Changing the change.

Abstract

Four years ago, I was a Foundation Year 2 doctor on a four-month General Practice (GP) placement in a rural Hertfordshire practice. In the short time that I was there, it became increasingly clear that something was lacking: menopausal health care and, perhaps even more concerning, accurate knowledge of this field within primary care. I was first aware of this at the very local level, although it didn’t take long to ascertain the problem was far more widespread. In the first instance, all I knew was that I kept seeing women, largely in their mid-late 40s, who – for one reason or another – were no longer coping with life. The vast majority of these women were in work and, for the most part, had partners and families at home. For the past 20 or so years they had been successfully juggling their professional, personal and social lives and, yet, suddenly here they were: sitting bewildered in a junior doctor’s consultation room, asking where it had all gone wrong. Dry eyes, insomnia, palpitations, anxiety, irritability, irregular menstrual bleeding, headaches; no matter the presenting symptom(s), it was abundantly clear that the real issue often ran deeper than the surface presentation. And this did not escape the patients in question. On an almost daily basis, I was asked whether their symptoms and concerns were ‘‘related to hormones’’, ‘‘could it be menopause?’’ or told emphatically ‘‘I know this is peri-menopause, but what can I do to make things more bearable?’’ Much of the time, I felt powerless to help. In most cases, if these women had sought advice previously, it wasn’t that my colleagues had failed to recognize their symptoms as potentially (peri-)menopausal. Indeed, whilst an unfortunate few had been told they were likely depressed, suffering stress or ‘‘just getting older’’, most had received acknowledgement that hormonal changes were afoot and some had been offered treatment in the form of hormone replacement therapy (HRT). Nevertheless, those who had not been prescribed HRT (appropriately or otherwise) were left floundering, and those who had been given hormones and had not responded as expected continued to struggle. I thought back to medical school, scanning my memory for useful nuggets concerning the ‘‘change of life’’ but couldn’t remember the menopause being discussed other than in the ‘‘be aware’’ category. Rather embarrassingly, it transpired that the sum total of my knowledge was that vasomotor symptoms were an indication for HRT. Palpitations, vaginal atrophy, nausea and aching joints were simply not on my radar; I was not even aware that HRT could be prescribed transdermally. A recent four-month stint in Obstetrics & Gynaecology had been no help; gynaecology on-calls and labour ward duties had left me none the wiser. I felt out of my depth. I asked one of the partners in my practice for advice, and wondered if there was a local menopause clinic to which we could refer those women we were unable to help further. I remember him shaking his head, saying there was no such service, despite it being badly needed. I was given the name of a private gynaecologist, with the suggestion that this could be passed onto those patients who wished (and were able) to go down that route. It felt as though we could do more. Fast-forward two years. Now a GP specialty trainee, I was once again in primary care and found myself facing a familiar challenge. I approached a local practice lead in Women’s Health, and asked if we could arrange a session to discuss HRT and how to prescribe it appropriately. I was told it was simple: ‘‘Open MIMS and turn to the section on Hormone Replacement Therapy. Start at the top and work your way down, depending on whether the woman needs continuous or sequential therapy. They don’t need progesterone if they have had a hysterectomy’’. That was it. I hoped that my GP Specialty Training Programme (GPSTP) release sessions would shed some light. However, the entirety of menopause was covered in 15min by a fellow trainee who admitted he hadn’t known the first thing until swotting up the previous evening. The session’s facilitator cheerfully told us that the key thing, when prescribing HRT, was to look at the price tag. ‘‘Transdermals are to be used as a last resort’’, we were told.