Priory Hospital Chelmsford

Breast cancer is the commonest cancer among women in the western world, accounting for up to 30% of all cancers in women. There is a long-standing controversy about the potential link to hormone replacement therapy (HRT), with large observational studies suggesting that HRT increases the risk, while the Women’s Health Initiative (WHI), a prospective, randomised placebo-controlled trial has reported several times over a period of 20 years that combined (oestrogen and progestogen) HRT increases the risk, while oestrogen-only HRT given to women who have had a prior hysterectomy, is associated with a significantly reduced risk of developing breast cancer.

The global increase in life expectancy to 74 years for women, while the median age of the menopause remains at 51 years, means that an increasing number of women will live a significant portion of their adult lives in the menopause. The WHI publications in 2003/4 reported on the dangers of hormone replacement therapy, in particular with respect to breast cancer and dementia risk. This resulted in a dramatic reduction in hormone replacement therapy prescription and use. However, the findings from the WHI studies have been re-appraised, and the new perspective is reflected in the guidance published by NICE in 2015 in which they recommended that more women be offered hormone replacement therapy as the benefits are now perceived to outweigh the risks for most women. However, controversy continues to surround hormone replacement therapy, and there are probably few areas in medicine where the misuse of terminology causes quite as much confusion as in hormone replacement therapy. Commonly used terms such as 'menopausal hormone therapy' and 'hormone replacement therapy' lack specificity and there is an urgent need for correct terminology to accurately describe the hormones replaced.

Combined (estrogen and a progestogen) hormone replacement therapy (cHRT) is associated with an increased risk of breast cancer, while estrogen replacement therapy is not. Whatever the underlying mechanism, it is the progestogen in cHRT that seems to increase the risk. Fear of breast cancer is a major limiting factor in the use of hormone replacement therapy, and when women discontinue cHRT because of side effects, the latter are often attributable to the progestogen component. cHRT is given to women with an intact uterus to protect against the effects of un-opposed estrogen such as an increased risk of endometrial cancer. Estrogen replacement therapy suffices for women with a prior hysterectomy. There is a clear distinction in risk and side effect profile between cHRT and estrogen replacement therapy. Apart from being the most effective treatment for menopausal symptoms, estrogen prevents osteoporosis, and may also have a potential role in prevention of Alzheimer’s Dementia, now the biggest killer of women in the United Kingdom. Evidence also suggests that progestogens could compromise the dementia-preventative effect of estrogen. Given the immense therapeutic and preventative potential of estrogen, the use of progestogens in cHRT needs re-appraisal. The levonorgestrel intrauterine system (LNg-IUS) could reduce breast cancer risk while protecting the endometrium. Other approaches to the safe use of progestogens await research.

The concept of community is central to the Church's understanding of itself and its mission, but in an age of freedom of information and personal movement unparalleled in human history, the traditional definitions of what constitutes a community are increasingly unusable. This article examines the idea of community in the Apostolic Church as seen in the New Testament. It is intended as a contribution to the ongoing and vital search for a concept of community appropriate for the Church in the twenty-first century.

Marie John writes that nursing students in 2008 expect to wear designer clothes and go on fancy holidays (reflections June 11). If clothing bought from car boot sales or Tesco are now considered designer then maybe this is an accurate reflection of me.

To highlight and discuss thyrotoxicosis after lithium withdrawal as a potential complication of lithium therapy for bipolar disorder. Both patients presented developed thyrotoxicosis, the first patient after stopping the lithium completely, and the second patient after a reduction in the lithium dose. Clinicians should be alert to the possibility of thyrotoxicosis emerging when lithium is being completely or partially withdrawn. Such withdrawal could unmask a latent hyperthyroidism.

The excellent initiative of the Community Practitioners' and Health Visitors' Association - that school nurses investigate poor toilet facilities - is to be applauded (news November 27).

Self-harm and suicide are amongst the most challenging and frightening problems that therapists and counsellors can encounter in the course of their work. The risk of clients harming themselves in the course of treatment can debilitate the therapists from acting creatively and collaboratively, and make their actions defensive, focused solely on risk assessment rather than therapeutic change.Yet it is precisely a creative and collaborative response, such as that engendered by solution-focused therapy and other models, that is the most likely to facilitate change and re-empower clients to take back charge of their lives. This article describes a solution-focused approach to working with suicidal clients that can be used in conjunction with traditional approaches and which focus on establishing safety as well as assessing risk.Working from this model the clinician shifts to identifying client strengths and coping skills, to collaborating with the client to establish meaningful goals and to helping the client envision a positive future. Arguably, such an approach can increase collaboration between therapist and client and lead to a more client-centred safety plan.

In the March 24 issue of Nursing Standard a joint RCN/JEC conference entitled 'Epilepsy: improving quality of life' was advertised.