Managing the menopause in primary care

Recently, awareness of the effects of the menopause and its treatment options have been the subject of media attention. Dr Rachel Birch, Medicolegal Consultant and member of Medical Protection’s Menopause Network, discusses lessons that can be learned from analysis of our case files.

Although the menopause is a natural phase of a woman’s life, for many women it is by no means straightforward. The perimenopause may last several years, during which time hormone levels may fluctuate until gradually falling to postmenopausal levels. For other women, the menopause may occur more suddenly, especially when brought about as the effect of surgical or medical treatments. In either of these scenarios, symptoms can be debilitating for women.

In recent years, the menopause has been very much in the spotlight, with celebrities sharing their experiences, bringing more focus and attention to what is a very important issue. The ‘Davina effect’ has led to a surge of patients consulting with their GPs about their menopausal and perimenopausal symptoms. Pharmacies, health food shops, magazines, adverts on buses…increasingly patients are asking themselves: “Could this symptom be due to the menopause?”

Around 70% of women experience menopausal symptoms, with one in four experiencing more severe symptoms. Some women may report constant symptoms, others more intermittent ones. Some women experience only one or two symptoms, whilst others may experience several symptoms at any given time. Common symptoms included vasomotor symptoms, menstrual changes, fatigue, insomnia, changes in body shape, cognitive issues, mood changes and joint pain.

From March to June 2021, the Department of Health and Social Care commissioned the Women’s Health – Let’s talk about it survey. 97,307 women in England responded and results showed that only 64% of women felt comfortable talking with healthcare professionals about the menopause. Only 9% felt they had sufficient information about the menopause and its symptoms.

The Chartered Institute for Personnel and Development (CIPD) undertook a survey of 1,409 women in 2019 and reported that 59% of participants felt that their menopausal symptoms had a negative impact on them at work. Of these women, nearly two thirds felt less able to concentrate and more than half reported experiencing more stress. 30% of women surveyed had taken sick leave due to the severity of their symptoms. 25% of women had considered leaving their job. 

It is clear the menopause may be a very challenging time for large numbers of women in the UK.

Medical Protection and the menopause

As an integral part of our “Supporting doctors through menopause” campaign,Medical Protection surveyed its members to understand the impact of the menopause on their wellbeing and careers. We received responses from 261 members in the UK and 354 in Ireland.

The results of the doctors in the UK revealed that 73% of female doctors experiencing the menopause have previously gone into work while being impacted by menopausal symptoms, and 65% were unsure where to seek support for their menopause symptoms at work. 68% of respondents were concerned about the potential impact of their symptoms on their performance at work, with 51% believing the impact of symptoms could potentially result in medicolegal issues. 36% of survey participants experiencing the menopause had considered reducing their hours as a result.

Although study numbers were small, these figures make difficult reading, especially considering the ongoing pressures in general practice due to the COVID-19 pandemic and increasing patient demand. In its policy paper, Medical Protection has made recommendations for the support of doctors experiencing menopausal symptoms and it is hoped that this has helped to further raise awareness of the importance of doctor wellbeing. I wanted to take the opportunity, in this article, to remind members that Medical Protection’s counselling service is available to any member experiencing stress or feeling under pressure; this includes support for anyone struggling with the menopause.

Patient care

At the time of Medical Protection’s survey, 26% of respondents in the UK reported feeling uncomfortable supporting and managing patients experiencing menopausal symptoms. 72% agreed they would welcome more training.

There are some useful sources of information available online. The National Institute for Health ad Care Excellence (NICE) has a guide to the diagnosis of the menopause and perimenopause and the Royal College of Obstetricians and Gynaecologists publishes a range of resources, including a helpful patient information leaflet. The Royal College of GPs (RCGP) has e-learning modules around the menopause and its treatment.

However, with the above Medical Protection survey results in mind, a detailed analysis was carried out of Medical Protection’s cases from recent years, to see if there were any helpful lessons to be learned regarding the management of the menopause in primary care.

Over the last 10 years, 548 cases were identified, 82% of which were from the UK. The remainder were made up of members’ cases in Ireland, South Africa, Australia, New Zealand, Asia and the Caribbean. 78% of the cases involved GPs. A further 15% involved gynaecologists, with the small remainder comprising of various other specialties. The cases spanned claims, complaints, regulatory investigations, incident reviews and inquests.

Three main themes emerged, and closely reflected what we tend to see as core issues within many areas of medicine – prescribing, diagnosis and management, and communication.

1. Prescribing HRT

This was by far the largest category, comprising 279 cases, making up 61% of all cases. Most of these cases involved our GP members. This is not unexpected, since a large proportion of HRT prescribing is carried out in primary care.

In 92 cases, inappropriate prescribing of unopposed oestrogen occurred, in patients who had an intact uterus or residual uterine tissue.

In the majority of these cases (73%) the patients developed postmenopausal or heavy vaginal bleeding, resulting in a need for further investigation, with the consequent anxiety that can be experienced by patients in such scenarios. In a third of these cases, the patients ultimately required hysterectomy. It is possible that many of these patients would not have required surgery, had they not been wrongly prescribed unopposed oestrogen.

In 20 patients the error was picked up before the patient developed abnormal bleeding or came to any harm. In two cases a patient’s Mirena coil was not appropriately replaced when it was being relied on as the progesterone component of HRT.

Sadly, in eight of these cases, the patient had already developed endometrial cancer by the time the prescribing error was noted.

There were 187 other cases involving prescribing HRT that were not related to unopposed oestrogen as follows:

• Alleged substandard HRT prescribing
• Alleged failure to advise of side effects of HRT
• Prescribing outside guidelines
• Failure to monitor and follow up patients prescribed HRT
• Refusal to prescribe HRT
• Alleged inappropriate withdrawal of HRT at a particular age
• Insufficient provision of information about HRT.
  

• Be familiar and up to date with the NICE guidance and consider undertaking RCGP menopause e-learning training.
• Ensure you are familiar with all relevant formulations and preparations of HRT.
• Ensure fail-safe practice systems in the prescription of HRT, such as recall systems for review and appropriate coding.
• Ensure medication reviews are undertaken at the recommended intervals.
• Be alert to common prescribing risks such as medications with similar names, especially when selecting from a drop-down menu.
• When prescribing unopposed oestrogen, especially repeat prescriptions, think “does this patient have an intact uterus?”
• Share learning within the practice if there are any adverse incidents or ‘near misses’ related to prescribing.

2. Diagnosis and management of the menopause

79 cases related to concerns about the diagnosis and management of the menopause. Whilst many of these cases involved secondary care colleagues, there were several themes relevant to general practice.

A large category (16%) related to failure to diagnose early menopause or premature ovarian insufficiency. The NICE guidance makes reference to the following definitions:

1. Early menopause is the cessation of ovarian function occurring between the ages of 40 and 45 years, in the absence of other causes of secondary amenorrhoea.
   
2. Premature ovarian insufficiency (or premature menopause) describes definitive loss of ovarian function before the age of 40 years.
   

3. Communication

Communication was seen frequently in cases as a contributory factor, leading to complaints and expressions of dissatisfaction from patients. This is unsurprising, since alleged issues over communication and consent are some of the commonest themes we tend to see in a wide range of case types, across the various specialties.

However, in 17 cases (3% of all menopause-related cases identified), concerns over the doctor’s manner and attitude were the primary issue. Patients’ perceptions, in these cases, were that the doctor was dismissive of their symptoms or uninterested in the menopause as being a potential factor in how they were feeling. In other cases, the patient felt that the GP was not trained in the menopause or up to date with the latest HRT preparations. Some patients were disappointed in the consent process for HRT, feeling that the GP did not provide enough information about the potential side effects or the alternatives to HRT available.

Learning points to consider:

General practice is a challenging, wide-ranging and important specialty. Doctors cannot be specialist in all areas. However, I hope that the points below may assist GPs in providing the best care for patients experiencing the menopause and consequently succeed in avoiding complaints or adverse outcomes.

• Keep your knowledge of menopause symptom recognition, diagnosis and management up to date.
• Take an open and inquiring approach, considering menopause alongside other differential diagnoses.
• A patient’s perception of the doctor’s manner and attitude is so important to a successful consultation – be open, interested and empathic around menopause care.
• Consider ensuring that at least one member of the primary care team has interest and expertise in menopause care, and ensure patients are aware of this, referring patients ‘in house’ when appropriate.
• When initiating HRT treatment, ensure a robust consent process, tailoring the discussion to each patient, based on their individual circumstances, wishes, expectations and concerns.
• Discuss the available options with the patient, including the option to take no action, and the relevant benefits, risks and potential side effects.
• Explain your reasoning behind any recommendation for a particular option in a way the patient can understand.
• Document the discussion and information shared in the patient’s medical record.
• Keep up to date with the indications for referral to specialist services – make the most of their expertise, especially in complex cases.
• As a practice, try to maintain or develop clear lines of communication with specialist services, eg through email or telephone advice.

In conclusion, it is clear that providing good, patient-centred menopause care is a challenge, but a very important focus for patients. Whenever a patient appears dissatisfied, or something goes wrong in the provision of their menopause care, try to work out why and how this happened and discuss this within your practice team.

The General Medical Council expects doctors to be “taking part in regular reviews and audits of your work and that of your team, responding constructively to the outcomes, taking steps to address any problems and carrying out further training where necessary” as well as “regularly reflecting on your standards of practice and the care you provide”. It is clear that they expect doctors to take steps to learn from adverse events. I hope that the analysis of the Medical Protection caseload will similarly contribute to your professional development and interest in this area.

If you have any queries relating to this article, please contact Medical Protection’s medicolegal advice line on 0800 561 9090.