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Medical Assessment for Menopause

To help us supply you with the most suitable treatment, please complete this online consultation.

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How many Gina packs have you used before?
About You
Are you a woman 50 years of age or older and your last period was over a year ago?
    We are unable to supply you with treatment. Please consult your GP.
    Please complete this question.
    Are you experiencing any of these vaginal symptoms?
    • Dryness
    • Soreness
    • Itching
    • Burning
    • Painful intercourse
    We are unable to supply you with treatment. Please consult your GP.
    Please complete this question.
    Are you satisfied with the improvement in vaginal symptoms you have experienced on Gina?
      We are unable to supply you with treatment. Please consult your GP.
      Please complete this question.
      If you just completed your first pack of Gina, have your vaginal symptoms become worse or if you just completed your second pack, have your vaginal symptoms become worse or remained the same?
        We are unable to supply you with treatment. Please consult your GP.
        Please complete this question.
        Your Health
        Have you been experiencing any of the following?
        • Current vaginal infection
        • Undiagnosed bleeding
        • Smelly or unusual vaginal discharge
        • Severe vaginal itching (for example, that interferes with sleep)
        • Pelvic pain or pain on urination
        • Lower abdominal pain, bloating or swelling
        • Any changes to the look or feel of your vulva
        • Sore red patches
        • Thickening, a lump or scarring
        • Itchy, white, smooth/crinkled patches of skin easily damaged
        • Rash
        We are unable to supply you with treatment. Please consult your GP. We are unable to supply you with treatment. Please consult your GP or local pharmacy. We are unable to supply you with treatment. Please consult your GP or local pharmacy.
        Please complete this question.
        Do you have an allergy (hypersensitivity) to estradiol, lactose or any other ingredient in Gina?
          We are unable to supply you with treatment. Please consult your GP.
          Please complete this question.
          Have you or any of your first-degree relatives (parent, sibling) ever been diagnosed with any of the following?
          • Cancer of the breast or genital tract
          • Endometrial hyperplasia (untreated or suspected)
          • Endometriosis
          • Previous or current blood clots in the legs (venous thrombosis) or lungs (pulmonary embolism)
          • Angina, stroke or myocardial infarction (heart attack)
          • A thrombophilic disorder (e.g. protein C, protein S or antithrombin deficiency, family history)
          • Vulval dermatoses
          • Liver problems
          • Porphyria (a rare metabolic disorder)
          • Any serious medical condition which may require immediate hospitalisation
          We are unable to supply you with treatment. Please consult your GP.
          Please complete this question.
          Your Medication
          Are you currently taking any medication (including over-the-counter, prescription or recreational drugs)?
          Are you taking any of the following medications?
          • Anticoagulants
          • Other local oestrogen therapy, including prescription Vagifem
          • Hormonal therapy, including systemic HRT
          We are unable to supply you with treatment. Please consult your GP or doctor for more information.
          Please complete this question.
          Have you experienced any problems whilst using Gina (e.g. problems using the applicator)?
            We are unable to supply you with treatment. Please consult your GP.
            Please complete this question.
            Agreement
            Do you understand that if you have taken a break from the treatment and the bothersome symptoms have returned, you have to restart your treatment starting with the initial dose for the first 2 weeks, and then continue with the maintenance dose?
              You must agree to this before continuing. If you need assistance, contact customer support.
              Please complete this question.
              Do you understand you should stop using Gina immediately and seek prompt advice from your GP?
              • If you develop any of the conditions listed under the ‘Do not use’ section in the Patient Information Leaflet and on the pack
              • If you have any new vaginal bleeding, spotting or itching
              You must agree to this before continuing. If you need assistance, contact customer support.
              Please complete this question.
              Do you understand that if you experience any of the following while taking Gina, you should seek prompt medical advice from your GP?
              • Yellowing of the skin or whites of the eyes
              • Significant increase in blood pressure (symptoms may include headache, tiredness, dizziness)
              • New migraine-type headache which happens for the first time
              • Pregnancy
              You must agree to this before continuing. If you need assistance, contact customer support.
              Please complete this question.
              Do you agree to the following?
              • You will read the patient information leaflet supplied with your medication
              • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment
              • The treatment is solely for your own use
              • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
              • You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber
              You must agree to this before continuing. If you need assistance, contact customer support.
              Please complete this question.
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              To find a treatment suitable for you, we just need you to answer a few questions.

              Ana Carolina Osorio De Faria Goncalves

              Ana Carolina Goncalves

              Superintendent Pharmacist

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              Need help?

              If you need help with this medical assessment, contact our helpline:

              0207 112 9014

              or email us

              help@pharmica.co.uk

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              We are regulated by the General Pharmaceutical Council

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