are. Check what gender reassignment genital surgeries your patient has had, if any. Also ask your patient what they prefer their genitals to be called, avoid words like vagina/vaginal unless told otherwise.
3. Set expectations: Let your patient know that there is no pressure to actually have their screening done in your first appointment together. Sometimes multiple appointments are needed so that trust is built up and your patient can prepare themselves in whatever way they need to, before a sample can actually be collected from their cervix. Try to avoid language such as ‘successful’, ‘inadequate’ etc.
4. Show and tell: Show your patient the equipment you will be using first. Knowing what to expect can help make things seem less scary. Show them the speculum and brush you plan to use and talk them through the procedure step by step before you begin.
5. Be aware: that your patient may not have experienced any vaginal penetration, which includes vaginal intercourse, using sex toys or tampons. Therefore they may find a speculum painful. Try the smallest size speculum, and make sure it is lubricated.
6. Relaxation is key: As humans, when we hear the words ‘just relax’, we often do the exact opposite! But if you can, let your patient know before your appointment together that being relaxed is important and will make the screening process easier. What normally relaxes them? Let them know they can bring in their favourite music, a stress ball, or a friend or partner for support. Whatever they can do to try and feel as calm as possible.
7. Testosterone: may affect the results of a cervical screening test, so be sure to check with your patient whether or not they are currently taking testosterone. Testosterone can cause changes to the cervix that can mimic cervical dysplasia (abnormal cells). Using an extended brush can help to get a better sample of cervical cells. Someone taking testosterone is more likely to receive an abnormal cervical screening result, and be referred for a colposcopy. Let your patient know that this is the case and reassure them that taking testosterone isn’t increasing their risk of cervical cancer.

Performing the screen

1. Control: Throughout the appointment remind your patient that they are in control, and that they can tell you to stop or change their mind at any time. Some patients can feel very vulnerable during a screening appointment, so letting them know that everything is on their terms can help balance this. Letting them know that if it is easier for them they can help you guide in the speculum. Get informed and explicit consent, and double or triple check!

2. Moisture: If your patient is taking testosterone, they will have less natural vaginal lubrication, which can make a cervical screening test more uncomfortable for them and harder for you in terms of inserting the speculum. Advise them to use a natural vaginal moisturiser before the appointment to make using a speculum easier and more comfortable. An oestrogen cream is also something that is helpful in this situation, but understandably many trans men will not want to use anything oestrogen-based, even if it is a localised product, i.e. won’t do anything to the body other than make the vaginal wall more moisturised.

3. Patients first: If your patient is finding the appointment really difficult, or taking the sample is causing a lot of discomfort or pain, it may be better for your patient to not go through with the screening test at this moment. It might be better to recommend trying again at another appointment. Sometimes, after thinking about their risk of having HPV, i.e. their sexual activity/history (if any), a patient may decide against completing their screening. Their overall wellbeing is a priority, particularly if the risk of cervical cancer is low.

Follow up

4. Plan b: Sometimes it just isn’t possible to finish the cervical screening test, either because you can’t take the sample or your patient would prefer not to go ahead with the appointment. If appropriate, you might want to tell your patient about self-testing kits that can be done at home. It will come at a financial cost to them, and the chances of a poor sample or inaccurate result are higher, but is better than no test at all.

Not all women with PCOS will have all of the symptoms, and each symptom can vary from mild to severe.

Some women only experience menstrual problems or are unable to conceive, or both.

Common symptoms of PCOS include:

• irregular periods or no periods at all
• difficulty getting pregnant (because of irregular ovulation or failure to ovulate)
• excessive hair growth (hirsutism) – usually on the face, chest, back or buttocks
• weight gain
• thinning hair and hair loss from the head
• oily skin or acne

You should talk to your GP if you have any of these symptoms and think you may have PCOS.

Fertility problems

PCOS is one of the most common causes of female infertility. Many women discover they have PCOS when they’re trying to get pregnant and are unsuccessful.

During each menstrual cycle, the ovaries release an egg (ovum) into the uterus (womb). This process is called ovulation and usually occurs once a month.

But women with PCOS often fail to ovulate or ovulate infrequently, which means they have irregular or absent periods and find it difficult to get pregnant.

Risks in later life

Having PCOS can increase your chances of developing other health problems in later life.

For example, women with PCOS are at increased risk of developing:

• type 2 diabetes – a lifelong condition that causes a person’s blood sugar level to become too high
• depression and mood swings – because the symptoms of PCOS can affect your confidence and self-esteem
• high blood pressure and high cholesterol – which can lead to heart disease and stroke
• sleep apnoea – overweight women may also develop sleep apnoea, a condition that causes interrupted breathing during sleep

Women who have had absent or very irregular periods (fewer than 3 or 4 periods a year) for many years have a higher than average risk of developing cancer of the womb lining (endometrial cancer).

But the chance of getting endometrial cancer is still small and can be minimised using treatments to regulate periods, such as the contraceptive pill or an intrauterine system (IUS).

Resistance to insulin

Insulin is a hormone produced by the pancreas to control the amount of sugar in the blood. It helps to move glucose from blood into cells, where it’s broken down to produce energy.

Insulin resistance means the body’s tissues are resistant to the effects of insulin. The body therefore has to produce extra insulin to compensate.

High levels of insulin causes the ovaries to produce too much testosterone, which interferes with the development of the follicles (the sacs in the ovaries where eggs develop) and prevents normal ovulation.

Insulin resistance can also lead to weight gain, which can make PCOS symptoms worse, as having excess fat causes the body to produce even more insulin.

Hormone imbalance

Many women with PCOS are found to have an imbalance in certain hormones, including:

• raised levels of testosterone – a hormone often thought of as a male hormone, although all women usually produce small amounts of it
• raised levels of luteinising hormone (LH) – this stimulates ovulation, but may have an abnormal effect on the ovaries if levels are too high
• low levels of sex hormone-binding globulin (SHBG) – a protein in the blood that binds to testosterone and reduces its effect
• raised levels of prolactin (only in some women with PCOS) – a hormone that stimulates the breast glands to produce milk in pregnancy

The exact reason why these hormonal changes occur is not known.

It’s been suggested that the problem may start in the ovary itself, in other glands that produce these hormones, or in the part of the brain that controls their production.

The changes may also be caused by the resistance to insulin.

Genetics

PCOS sometimes runs in families. If any relatives, such as your mother, sister or aunt, have PCOS, the risk of you developing it is often increased.

This suggests there may be a genetic link to PCOS, although specific genes associated with the condition have not yet been identified.

The GP will ask about your symptoms to help rule out other possible causes, and check your blood pressure.

They’ll also arrange for you to have a number of hormone tests to find out whether the excess hormone production is caused by PCOS or another hormone-related condition.

You may also need an ultrasound scan, which can show whether you have a high number of follicles in your ovaries (polycystic ovaries). The follicles are fluid-filled sacs in which eggs develop.

You may also need a blood test to measure your hormone levels and screen for diabetes or high cholesterol.

Diagnosis criteria

A diagnosis of PCOS can usually be made if other rare causes of the same symptoms have been ruled out and you meet at least 2 of the following 3 criteria:

• you have irregular periods or infrequent periods – this indicates that your ovaries do not regularly release eggs (ovulate)
• blood tests showing you have high levels of “male hormones”, such as testosterone (or sometimes just the signs of excess male hormones, even if the blood test is normal)
• scans showing you have polycystic ovaries

As only 2 of these need to be present to diagnose PCOS, you will not necessarily need to have an ultrasound scan before the condition can be confirmed.

Referral to a specialist

If you’re diagnosed with PCOS, you may be treated by your GP or referred to a specialist, either a gynaecologist (a specialist in treating conditions of the female reproductive system) or an endocrinologist (a specialist in treating hormone problems).

Your GP or specialist will discuss with you the best way to manage your symptoms. They’ll recommend lifestyle changes and start you on any necessary medicine.

Follow-up

Depending on factors like your age and weight, you may be offered annual checks of your blood pressure and screening for diabetes if you’re diagnosed with PCOS.

Treatment options can vary because someone with PCOS may experience a range of symptoms, or just 1.

The main treatment options are discussed in more detail below.

Lifestyle changes

In overweight women, the symptoms and overall risk of developing long-term health problems from PCOS can be greatly improved by losing excess weight.

Weight loss of just 5% can lead to a significant improvement in PCOS.

You can find out whether you’re a healthy weight by calculating your body mass index (BMI), which is a measurement of your weight in relation to your height.

A normal BMI is between 18.5 and 24.9. Use the BMI healthy weight calculator to work out whether your BMI is in the healthy range.

You can lose weight by exercising regularly and eating a healthy, balanced diet.

Your diet should include plenty of fruit and vegetables, (at least 5 portions a day), whole foods (such as wholemeal bread, wholegrain cereals and brown rice), lean meats, fish and chicken.

Your GP may be able to refer you to a dietitian if you need specific dietary advice.

Read more about losing weight, healthy eating and exercise.

Medicines

A number of medicines are available to treat different symptoms associated with PCOS.

These are described below.

Irregular or absent periods

The contraceptive pill may be recommended to induce regular periods, or periods may be induced using an intermittent course of progestogen tablets (which are usually given every 3 to 4 months, but can be given monthly).

This will also reduce the long-term risk of developing cancer of the womb lining (endometrial cancer) associated with not having regular periods.

Other hormonal methods of contraception, such as an intrauterine system (IUS), will also reduce this risk by keeping the womb lining thin, but they may not cause periods.

Fertility problems

With treatment, most women with PCOS are able to get pregnant.

The majority of women can be successfully treated with a short course of tablets taken at the beginning of each cycle for several cycles.

If these are not successful, you may be offered injections or IVF treatment. There’s an increased risk of a multiple pregnancy (rarely more than twins) with these treatments.

A medicine called clomifene is usually the first treatment recommended for women with PCOS who are trying to get pregnant.

Clomifene encourages the monthly release of an egg from the ovaries (ovulation).

If clomifene is unsuccessful in encouraging ovulation, another medicine called metformin may be recommended.

Metformin is often used to treat type 2 diabetes, but it can also lower insulin and blood sugar levels in women with PCOS.

As well as stimulating ovulation, encouraging regular monthly periods and lowering the risk of miscarriage, metformin can also have other long-term health benefits, such as lowering high cholesterol levels and reducing the risk of heart disease.

Metformin is not licensed for treating PCOS in the UK, but because many women with PCOS have insulin resistance, it can be used “off-label” in certain circumstances to encourage fertility and control the symptoms of PCOS.

Possible side effects of metformin include nausea, vomiting, stomach pain, diarrhoea and loss of appetite.

As metformin can stimulate fertility, if you’re considering using it for PCOS and not trying to get pregnant, make sure you use suitable contraception if you’re sexually active.

The National Institute for Health and Care and Excellence (NICE) has more information about the use of metformin for treating PCOS in women who are not trying to get pregnant, including a summary of the possible benefits and harms.

Letrozole is sometimes used to stimulate ovulation instead of clomifene. This medicine can also be used for treating breast cancer.

Use of letrozole for fertility treatment is “off-label”. This means that the medicine’s manufacturer has not applied for a licence for it to be used to treat PCOS.

In other words, although letrozole is licensed for treating breast cancer, it does not have a license for treating PCOS.

Doctors sometimes use an unlicensed medicine if they think it’s likely to be effective and the benefits of treatment outweigh any associated risks.

Find out more about unlicensed and off-label use of medicines

If you’re unable to get pregnant despite taking oral medicines, a different type of medicine called gonadotrophins may be recommended.

These are given by injection. There’s a higher risk that they may overstimulate your ovaries and lead to multiple pregnancies.

Unwanted hair growth and hair loss

Medicines to control excessive hair growth (hirsutism) and hair loss (alopecia) include:

• particular types of combined oral contraceptive tablets (such as co-cyprindiol, Dianette, Marvelon and Yasmin)
• cyproterone acetate
• spironolactone
• flutamide
• finasteride

These medicines work by blocking the effects of “male hormones”, such as testosterone, and some also suppress production of these hormones by the ovaries.

A cream called eflornithine can also be used to slow down the growth of unwanted facial hair.

This cream does not remove hair or cure unwanted facial hair, so you may wish to use it alongside a hair removal product.

Improvement may be seen 4 to 8 weeks after treatment with this medicine.

But eflornithine cream is not always available on the NHS because some local NHS authorities have decided it’s not effective enough to justify NHS prescription.

If you have unwanted hair growth, you may also want to remove the excess hair by using methods such as plucking, shaving, threading, creams or laser removal.

Laser removal of facial hair may be available on the NHS in some parts of the UK.

Other symptoms

Medicines can also be used to treat some of the other problems associated with PCOS, including:

• weight-loss medicine, such as orlistat, if you’re overweight
• cholesterol-lowering medicine (statins) if you have high levels of cholesterol in your blood
• acne treatments

Surgery

A minor surgical procedure called laparoscopic ovarian drilling (LOD) may be a treatment option for fertility problems associated with PCOS that do not respond to medicine.

Under general anaesthetic, your doctor will make a small cut in your lower tummy and pass a long, thin microscope called a laparoscope through into your abdomen.

The ovaries will then be surgically treated using heat or a laser to destroy the tissue that’s producing androgens (male hormones).

LOD has been found to lower levels of testosterone and luteinising hormone (LH), and raise levels of follicle-stimulating hormone (FSH).

This corrects your hormone imbalance and can restore the normal function of your ovaries.

Pregnancy risks

If you have PCOS, you have a higher risk of pregnancy complications, such as high blood pressure (hypertension), pre-eclampsia, gestational diabetes and miscarriage.

These risks are particularly high if you’re obese. If you’re overweight or obese, you can lower your risk by losing weight before trying for a baby.

Risks of alcohol misuse

Short-Term

The short-term risks of alcohol misuse include:

• Accidents and injuries requiring hospital treatment, such as a head injury
• Violent behaviour and being a victim of violence
• Loss of personal possessions, such as wallets, keys or mobile phones
• Alcohol poisoning – this may lead to vomiting, fits (seizures) and falling unconscious
• Unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs)

People who binge drink (drink heavily over a short period of time) are more likely to behave recklessly and are at greater risk of being in an accident.

Long-Term

Persistent alcohol misuse increases your risk of serious health conditions, including:

As well as causing serious health problems, long-term alcohol misuse can lead to social problems for some people, such as unemployment, divorce, domestic abuse and homelessness.

If someone loses control over their drinking and has an excessive desire to drink, it’s known as dependent drinking (alcoholism).

Dependent drinking usually affects a person’s quality of life and relationships, but they may not always find it easy to see or accept this. Severely dependent drinkers are often able to tolerate very high levels of alcohol in amounts that would dangerously affect or even kill some people.

A dependent drinker usually experiences physical and psychological withdrawal symptoms if they suddenly cut down or stop drinking, including:

This often leads to “relief drinking” to avoid withdrawal symptoms.

Getting Help

You may need help if:

• You often feel the need to have a drink
• You get into trouble because of your drinking
• Other people warn you about how much you’re drinking
• You think your drinking is causing you problems

If you’re concerned about your drinking or someone else’s, a good first step is to see a GP. They’ll be able to discuss the services and treatments available.

Your alcohol intake may be assessed using tests such as the two below

As well as the NHS, there are a number of charities and support groups across the UK that provide support and advice for people with an alcohol misuse problem. For example, you may want to contact:

See a full list of alcohol charities and support groups

Treating alcohol misuse

How alcohol misuse is treated depends on how much alcohol a person is drinking. Treatment options include:

• Counselling – including self-help groups and talking therapies, such as cognitive behavioural therapy (CBT)
• Medicines
• Detoxification – this involves a nurse or doctor supporting you to safely stop drinking; this can be done by helping you slowly cut down over time or by giving you medicines to prevent withdrawal symptoms

There are 2 main types of medicines to help people stop drinking. The first is to help stop withdrawal symptoms and is given in reducing doses over a short period of time. The most common of these medicines is chlordiazapoxide (Librium). The second is a medicine to reduce any urge you may have to drink. The most common medicines used for this are acamprosate and naltrexone.

These are both given at a fixed dose, and you’ll usually be on them for 6 to 12 months.

Electronic prescriptions

Most prescriptions are now signed, sent and processed electronically.

You have 2 choices for how this works.

• You can choose a pharmacy or dispenser to dispense all your prescriptions. When you get a prescription, it will be sent electronically to the dispenser you have chosen. You can collect your medicines or appliances without having to hand in a paper prescription.
• You can decide each time you are issued a prescription where you would like it to be dispensed. When you are issued a prescription, you will be given a paper copy that you can take to any pharmacy or other dispenser in England. The paper copy will contain a unique barcode that will be scanned to download your prescription from the secure NHS database.

Choosing a pharmacy

If you get regular prescriptions or are already using a prescription collection service (where a pharmacy collects prescriptions from your GP practice for you) then choosing a pharmacy to dispense all your prescriptions may save you time by avoiding unnecessary trips to your GP.

You will still order your repeat prescriptions in the same way as you do now, but your prescriptions will be sent electronically to the pharmacy or dispenser of your choice.

You will not have to collect a paper repeat prescription from your GP practice.

Cancelling or changing your choice of pharmacist or dispenser

You can change or cancel your choice of dispenser at any time. Simply speak to your GP or pharmacist before you order your next prescription.

You should allow time for the update to take place to avoid your next prescription being sent to the wrong place.

Repeat prescriptions

Repeat prescriptions can be issued in 2 different ways:

1. You order the prescription to be approved by a GP each time you need a refill.
2. You order the prescription once and a GP approves a series of refills for you. They are sent to the pharmacy automatically, so you do not need to order them each time. This is called electronic repeat dispensing. The GP surgery or pharmacy will let you know when you need to re-order your prescription.

In both cases, you can:

• choose a specific pharmacy (nominated pharmacy) to collect your prescriptions from each time – call or contact the pharmacy online a few days before you run out of medicine to check your prescription is ready to collect
• decide each time you’re given a prescription where to collect it – you’ll be given a paper copy with a barcode to take to any pharmacy in England, or the pharmacy can find your prescription using your NHS number

As part of the repeat prescription service, the pharmacist will ask if you’re having any problems or side effects with your medicines and, where appropriate, they can discuss this with you and your GP.

Ordering repeat prescriptions online

If you receive medicine on repeat prescription, you can now use several apps and websites to order your repeats online. You can then collect your medicines from a pharmacy or have them delivered to your home (where available).

You can only order repeat prescriptions. You cannot order one-off, short-term prescriptions.

When you order a repeat prescription online, you can have your prescription sent electronically to a pharmacy or dispenser of your choice. This means you no longer need to collect a paper prescription from your GP surgery. For a full list of apps and websites you can use visit the NHS website

If you have not already chosen your regular pharmacy or dispenser (called a “nomination”), some apps and websites allow you to set one up. If they do not:

• contact the pharmacy or dispenser you want to nominate
• contact your GP surgery to set one up

You can order a repeat presctiption through the NHS website.

You need an NHS login to use this service. If you do not have an NHS login, you’ll be asked to set one up.

 

Quick links:

Find out about free prescriptions for :

You can get free NHS prescriptions if, at the time the prescription is dispensed, you:

• are 60 or over
• are under 16
• are 16 to 18 and in full-time education
• are pregnant or have had a baby in the previous 12 months and have a valid maternity exemption certificate (MatEx)
• have a specified medical condition and have a valid medical exemption certificate (MedEx)
• have a continuing physical disability that prevents you going out without help from another person and have a valid medical exemption certificate (MedEx)
• hold a valid war pension exemption certificate and the prescription is for your accepted disability
• are an NHS inpatient

You’re also entitled to free prescriptions if you or your partner (including civil partner) receive, or you’re under the age of 20 and the dependant of someone receiving:

• Income Support
• income-based Jobseeker’s Allowance
• income-related Employment and Support Allowance
• Pension Credit Guarantee Credit
• Universal Credit and meet the criteria

If you’re entitled to or named on:

• a valid NHS tax credit exemption certificate – if you do not have a certificate, you can show your award notice. You qualify if you get Child Tax Credits, Working Tax Credits with a disability element (or both), and have income for tax credit purposes of £15,276 or less
• a valid NHS certificate for full help with health costs (HC2)

People named on an NHS certificate for partial help with health costs (HC3) may also get help.

Read more about who can get free NHS prescriptions.

Check if you’re eligible for free prescriptions

There’s a simple way to find out if you’re eligible for free NHS prescriptions and any help with other NHS costs.

Free prescriptions for certain medical conditions

People with certain medical conditions can get free NHS prescriptions.

Medical exemption certificates are credit-card-size cards. They are issued if you have:

• cancer, including the effects of cancer or the effects of current or previous cancer treatment
• a permanent fistula (for example, a laryngostomy, colostomy, ileostomy or some renal dialysis fistulas) requiring continuous surgical dressing or an appliance
• a form of hypoadrenalism (for example, Addison’s disease) for which specific substitution therapy is essential
• diabetes insipidus or other forms of hypopituitarism
• diabetes mellitus, except where treatment is by diet alone
• hypoparathyroidism
• myasthenia gravis
• myxoedema (hypothyroidism requiring thyroid hormone replacement)
• epilepsy requiring continuous anticonvulsive therapy
• a continuing physical disability that means you cannot go out without the help of another person (temporary disabilities do not count, even if they last for several months)

How to apply for a medical exemption certificate

Free prescriptions for pregnant women

If you’re pregnant or have had a baby in the past 12 months, you get free prescriptions if you have a valid maternity exemption certificate.

Maternity exemption certificates are credit-card-size cards.

To apply for a maternity exemption certificate, contact your doctor, midwife or health visitor.

The certificate will last until 12 months after the expected date of birth of your baby.

If your baby’s born early, you can continue to use your certificate until it expires.

If your baby is born late, you can apply for an extension.

If you apply after your baby is born, your certificate will last for 12 months from your baby’s birth.

Free prescriptions if you have a low income

If you have a low income, you may be eligible to receive financial help through the NHS Low Income Scheme.

To apply for an HC2 certificate, complete form HC1, which is available from Jobcentre Plus offices or most NHS hospitals. You might also be able to get an HC1 form from your doctor, dentist or optician.

You can also get an HC1 form by calling 0300 123 0849.

You qualify for a full help HC2 certificate (which includes free NHS prescriptions) if your income is less than or equal to your requirements, or your income is greater than your requirements by no more than half the current English prescription charge.

You qualify for a limited help HC3 certificate if your income is greater than your requirements by more than half the current English prescription charge.

The HC3 certificate shows how much you have to pay towards your health costs.

Certificates are usually valid for between 6 months and 5 years, depending on your circumstances.

How can I claim a refund on a prescription charge?

Ask the pharmacist, hospital or doctor for the refund form (FP57) when you pay for your prescription. You cannot get one later.

You must apply for a refund within 3 months of paying the prescription charge.

If you receive Universal Credit and meet all the criteria to be entitled to help with health costs but did not get a refund form (FP57), contact the NHS Business Services Authority. They’ll consider applications for refunds on a case-by-case basis.

Important numbers

A PPC covers all your NHS prescriptions, including NHS dental prescriptions, no matter how many items you need.

But it does not cover the cost of other health items, such as the provision of wigs and fabric supports, which are only provided through the hospital service.

There are 2 PPC options to choose from:

1. The 3-month PPC costs £30.25 and will save you money if you need more than 3 prescribed items in 3 months.
2. The 12-month PPC costs £108.10 and will save you money if you need more than 11 prescribed items in a year.

There are several payment options available. If you choose the 12-month PPC, you can pay for this upfront, or by 10 monthly direct debit instalments.

How much can I save?

If you need:

• 2 items each month –

you can save £116.30 with a 12-month PPC

• 3 items each month –

you can save £228.50 with a 12-month PPC

• 4 items each month –

you can save £340.70 with a 12-month PPC

How to apply for a PPC

Check if you’re entitled to free prescriptions before you apply for a PPC.

It’s quickest to buy a PPC online. The PPC will start from the day you submit your application, unless you request a different start date, but the start date must be within 1 month before or after the date of your application.

If you prefer talking to someone, you can call the PPC order line on 0300 330 1341. Your certificate will be valid from the day you make the phone call, unless you request otherwise.

Make sure you have your bank details or credit or debit card details ready.

You can receive your certificate details by email if you provide an email address, print them at the end of your online application, or receive the details by post.

Although a PPC is valid from the day of your application (unless otherwise requested), it may take a couple of days to receive the details of your certificate by post. If you pay prescription charges while you’re waiting for the details to arrive, you can get a refund, as long as you get an NHS refund form (FP57) when you pay.

Some pharmacies may be able to sell you a PPC. You will not be able to pay by direct debit if you buy a PPC at a pharmacy.

Useful tips

• Remember to apply for a new PPC in plenty of time, otherwise you’ll have to pay full prescription charges if it expires.
• It’s important that you do not use your certificate after it expires. The NHSBSA checks that patients who claim for free NHS prescriptions are entitled to the exemption they have declared.
• Check that your certificate is valid before claiming free NHS prescriptions
• If you have to pay for prescriptions while you’re waiting for details about a new PPC and need to apply for a refund, ask the pharmacist for an NHS receipt (FP57) so you can claim back the cost. Your PPC must cover the date you paid the prescription charge.
• You can claim for the refund of prescription charges up to 3 months after paying. The FP57 explains what to do.
• If you buy a 12-month PPC by direct debit, you are entering into a commitment to pay all the instalments.

 

If you have a prescription:

If you already have a prescription and urgently need the medicine, try the following steps:

• If your local pharmacy is closed, you can get your medicine from any pharmacy as long as they have it in stock. Use the NHS pharmacy service search to find other nearby pharmacies and their opening hours – some are open until midnight or later, even on public holidays.
• If you’d like to speak to someone first, call NHS 111 free of charge by dialling 111 on your mobile or landline. The person you speak to can look up an out-of-hours pharmacy or another NHS service in your area.
• You can also use the NHS walk-in centre service search to find your nearest walk-in centre. These can sometimes dispense medicines after a consultation.
• If it’s urgent, you can call your GP surgery. They should have details of their out-of-hours service recorded on their answering machine. This is the service your GP runs outside their usual opening hours and on public holidays – do not use this routinely. You can use the NHS GP service finder to find your GP surgery’s phone number.
• If it’s an emergency and you’ve tried all of the above unsuccessfully, use the service search to find your nearest A&E.

If you do not have a prescription

If you run out of prescription medicine and do not have a prescription with you, you can get an emergency supply from a pharmacy without a prescription.

Take an old prescription or the medicine’s packaging with you, if you have it.

Pharmacies

You’ll be assessed by the pharmacist to find out:

• if you need the medicine immediately
• who previously prescribed the medicine (to make sure they’re a trusted source)
• what dose of the medicine would be appropriate for you to take

The pharmacist needs to know the answers to all of these questions before they can supply a prescription-only medicine without a prescription in an emergency. They will keep a record of your details, the medicine they provide and the nature of the emergency.

If the pharmacist is not satisfied that the medicine and dose is appropriate for you, they may not supply the medicine.

Only a limited range of controlled medicines can be prescribed in an emergency, such as those for epilepsy (phenobarbital). Many commonly used controlled medicines, such as morphine or diamorphine, cannot be supplied without a prescription by a pharmacist in an emergency.

You may need to pay for this service and medicine, even if you do not normally, because they’re being provided without a prescription. This may vary between pharmacies.

GPs and walk-in centres

If you run out of medicine while you’re away from home, you may be able to have a consultation with a local GP and get a prescription for a limited supply of medicines. You’ll then need to find a pharmacy that’s open.

You can also go to an NHS walk-in centre. They may be able to organise a GP consultation. Sometimes, they can give you medicine after you’ve seen a nurse.

These services staffed by expert advisers provide a range of proven methods to help you quit. They’ll give you accurate information and advice, as well as professional support, during the first few months you stop smoking. They also make it easy and affordable for you to get stop smoking treatments, such as:

• Varenicline (Champix)
• Bupropion (Zyban)
• Nicotine replacement therapy, such as patches and gum

One-to-one and group stop smoking services

You’ll normally be offered a one-to-one appointment with an adviser, but many areas also offer group and drop-in services as well. Depending on where you live, the venue could be a local GP surgery, pharmacy, high-street shop, or even a mobile bus clinic.

Jennifer Percival, who trains stop smoking advisers, says that using both treatment and specialist support is proven to give you the best chance of stopping smoking.

“The majority of people who see an adviser will get through the first month after quitting without smoking a cigarette.

“Overall, you’re up to 4 times more likely to stop smoking for good if you use a combination of stop smoking treatment and receive support from an NHS Stop Smoking Service.” she says.

How to contact a stop smoking adviser

Your GP can refer you, or you can phone your local stop smoking service to make an appointment with an adviser.

What happens at the first stop smoking session?

At your first meeting with an adviser, you’ll talk about why you smoke and why you want to quit, as well as any attempts you’ve made to quit in the past. You’ll also be able to decide on a quit date.

You’ll be offered a breath test, which shows the level of carbon monoxide – a poisonous gas in cigarette smoke – in your body.

“You don’t need to be sure you want to quit or have a quit plan in mind before this meeting,” says Jennifer.

“You can use the time to talk your situation through with the adviser without making a commitment. If you do decide to quit, the adviser can help you form an action plan and set a quit date, usually in a week or so.”

Stop smoking aids

At your first session, you’ll also discuss NHS-endorsed stop smoking treatments available to help you. These are nicotine replacement products (including patches, gum, lozenges, inhalators and mouth and nasal sprays) and the stop smoking tablets Champix (varenicline) and Zyban (bupropion).

“No one is forced to use treatment,” says Jennifer, “but we’ll encourage it because the results are better. We can help you decide which type of treatment is right for you and how to use it.

“In some cases, we can directly supply you with the treatment before you leave, or we can arrange for you to receive a prescription or a voucher for it.

“In the case of nicotine replacement therapy, it often works out at least a third cheaper than buying it from a pharmacy.”

There’s evidence that e-cigarettes can help people stop smoking. E-cigarettes aren’t currently available as medicines so they can’t be supplied by stop smoking services or prescribed on the NHS but, if you want to use an e-cigarette to help you quit, you can still get advice and support from a stop smoking adviser to give you the best chance of success.

Read more about using e-cigarettes to stop smoking

Jennifer points out that NHS stop smoking advisers only provide evidence-based support. “We won’t suggest or recommend hypnosis or acupuncture as there’s not enough evidence they help you stop smoking.”

Talk to your GP

Many people don’t realise that their GP can help them quit smoking. Your doctor can do a lot, such as enrolling you in a “stop smoking” clinic, and prescribing nicotine replacement therapy, such as patches and gum, or stop smoking medication such as Champix.

10 self-help tips to stop smoking

Join your local stop smoking service

Did you know that you’re up to 4 times more likely to quit successfully with the help of your local stop smoking service?

Services staffed by trained stop smoking advisers are available all over the country. You can join a local group that meets once a week, or have one-to-one support if you prefer. You usually go for a few weeks and work towards a quit date.

Find your nearest NHS Stop Smoking Service, or call the Smokefree National Helpline on 0300 123 1044 to speak to a trained adviser.

Find online support

For online support including apps, communities and motivational emails, visit Better Health.

Have an emergency phone number to hand

Keep an emergency number, perhaps for your local stop smoking service or the national helpline.

“We’re here on 0300 123 1044 from Monday to Friday 9am to 8pm, and Saturday and Sunday 11am to 4pm answering calls from people who are about to have a cigarette and want help not lighting up,” says Chris, one of the helpline advisers. “We can talk about why you want to smoke and how to deal with your cravings.”

Read more about how to cope with cravings

Consider using a nicotine-containing product

Cigarettes are addictive, and self-control alone might not be enough for you to stop entirely. Give yourself a better chance of success by using nicotine replacement therapy (NRT). This is available on prescription from your GP, from your local stop smoking service or from a pharmacist.

You could also consider trying e-cigarettes. While they’re not risk-free, they are much safer than cigarettes and can help people stop smoking.

Read more about using e-cigarettes to stop smoking

Find your nearest NHS stop smoking service, or call 0300 123 1044

If you relapse after quitting, the key is to learn from what went wrong so you’re more likely to succeed next time.

If you’re tempted to start smoking again, call the free NHS Smokefree helpline on 0300 123 1044 to get support from a trained adviser.

When you quit smoking, it’s important to be positive and really believe that you’ll be successful. You shouldn’t expect to start smoking again. A slip-up shouldn’t mean that you’ll return to smoking the way you did before. It’s an opportunity to learn a bit about yourself and what will help you to be more successful in the future.

If you do relapse, don’t worry. It can take a few tries to quit smoking for good.

It can be helpful to commit yourself to the “not a single drag” rule. Promise to yourself and others that you’ll not even have a single drag on a cigarette. By sticking to this simple rule, you can guarantee that you won’t start smoking again.

Preventing slip-ups

Why is it that some people who have stopped return to smoking? The main reason is giving in to cravings. These are powerful urges to smoke, often triggered by stress, seeing other people smoking, getting drunk, or emotional events like arguments.

The best way to withstand cravings is a combination of stop smoking medicines and behavioural changes. It’s also important to stay away from people who smoke. Most people who relapse do so because they’re with other people who are smoking, and this is usually after having asked one of them for a cigarette.

Get practical advice on how to relieve cravings

Help to prevent relapse

The risk of relapse is highest in the first few weeks after stopping. But some people can relapse several months, or even years, after stopping smoking.

Avoiding a relapse is best, but if you do give in to temptation, don’t despair. Really think about what went wrong and plan how you’ll deal with a similar situation in the future.

If you have had a cigarette or two:

• Don’t give up – you can still avoid a full relapse. Commit to the “not a single drag” rule and get back on with it.
• Remind yourself why you want to quit. Then take control again.
• Get support – call the free NHS Smokefree helpline on 0300 123 1014 to speak to a trained adviser. Lines are open Monday to Friday, 9am to 8pm and Saturday and Sunday, 11am to 5pm.
• Make it hard to smoke – avoid places where you can easily ask someone for a cigarette. And don’t buy a packet.
• Stay strong – if you’re tempted to smoke again, force yourself to wait 2 hours. Then decide if you really need the cigarette.
• Keep taking any prescribed stop smoking medicine or using nicotine replacement therapy, unless you go back to regular smoking. It can help you get back on track.

If you have relapsed and are back to regular smoking:

• Don’t become despondent – set a new quit date, maybe in a week or so.
• Learn from your mistakes – what caused you to slip up? Think of ways you could have avoided smoking. Work on your coping skills so you’re prepared next time you’re in the same situation.
• Talk to your doctor or local stop smoking service if you need more help to cope with cravings in your next quit attempt.
• Stay positive – making mistakes or slipping up can be a useful experience if you’re prepared to learn from it. Remember, you’ll be stronger next time because you’ll know what to look out for.

More information

Read the answers to common questions about stopping smoking, including:

• Why should I stop smoking if I’m pregnant?
• Who can use nicotine replacement therapy?
• Where can I get help to stop smoking?

The most effective way to tackle cravings is a combination of stop smoking medicines and behavioural changes.

Going cold turkey may be appealing and works for some, but research suggests that willpower alone isn’t the best method to stop smoking. In fact, only 3 in every 100 smokers manage to stop permanently this way.

Using nicotine replacement therapy (NRT) and other stop smoking medicines can double your chances of quitting successfully compared with willpower alone. This is because untreated cravings often result in lapses.

Read more about stop smoking treatments available on the NHS and privately.

Types of cravings

Cravings happen because your body misses its regular hits of nicotine.

There are 2 types of craving.

The steady and constant background craving for a cigarette decreases in intensity over several weeks after quitting.

Sudden bursts of an intense desire or urge to smoke are often triggered by a cue, such as having a few drinks, feeling very happy or sad, having an argument, feeling stressed, or even having a cup of coffee. These urges to smoke tend to get less frequent over time, but their intensity can remain strong even after many months of quitting.

Tackling Cravings

There are 3 tried and tested ways to tame cravings:

• Nicotine Replacement Therapy
• Prescription stop-smoking medicines
• Behavour changes

Nicotine replacement therapy

Nicotine replacement therapy (NRT) gives your body the nicotine it craves without the toxic chemicals that you get in cigarettes, so it doesn’t cause cancer. It helps you stop smoking without having unpleasant withdrawal symptoms.

NRT won’t give you the same “hit” or pleasure you would expect from a cigarette, but it does help reduce cravings.

NRT is available as gum, patches, lozenges, microtabs, inhalator, nasal spray, mouth spray and oral strips.

It’s important to use the right NRT product for your lifestyle. Some products, like the patch, release nicotine into your system slowly and steadily, so they’re ideal for relieving background cravings. Others, such as the nasal spray and mouth spray, release nicotine quickly in short bursts, so they’re better suited to sudden intense cravings. A good strategy is to use the nicotine patch to manage the steady and constant background cravings, and carry a fast-working product with you to deal with the sudden intense cravings.

Discuss the NRT products available over the counter with your pharmacist, or talk to your local NHS stop smoking adviser or GP about receiving NRT on prescription.

Stop smoking medicicnes

The prescription tablets Zyban (bupropion) and Champix (varenicline) are an alternative to NRT in helping you stop smoking. They don’t contain nicotine, but work on your brain to dampen cravings.

As they take a few days to work fully, you need to start these medicines for a week or two before you stop smoking. Ask your doctor or a local stop smoking adviser whether prescription medicines may help you.

Read more about prescription stop smoking medicines

Change your behaviour

NRT and stop smoking medicines can help curb cravings, but they can’t completely eradicate them. There are some additional things that can help.

Avoid triggers

For you, some events or times of the day may have a strong association with smoking: after food, with a coffee, after putting the kids to bed, when chatting to a friend, or having an alcoholic drink.

Try doing something different at these times. You don’t have to make this change forever, just until you have broken the association with smoking.

Stay strong

Expect your cravings to be at their worst in the first few weeks after quitting. The good news is that they’ll pass, and the quickest way to achieve this is to commit to the “not a single drag” rule.When you’re ready to stop for good, promise yourself “I won’t even have a single drag on a cigarette”.

If you feel like smoking, remember “not a single drag” to help the feeling pass.

Exercise

Physical activity may help reduce your nicotine cravings and relieve some withdrawal symptoms. It may also help you reduce stress and keep your weight down.

When you have the urge to smoke, do something active instead. Going to the gym or local swimming pool are good, as is a little gentle exercise like a short walk, or something useful like doing the housework or gardening.

Find out how to do more exercise

Be prepared

Expect cravings at special events like holidays, funerals or weddings.

You may have never experienced these before as a non-smoker, so you’ll associate them strongly with smoking. Have some fast-acting NRT with you just in case.

Get more self-help tips to stop smoking

Delay

When the urge to smoke strikes, remember that although it may be intense, it’ll be shortlived and will probably pass within a few minutes. Each time you resist a craving, you’re 1 step closer to stopping smoking.

To reduce the risk of unequal pay, it’s good practice to:

• have an equal pay policy
• have up to date job descriptions that accurately describe the work that staff do

make sure that men and women who do the same work do not have different job titles

• be consistent when deciding people’s pay and contractual terms and conditions, for example have 1 pay structure for the business and limit who can decide on salaries for new staff

Read about risky practices for equal pay on the Equality and Human Rights Commission (EHRC) website.

Having an equal pay policy

An equal pay policy can help you be clear and open with staff about your policy on pay and other terms and conditions.

An equal pay policy should say how you:

• will try to achieve equal pay
• will check whether the policy is working
• will deal with any complaints about equal pay
• are committed to resolving any unequal pay issues in your workplace

The policy should be clear and easy for staff to understand. If the workplace has a trade union or employee representatives, you should agree the policy with them.

Find out about equal pay policies on the EHRC website.

Checking for equal pay issues

You can check for equal pay issues in different ways, depending on how many staff you have.

If you have 50 or more staff

You can check for issues by doing an ‘equal pay audit’ if you have 50 or more staff.

You can audit the whole workplace, or just one department to start with if it’s the first one you’ve done. You should share the results with staff included in the audit.

To do an equal pay audit, you’ll need to:

• check if there are people doing ‘equal work’ (work that equal pay law classes as the same, similar, equivalent or of equal value)
• carry out job evaluations, where needed, to measure the value of different jobs and identify any that count as ‘equal work’ – find out about job evaluations from EHRC
• gather details on pay and contractual terms and conditions for people doing ‘equal work’ to see if there are any differences between men and women
• if there are differences, check the reasons for them and if they’re legal or illegal – this can be a complex area so it’s a good idea to get legal advice
• decide on an action plan – for example, resolving any cases of unequal pay as soon as possible

If the workplace has a trade union or employee representatives, you should consult them when:

• carrying out an equal pay audit
• deciding how to resolve any cases of unequal pay

Find out how to do an equal pay audit on the EHRC website.

If you have fewer than 50 staff

You can check for equal pay issues by doing an ‘equal pay review’ if you have fewer than 50 staff. An ‘equal pay review’ has fewer steps than an ‘equal pay audit’.

To do an equal pay review, you’ll need to:

• check if there are people doing ‘equal work’
• gather details on pay and contractual terms and conditions for people doing ‘equal work’ to see if there are any differences between men and women
• decide on an action plan – for example, resolving any cases of unequal pay as soon as possible

You should share the results with staff included in the review.

Find out how to do an equal pay review on the EHRC website.

Risk of legal action against you

If someone feels they are not getting equal pay, they might be able to make a claim to an employment tribunal for equal pay.

They might also be able to make a claim for sex discrimination, if they feel they were also treated unfairly because of their sex.

To make an equal pay claim, they must compare their pay and contractual terms and conditions against someone else (a ‘comparator’). The comparator must:

• be of the opposite sex
• do ‘equal work’
• work for the same employer

More than one comparator can be used. A comparator can be someone who currently works for you, or someone who used to.

An employment tribunal judge will consider factors including:

• whether the person making the claim is doing equal work, compared to a comparator
• any differences in pay and contractual terms and conditions between the person making the claim and their comparators
• if you followed the EHRC statutory code of practice on equal pay, for example if you’ve checked for equal pay issues

If you lose an equal pay claim, you can be forced to carry out an equal pay audit and publish the results. This does not apply to employers with less than 10 staff, or employers less than 1 year old when the equal pay complaint was made.

Further help and support

If someone feels they are not getting equal pay, they might be able to make a claim to an employment tribunal for equal pay.

They might also be able to make a claim for sex discrimination, if they feel they were also treated unfairly because of their sex.

To make an equal pay claim, they must compare their pay and contractual terms and conditions against someone else (a ‘comparator’). The comparator must:

• be of the opposite sex
• do ‘equal work’
• work for the same employer

If you need help with an equal pay issue you can get:

• tailored support from Acas
• legal advice

You can also book Acas training on equality, diversity and inclusion.

You should talk to your employer to try and resolve the issue if you feel you’re not getting equal pay compared to someone who is all of the following:

• of the opposite sex
• does ‘equal work’ (work that equal pay law classes as the same, similar, equivalent or of equal value)
• vworks for your employer

Checking for evidence

To help see if there’s an equal pay issue, you should check:

• your pay and how it’s made up so you can compare it with others – for example, how much basic pay, overtime or commission you get
• pay and benefits for people of the opposite sex doing work you think is ‘equal work’ for your employer

You can ask your employer or manager for information about pay and contractual terms and conditions, if you think you have an equal pay case.

Your employer can only give you general information about other people’s pay and terms and conditions. They cannot share any personal details about other employees because of data protection law (UK GDPR).

For example, you could ask for general information about:

• how much people of the opposite sex who do the same or similar work as you earn
• the contractual terms and conditions for people of the opposite sex who do the same or similar work as you
• the reason for any differences in pay and terms and conditions, if there are any

It’s best to talk to your employer first, if you feel you can, and then put your questions in writing.

You could also ask others at work about their pay and benefits, if it’s about equal pay. For example, you could ask someone of the opposite sex who does the same or similar work how much they earn. They’re allowed to tell you, but it’s up to them to decide if they want to.

Raising an issue

It’s best to raise an issue informally first by talking to your employer. If this approach doesn’t work, you can raise the issue formally. This is known as raising a formal grievance.

If you have any evidence at this stage, it’s a good idea to share it with your employer when you raise the issue.

Making an equal pay claim

If you’re not able to resolve the problem with your employer, you might be able to make a claim to an employment tribunal for equal pay.

You might also be able to make a claim for sex discrimination, if you have been treated unfairly because of your sex.

To make an equal pay claim, you’ll need to show your pay and conditions are worse than someone else’s (a ‘comparator’). The comparator must:

• be the opposite sex to you
• do ‘equal work’
• work for the same employer

More than one comparator can be used. A comparator can be someone who currently works for your employer, or someone who used to.

This is a complex area so it’s a good idea to get legal advice.

Find more advice on equal pay from the Equality and Human Rights Commission (EHRC).

You can check in any way that feels comfortable for you.

This information was published by CoppaFeel! in February 2022. It is due for review in February 2025.

You are never too young to start

Although breast cancer is rare in younger people, it can still happen, as all genders have breast tissue, which develops at a young age.

Breast screening is great but limited

In the UK, only women will be invited to routine breast screening from the age of 47-50 years old, which takes place every 3 years. For that reason, checking your boobs is especially important for those who aren’t screened. But even if you have mammograms (the breast screening test) it is important to check in between your appointments.

It isn’t always hereditary

Less than 10% of breast cancers are caused by a family history. Most people who receive a diagnosis, won’t know why the disease has developed.

Everyone has breast tissue

Checking your chest is for guys, gals and non-binary pals as everyone has breast tissue. Around 55,000 women and almost 400 men are diagnosed with breast cancer in the UK every year.

In the UK…

• 1 in 7 women will be affected by breast cancer in their lifetime.
• Around 400 men are diagnosed every year.
• Around 2,300 women are diagnosed aged 39 or under.
• In females aged 25-49, breast cancer is the most common cancer, accounting for more than 4 in 10 (44%) of all cases in 2014-2016.

*Statistics from Cancer Research UK and Breast Cancer Now

Our research shows…

• Younger women aged 18-24 years old consistently check their boobs less than those 25-35 years old.
• Only 36% of women aged 18-35 years old check their boobs monthly.
• Only 54% of women would immediately visit their doctor upon discovering early signs and symptoms.
• Just over half of young women are confident to start checking their boobs.

But

• 78% believe it is important to raise awareness of breast cancer amongst young women.
• Women who are aware of CoppaFeel! are more likely to check their breasts and know the signs and symptoms compared with those who are not.

*Statistics from CoppaFeel! annual research December 2020.

This information was published by CoppaFeel! in February 2022. It is due for review in February 2025.

Who is invited?

Breast screening uses image scans to look for breast cancer. Breast screening could be by one of two scans:

• Mammogram
• Ultrasound

The national screening programme in the UK uses mammogram, a type of x-ray, to scan women aged 50 – 71. Women in that age group are invited to be scanned every 3 years. It is rare for men to have breast cancer, so they are not invited to be screened as part of a national screening programme.

Why don’t we screen women under 50?

Women with a high risk of breast cancer can be screened at any age. However, low-risk women under 50 are not invited to be screened as part of the national screening programme. This is because the risks of screening women under 50 would outweigh the benefits. X-ray exposes you to a tiny amount of radiation, and any exposure to radiation can very slightly increase your risk of cancer. Mammograms of young women are also more difficult to read, as their breast tissue is denser. Women under 50 would need more frequent scans, so they would have more exposure to radiation.

It is important to get to know your breasts and chest area whether you are screened or not. Make sure you know what is normal for you and your body. If you notice any unusual changes, make an appointment to see your GP, even if you have a scan appointment coming up.

Mammogram

A mammogram is an x-ray of the breast. When you go for a mammogram, a female staff member (mammographer) will be in the room with you. The mammographer will tell you to undress to the waist and stand in front of the mammogram machine. She will help to position you so she can take the best scan of your breast. You will have a scan of one breast first, and then the other breast. Some people find mammograms slightly uncomfortable, but it is over very quickly! You can still have a mammogram if you have breast implants, just let your mammographer know before your scan.

Ultrasound

If you are a woman under 50 and you are high risk, or if you are referred to the breast clinic, you will most likely have an ultrasound scan. Ultrasound is painless. It is a good scan for looking at young breast tissue. That’s because young breast tissue is denser than breast tissue in older people. You can learn more about dense breasts here. For the ultrasound, you will be asked to undress to the waist and sit or lie down on a couch. The doctor will put some clear gel on your breast and armpit, and then move the handheld scanner all over that area. Ultrasound is safe for women who are pregnant or breastfeeding. If you are pregnant or breastfeeding you can still be referred to the breast clinic for tests if you need to be.

This information was published by CoppaFeel! in February 2022. It is due for review in February 2025.

We often get asked how to check your breasts with breast implants. The answer is that there is no special technique for checking your breasts if you have implants, you just need to get to know your normal and check regularly.

If you have recently had implants, you will need to get used to your new normal. This is the case if you’ve had any surgery to your chest. It can take a while to get used to the changes and how your chest now looks and feels. You might have changes to sensitivity or new scar tissue, but the key is getting to know what’s normal for you, and to contact your doctor if you have any concerns.

Here’s our top tips for checking with implants:

• Look in the mirror and familiarise yourself with how your breasts look now.
• Feel all your breast tissue. Remember your breast tissue goes up to your collarbone and under your armpits.
• Try checking in different positions. For example, try checking while standing up and lying down to get to know your breasts in different positions.
• Take note of anything new after your surgery, such as scars or new firmness.
• Be patient. You will get used to your new normal, just keep checking once a month.
• Talk to your doctor if you notice anything unusual or a new change occurs

Risks

There are risks with all surgery, and there are risks with all implants (prosthesis). However, there is no evidence that breast implants increase your risk of breast cancer.

There is a rare form of cancer called Breast Implant Associated Lymphoma, which is linked to a very small number of breast implants. Breast Implant Associated Lymphoma is not breast cancer, it is a rare cancer of the immune system. These links have been found in about 1 in 24,000 cases. The data tells us that complications linked to breast implant surgeries are rare and not usually serious.

The vast majority of breast implant surgeries are safe. If you are thinking about having breast implants, you can talk to your GP. The NHS also has good advice here.

Related Conditions

Breast Implant Illness is a term sometimes used to describe lots of health conditions that may be linked to breast implants. Breast Implant Illness is not an official diagnosis, because there is currently a lack of evidence that these illnesses are caused by the implants. However, doctors know about Breast Implant Illness because people with implants tell them about symptoms and illnesses following their implant surgery. These symptoms include fatigue, chest pain and ‘brain fog’.

This information was published by CoppaFeel! in February 2022. It is due for review in February 2025.