Making menopause more inclusive: What needs to change about GP care

Not enough GPs understand or recognise the symptoms of menopause, meaning too many women are struggling to get the right treatment. A simple system change could make a big difference - to both GPs and their patients.

This series of articles has been commissioned by Eleanor Mills, Editor in Chief at Noon about the inequalities facing Queenagers in health care. This series of articles has been edited by her and reflect her editorial judgement. The articles have been paid for by Theramex.

The vast array of symptoms women who are going through the menopause experience includes everything from the classic night sweats and hot flushes to hair loss, joint stiffness, sleeplessness, memory problems, tinnitus, palpitations, vaginal dryness, acne, migraines, discomfort during sex, anxiety, itchy eyes, loss of confidence, tearfulness, low libido, recurrent urinary tract infections, pins and needles, restless legs, depression and a constant metallic taste in the mouth.

With such a wide range of symptoms, it is not surprising that many women fail to realise that a problem they may be suffering from is actually a sign they are going through the menopause or perimenopause – until their GP diagnoses it.

In a landmark study of more than 4,000 menopausal women by the Fawcett Society last year, one shocking statistic stood out to us at Noon.

The study found that, among women who had approached their GP about their symptoms, almost a third (31%) had to endure multiple appointments before their GP realised they were experiencing menopause or perimenopause.

And even though official guidance says that hormone replacement therapy (HRT) should be offered to women who are struggling with menopause symptoms, just 39% of women said that their GP or nurse offered them HRT as soon as the reason for their suffering was discovered.

One simple change would help the thousands of menopausal women who are struggling to get the medical help and advice they need. This week, the Labour MP Carolyn Harris told Noon she wants menopause to be incorporated into the government’s Quality and Outcomes Framework (QOF) programme, a scheme which rewards GP practices in England, Wales and Northern Ireland for the quality of care they provide.

Such a move would ensure GPs will not only be motivated, but incentivised, to have more conversations with women about the symptoms of menopause and perimenopause and to improve their ability to diagnose these conditions – just as GPs are both motivated and incentivised to manage and prevent other major public health concerns like smoking, diabetes, depression and obesity.

“Menopause should definitely be on the QOF,” Harris told Noon. At the moment, she says,  there’s not enough knowledge amongst the medical profession, to identify menopause. “And there’s not enough confidence within the medical profession to prescribe HRT, if that’s what the person wants.” Women today are missing out on the treatments they need because of their GPs’ lack of confidence and lack of knowledge, she says.

Dr Nighat Arif, a GP with a specialist interest in women’s health, agrees: “We should be encouraging doctors to have that conversation with women, because it’s part of preventative care.”

Incorporating menopause into the QOF programme would mean that, when a woman in her early 40s goes to see her GP for any reason, a message might pop up on the computer system of the GP suggesting that a conversation about the symptoms of the menopause and the benefits of HRT would be timely. “We know that starting HRT earlier rather than later has better outcomes,” says Dr Arif. “It’s a reminder for the doctor to have that conversation with the patient.”

Such a strategy will also save the NHS money in the long run, she says. In the past, women’s menopausal symptoms have often been misunderstood by GPs – and misdiagnosed. “If a GP is not thinking of perimenopause or menopause as the diagnosis, they may end up spending money doing unnecessary investigations – when actually the diagnosis is right in front of them.”

Historically, women’s health has not been adequately taught at medical school and not all GPs have received enough menopausal training, she says. “There’s misogyny in the healthcare system – and women aren’t taken seriously. This is partly because, traditionally, menopause has been seen as a normal part of the process of life, not something that women need to go round bothering doctors about” Dr Arif says.

Such an attitude is particularly common in Black and Asian communities. “In ethnic minority communities, some people think you have to be on death’s door to go see the doctor. Because doctors are such prized individuals in the community, their time is seen as really precious.”

Religious women in these communities may optimistically believe that their faith alone will enable them to overcome their menopausal symptoms. “They think: if I pray hard enough at the temple, if I show commitment to God, then I will get better. And if I say to anyone that I’m not getting better, then it shows that I’m not committed to my faith. Western-trained doctors don’t understand that there are these barriers that these women face.”

Junior doctors are taught how to identify heart disease and do resuscitation at medical school, but they aren’t taught about the menopause, even though, as Dr Arif says “you’re more likely to see a woman with perimenopausal symptoms in your surgery than someone collapsing from a cardiac arrest.”

If the menopause was made part of the QOF framework, Dr Arif thinks GPs would be more incentivised to educate themselves about menopausal symptoms, the issues that prevent women from seeking treatment and the wide range of body-identical HRT that has been approved for use in the NHS. “Currently, not all doctors understand HRT, because of  the lack of HRT training given to GPs. So they’ll only prescribe what they know.”

One of the knock-on effects of this is that it can lead to local shortages of a particular product, meaning women simply cannot get hold of the treatment they have been prescribed.

Jenny Haskey, CEO of The Menopause Charity, also wants the menopause to be introduced into the QOF programme. “It’s about ensuring all women can access the treatment they deserve. I hear from so many women who don’t even bother going to their doctors, because they know they won’t receive the treatment that’s been recommended by NICE. It’s a bit of a postcode lottery at the moment.”

Women who have managed to educate themselves about the menopause often have to challenge their doctor to get HRT, she says. “Every day, I hear from women whose doctors refuse to give them treatment.” Those who are struggling with psychological symptoms of the menopause, such as loss of confidence and anxiety, may not feel able to argue their case with a highly-educated medical professional. “They’re trying to just keep calm and carry on. And that’s not a way to live. The result is those women are leaving their workplaces, and having difficulties at home.”

Haskey believes that if the menopause was part of GPs’ QOF programmes, the quality of care offered to women would be more consistent. “I think it would encourage doctors to do more training – because there’s so much they need to learn and understand,” she says. At the moment, not enough doctors are able to spot the signs of menopause or peri-menopause correctly, but that might change if doctors were incentivised by the QOF framework to be on the lookout for these conditions. “It would be a positive step in the right direction. And every positive step forward helps at least one more woman.”

By Donna Ferguson

Donna Ferguson is an award-winning freelance journalist for The Guardian, The Observer, the Mail on Sunday and Good Housekeeping magazine. She is a committee member of Women in Journalism UK.

If you are fired up by watching this and would like to sign the Noon petition, backed by everyone on the panel, to make menopause a QOF then click here

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