Confused about what your doctor can do for you, or concerned you’ve been given bad advice? Dr Ellie Cannon is here to help
When women were asked for their experiences of accessing menopause care in England, their responses revealed clear challenges: symptoms not taken seriously and difficulties getting HRT alongside a broad spectrum of unhelpful and distressing conversations.
Some women do get excellent care but the postcode lottery is stark and shameful. So much so, a UK Menopause Taskforce has been set up alongside the Women’s Health Strategy to take these issues forward both in healthcare and in the workplace.
Care and advice do not seem to be standard, meaning that many women feel ignored and abandoned at their most vulnerable time. This strikes me as odd and unnecessary in the age of the internet: for all doctors, even if menopause isn’t taught well historically at medical school, have guidelines at their fingertips from NICE and the Royal College of Gynaecologists to name just two.
Menopausal women have been left confused, anxious and embarrassed due to this lack of standard care. So, to help alleviate many typical worries, I’ve compiled a list of the questions any woman can ask her GP and what she should be told…
Am I better off accessing private care?
NHS GPs and menopause clinics should be set up to provide best-level menopause care with well-evidenced guidelines to follow and safe, effective treatments on offer. So if you ask your GP this, they should really say ‘no’.
The trouble is that often women are forced into the hands of the private sector because getting appointments is difficult on the NHS and/or doctors do not know enough about the condition. Also, access to good menopause care can be patchy, pushing many women into the private sector out of desperation. But this option is also fraught with problems. Women are often offered unnecessary testing such as extensive hormone profiles and expensive treatments that are not proven to work. A great example of this are the commercially available bioidentical hormones that are claimed to be natural and therefore ‘safer’, which are oversold privately despite not being regulated or licensed in the UK (due to lack of evidence that they work or are safe). In fact, many standard HRT hormones are from natural sources and are closely regulated. Menopause has sadly become a great moneyspinner.
If your GP is not well versed in menopause care, ask for a referral to a local hospital-based menopause clinic or to follow up with a GP who is more knowledgeable in the area. Going privately can cost a great deal, and often it’s not worth it.
Am I missing out by not having HRT?
If you and your friends are talking so much about menopause and HRT that you feel you are missing out if you are not having it, then firstly let me commend you for this healthy openness on the subject. However, the answer is no, not all women will have menopause symptoms nor require – or want – treatment. Part of our aim to improve women’s healthcare is an understanding that we don’t all need the same thing. So
no, you don’t have to take HRT unless you have symptoms that you feel could benefit. You may also prefer to look at other options such as aerobic exercise and dietary changes or just wait and see how you go. And there is no age limit to starting HRT, so if you wanted to try it later on, you can.
I’ve heard that taking testosterone helps low libido – can you prescribe it?
When we talk about HRT, most women are referring to the two female hormones oestrogen and progesterone. A third one – the male hormone testosterone – also comes into the picture when we talk about libido and the lack of sexual desire that can come with the menopause. It is not usually a part of HRT tablets and preparations but is given as an additional drug. Usually we start women on normal HRT first and see if libido improves, and if it doesn’t we would add in testosterone. It is recommended for persistent low sex drive, but there is not enough science at the moment for it to be prescribed for low energy, low mood or brain fog with menopause. We usually give it on the NHS as a gel, which you rub into your skin. We are prescribing it on what’s called an ‘off licence’ basis: it’s actually not licensed for this use but it is part of the national guidance on menopause. If a doctor has enough experience and knowledge we can offer it to our patients.
If a GP isn’t familiar with it they may prefer to defer to a specialist, which is perfectly acceptable as long as they explain why. We usually recommend you try it for between three and six months and we would get people to take a blood test to check they’re not taking too much.
I don’t want to take HRT – what are the alternatives?
The best possible answer to this question from a doctor should really be to ask why you don’t want HRT. Is it because of potential risks in your own family, such as breast cancer, or because you don’t like the idea of a daily tablet? The reason this is so important to talk through is because each woman should have individualised care for the menopause, and HRT is not just one drug. HRT comes in all shapes and sizes – tablets, creams, patches, gels and also as a vaginal cream – in different doses, allowing bleeds or not. It’s important that you know all of these different options and what each can do before you reject HRT completely. It may be that when you say you don’t want HRT, what you mean is you don’t want HRT tablets – but an HRT cream like oestrogen may be exactly what you need for vaginal dryness symptoms.
There are also plenty of non-HRT options to treat the menopause. There is some evidence that isoflavones in soya products, St John’s wort or black cohosh can relieve hot flushes and sweats but, unfortunately, the safety of these remedies is uncertain and preparations vary a great deal. Vaginal moisturisers and lubricants can be used for dryness and bladder symptoms, and cognitive behavioural therapy is an option for menopausal anxiety. Acupressure and acupuncture and aromatherapy are worth a go but there are no guarantees that they will help.
I’m still having periods but my perimenopause symptoms are severe – can you still give me HRT?
Yes, we can. Perimenopause is the time, usually over the age of 45, when a woman starts to have irregular periods and symptoms of the menopause such as hot flushes and sweats. Menopause is said to have occurred once a woman has had no periods for 12 months. The perimenopause can last for a few years and can certainly be debilitating, with symptoms of exhaustion, hot flushes, poor sleep and even heavy bleeding.
If you are over 45 with symptoms of perimenopause you can start HRT on a specific regime for perimenopausal women. If you already have a hormonal contraception coil with progesterone, it can stay put as part of your HRT – with oestrogen in tablet or gel form given in addition.
My mood and sleep are terrible with the menopause. Should I be prescribed with HRT or antidepressants?
The right answer to this is, let’s talk about it. Antidepressants are not considered the correct treatment for a menopausal woman with low mood or psychological symptoms and GPs are often criticised for prescribing them instead of HRT. However, they are an appropriate option for a woman diagnosed with depression separately to the menopause who has previously benefited from the use of them. It is so important that women are offered individualised care for the menopause as there is such variation in how people experience this stage.
Cognitive behavioural therapy is also considered to be an option for low mood
or anxiety associated with the menopause and, in some cases, for physical symptoms, too. This is not a fob-off: these are genuine treatments that are known to help and can be very effective for a woman not wanting to take HRT or who wants to try it as an extra.