Why DO so many GPs refuse to give women HRT?
. . . even though patients are struggling with menopausal symptoms – and the expert consensus is that hormone treatment is safe
AFTER two years of trying to manage the debilitating symptoms of the menopause on her own, Jayne Caple went to her GP at the end of her tether. What had started with night sweats and feeling out-of-sorts had progressed to insomnia, exhaustion and anxiety, and the 51-year-old wasn’t coping.
‘I would wake at 3 or 4am every night and not be able to get back to sleep, then be exhausted during the day, and I became very anxious,’ says Jayne, who runs her own marketing business and lives with husband Tim, 53, and their 16-year-old daughter Grace.
‘I’ve always been very good at juggling and multi-tasking, and used to sleep well, so it floored me. I couldn’t function and I just didn’t feel like myself. I’d come home from work and be asleep on the sofa from 7pm to 9pm, missing time with my daughter and husband, then go to bed,’ she says.
‘I started making excuses not to go out with friends because I knew it would make me even more exhausted. On the odd occasion we did go to a friend’s house for supper, we were always first to leave.
‘The final straw was when I was in a restaurant one evening and I pretty much fell asleep at the table. I knew I had to get help.’
Around 80% of women going through the menopause or during the lead-up to it (known as perimenopause) experience symptoms including hot flushes, sweats, mood swings, stiffness and loss of libido.
Symptoms can start years before the actual menopause — defined as one year after periods stop — and continue for an average of four years afterwards.
For around a quarter of these women, symptoms are severe, having an impact on their relationships and their work, according to a survey carried out by the private medical firm Nuffield Health in 2014.
WOMEN WRONGLY TOLD THEY NEED BLOOD TESTS
BUT many women who are going through menopause and suffering terrible symptoms struggle to get HRT from their GPs.
Since 2015, HRT — which comes in a pill, patch or gel — has been recognised by NICE as an effective treatment for many women who have hot flushes, night sweats and low mood.
Furthermore, it says women over 45 with these symptoms can be prescribed HRT without having to have a blood test — a FollicleStimulating Hormone (FSH) test — to check their hormone levels.
This is because the results of these tests can fluctuate greatly in the lead-up to the menopause, making them ‘unreliable and a waste of money’, says NICE (the test is being phased out in other countries, too).
However, when Jayne went to her GP describing her symptoms and asking for HRT, her doctor wrongly insisted that she have the blood test before they would prescribe anything. Then, when the results came back normal, and although the GP acknowledged that she probably was menopausal, she was refused HRT and told to come back in a couple of months.
‘I was desperately disappointed and upset because I needed help,’ says Jayne.
‘It also made me feel a bit stupid, as if the symptoms I’d been experiencing weren’t severe enough to warrant the treatment — yet I wasn’t functioning.’
Prescriptions for HRT have risen slightly over the past three years and Alison Begas, chief executive of Dublin’s Well Woman clinics, says in recent years they have seen an increase in the prescribing of HRT due to a gradual return to the medication, only around 10% of women with menopausal symptoms were taking the treatment in 2015, according to NICE. And some experts believe many other women could benefit from HRT — yet aren’t getting it.
THOUSANDS MAY BE MISSING OUT
‘AT a conservative estimate, between 70 and 80% of women with menopausal symptoms could potentially take HRT, which usually provides more benefits than risks to these women,’ explains Dr Louise Newson, a menopause expert who works out of her own private clinic.
‘Yet many thousands are not being offered a treatment that can not only improve symptoms but lower their future risk of heart disease, diabetes, osteoporosis and osteoarthritis,’ she adds.
So why are so many menopausal women not getting the drug?
For 15 years, HRT was mired in controversy after two major studies, in 2002 and 2003, suggested it significantly increased women’s risk of breast cancer.
Following the research, the number of those taking HRT more than halved as both women and doctors lost confidence in the drug. Then, in 2015, NICE published a review of existing studies which found that the risks had been overstated.
It said taking HRT does not increase the risk of heart disease when started in women under 60, and is not linked to type 2 diabetes, while oestrogen-only HRT brings little or no increase in the risk of breast cancer.
HRT with both oestrogen and progestogen is associated with a small increase in the risk of breast cancer, but this reduces within five years after a woman stops taking HRT.
The hope was that this would reassure both women and doctors that HRT is safe for most women.
Yet according to new research presented at the World Congress on Menopause, in Vancouver, many doctors are still not confident about prescribing HRT.
The study of 203 health professionals (77% of whom were GPs) found a third were not confident about how to manage the menopause and 23 per cent felt unsure about prescribing HRT to otherwise healthy women because of confusion about the risks.
A quarter wrongly thought that any type of HRT increases the risk of breast cancer.
Meanwhile, only half (52%) had received any formal training on the menopause and 25% were not aware of the different types and doses of HRT.
‘FEW GPS HAVE READ GUIDELINES’
RATHER than giving women HRT, more than half had prescribed or offered antidepressants to menopausal women who had low mood or anxiety. Yet the official advice is that such women should be offered HRT to alleviate their symptoms unless they have a diagnosis of clinical depression.
‘In this case, the low mood is the result of a hormonal issue and there is little evidence that antidepressants will help,’ says Dr Heather Currie, a spokeswoman for the Royal College of Obstetricians and Gynaecologists and former chair of the British Menopause Society.
Dr Newson, who led the survey, says she wasn’t surprised by the findings: ‘There is very poor training in medical school and little ongoing education of doctors about the menopause.
‘When I was at medical school in the late 1980s and early 1990s, I didn’t receive any undergraduate or postgraduate training about the menopause — I only know about it after taking the initiative myself to go on courses so I could improve women’s health, which is so often neglected. Very few GPs have read the NICE guidance on the diagnosis and management of the menopause.
‘I’m not surprised, really — there is so much for them to read and general practice is incredibly busy.
‘However, the menopause will affect 50% of their patients and doctors aren’t always giving them
the help they need.’
Dr Newson adds: ‘For many women, the symptoms are a complete misery and we should be doing much more to help them. It’s about helping women weigh up the risks and benefits — in my experience, many are happy to take a small risk to get their lives back.’
FOBBED OFF
ACCORDING to Diane Danzebrink, a private psychotherapist who specialises in the menopause, many women asking for HRT and other menopause treatments are fobbed off by their doctors.
‘Women are desperate for help and there are an awful lot who want HRT but are not getting it because of poor GP education,’ she says.
‘I know for a fact there are lots of GPs who have never heard of NICE guidelines on the menopause, and more that have never read them. ‘Unfortunately, a lot of GPs are working with out-of-date information and consequently a lot of women are told “we don’t recommend it” or are prescribed antidepressants for low mood when they should be getting HRT,’ adds Diane.
‘Many of the women I counsel are very emotional and frustrated because they have tried to address their symptoms and they have been turned away, fobbed off or not listened to.
‘In the worst-case scenarios, women have to leave their jobs as they struggle with mental health and physical symptoms.’
Recently, she counselled three former nurses who received so little support from their GPs and at work that they all quit their jobs.
‘I don’t think this is a particular issue with male GPs, but inadequate education on the subject of the menopause. However, if the menopause affected men, we would be in a very different place now.’
But it’s not just doctors who remain unsure about HRT — women themselves often don’t ask for it.
A poll last year for Good Health revealed that more than a third of women — 37% — were ‘very concerned’ about the side-effects of HRT, and only 27% felt the benefits of the treatment outweighed the possible risks.
As a result, only 17% of those who had been through the menopause said they had used HRT to help with symptoms (a similar number used supplements such as black cohosh, milk thistle and omega-3 instead), according to the survey of 2,002 women aged 30 to 80 by Ipsos Mori.
WHAT ABOUT THE HEALTH RISKS?
EVEN among those currently taking HRT, 40 per cent said they were worried about side-effects.
Klim McPherson, emeritus professor of public health epidemiology at Oxford University, who worked on one of the original studies in 2003 that found a raised breast cancer risk, remains concerned about the health risks of HRT despite the NICE advice and similar international guidelines.
He says he is pleasantly surprised that women are still not asking for HRT: ‘Women are clearly more sensible than some people think.
‘The short-term benefits are clear — but women should know more about the risks than they normally do.
‘I’m not against any HRT; it just should be used with caution and respect.’
Dr Currie admits HRT is not for everyone — some women don’t want to go on medication or are unhappy with the side-effects.
However, latest evidence shows the risks are small and, for most women, outweighed by the benefits if treatment is started before the age of 60 or within ten years of the menopause.
The consensus is that more needs to be done to educate doctors and help women through the menopause based on all the information.
A number of specialist menopause clinics are offered by GPs around the country, including at Dublin’s Well Woman clinics.
There are also a number of gynaecologists around Ireland who offer appointments without referral from GPs.
After being sent away by her GP, Jayne decided to seek help for her symptoms privately with Dr Newson. ‘After talking it through with her, in my case I felt the benefits of HRT definitely outweighed the risks,’ says Jayne.
She has been on HRT now for a month, which she says has been ‘a revelation’.
‘After four days I started sleeping properly and within two weeks I knew I was in a really good place,’ she says.
Jayne advises other women wanting to go on HRT to do their homework before seeing their GP.
‘Before I went to my GP, I didn’t know about the NICE guidelines. If I’d known, I would have felt more confident to push for the treatment.
‘I’d urge women wanting to go on HRT to read up on it beforehand because GPs don’t always seem to be up-to-date on the latest advice and don’t want to prescribe it.’