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.
When it feels as if your body is producing enough heat to warm your entire home, turning the thermostat down to save on energy bills doesn’t feel like such a big deal. Struggling to get the diagnosis and treatment you need to tackle the, often debilitating, symptoms of menopause feels like a much bigger deal indeed.
That struggle can start with recognising that the muscle aches and joint pains, difficulty sleeping and feeling tired and drained, skin changes, brain fog and weight gain, the palpitations and recurrent urinary tract infections you might have been experiencing are all symptoms of the menopause.
With all the current pressure on the healthcare system, it can be another challenge getting an appointment to see a GP. And although GP’s are much better at recognising menopause symptoms, it’s true that historically there was more of an inclination to prescribe antidepressants than HRT.
Nowadays, whilst you’re more likely to be seen by a doctor who has the experience and training to know the menopause is probably the cause of your symptoms, and to prescribe some sort of HRT treatment, there’s the conversation to navigate over what kind of HRT you’ll need and in what dose.
“The best type of HRT for you will depend on your symptoms, medical history and background risk factors for your age,” says Dr Nighat Arif, GP and Noon’s women’s health expert. “Every woman is different.”
Arming yourself with the knowledge and information to recognise, push for and feel comfortable with the prescription you need to help you through your menopause is key to making it as comfortable an experience as possible. We’ll get to the information bit in a moment, but first, it will help to understand the issues that are affecting the diagnosis, prescription and availability of HRT.
HRT inequalities – the bigger picture
At the heart of all the difficulties concerning patient care are the bigger picture issues that are affecting the whole GP system and service.
As Dr Toni Hazell, a GP in a teaching practice in North London who has a particular interest in women’s health issues, explains: “Women are being let down (as are all patients) because funding of general practice is massively less in real terms than it was 10 years ago and GPs are leaving in their droves because of the pressures and burn out.
I think that you should ideally have one full time equivalent GP per about 1500 patients. I know practices that are up to between 3,000 and 4,000. In some GP training schemes, roughly half leave UK general practice immediately after qualifying, and of the other half, very few are working more than 4-6 sessions of daytime GP a week because it’s a recipe for burnout. And in deprived areas, like the one I work in, it can be harder still to recruit. So we can’t provide the access we’d like to menopause and HRT treatment because women find it difficult to get an appointment.
There’s also the issue that women who do get to see a GP might want to see a woman doctor (which has the knock on effect that some male doctors are becoming less skilled in women health because they’re just not seeing enough patients), and in practices where there might be only one woman doctor, that limits the availability of appointments even further.”
When it comes to menopause and HRT specifically, Dr Hazell goes on to say “I qualified as a GP in 2004, and since then HRT has gone in and out of fashion. When I first started practising, I prescribed it regularly. Then for a period, with the health scares around it, no-one wanted it. Also I found that even though I was a female GP with an interest in women’s health, patients just weren’t coming in to talk about their menopause. More recently, with Davina McCall’s documentary and all the increased publicity and conversation around menopause, that’s changed, which is great, but it means demand for HRT has increased exponentially and there just isn’t the supply of doctors or actual medicine to meet it.”
Another factor to take into account when considering HRT is whether it’s actually the appropriate treatment, or even the safe one. Dr Arif says “The NICE Guideline on Menopause from 2015 says that women with menopausal symptoms should be treated with HRT as a first line even if their symptoms are just psychological and not physical. However, HRT is not a silver bullet for the menopause, it’s just a part of the jigsaw that we put together to treat the big change in life. Every woman is unique and will have her own individual problems.”
There are also certain women for who HRT won’t be appropriate because they have a history of breast, ovarian or womb cancer and blood clots. And if a woman has untreated high blood pressure, that will need to be controlled before she can start HRT.
HRT – the facts
Now you understand all that, here’s what it will help you to know about HRT so that you can have the conversations you need to with your GP
Put simply, menopause is triggered by the decrease of the hormones oestrogen, progesterone and testosterone in your body, and HRT replenishes those hormones that you’re no longer making in sufficient quantities.
Oestrogen HRT will compensate for plummeting levels of oestrogen, which is a lubricant for blood vessels, vital for building new bone, cognitive function and producing collagen (the scaffolding of skin). Progesterone protects the lining of the womb against endometrial cancer. Testosterone is often prescribed as an add-on to HRT to help restore sex drive, sexual arousal, and ability to orgasm, but also to help with joint pains, cognitive function and fatigue, particularly in women who have had a surgical menopause after hysterectomy.
There are two different types of HRT – systemic, which travels throughout your whole body, individually reacting with every cell that has hormone receptors, and local, which can be used to treat specific symptoms such as genitourinary syndrome of menopause (GSM), a collection of symptoms including changes to the labia, clitoris, vagina, urethra, and bladder.
HRT comes in several forms
- Pills, patches, spays and gels: HRT pills can be either oestrogen-only or combined with progestogen, transdermal/skin patches, again oestrogen-only or combined, oestrogen gels, implants (which release oestrogen under the skin), and oestrogen sprays (containing estrodiol and known as Lenzetto), applied to the inner part of the arm between the wrist and the elbow.
- IUS implants: Intra-uterine systems such as Mirena deliver progestogen directly into the womb and function as a contraceptive too (you can still get pregnant when you are perimenopausal).
- Synthetic oestrogen and progestogen: These are the older types of HRT made of synthetic chemicals, some of which are derived from horse urine. They are not regarded as being as safe as the newer body identical HRT. Synthetic HRT comes in tablets or patches which combine both oestrogen and progestogen or contain only one.
- Bioidentical oestrogens: This type of natural HRT is made from plant chemicals and is the safest form of HRT when delivered transdermally ( through the skin). It’s available as gels, (e.g., Oestrogel and Sandrena) a spray (Lenzetto) and tablets (containing estradiol, such as Elleste Solo).
- Bioidentical progestogen: Micronised progesterone (Utrogestan) tablets, are the only body identical form of progestogen currently available. It is chemically identical to human hormones and made from plant sources. It’s used in conjunction with body identical oestrogen for women who have an intact uterus.
(Confusingly there are two types of bioidentical hormones: those that are regulated and prescribed by GPs, and compounded bioidentical HRT – available from private clinics or ‘specials’ from pharmacies – which are not regulated in the same way as medicines by the Medicines and Healthcare products Regulatory Agency (MHRA).
The British Menopause Society has tried to clear up some of the confusion by defining the two types as conventionally prescribed ‘regulated’ bioidentical hormone replacement therapy (rBHRT) or ‘compounded’ bioidentical hormone replacement therapy (cBHRT).
Both types are made from plant sources, but rBHRT is a regulated medicine and has been assessed for safety and efficacy. Meanwhile cBHRT is not subject to the same regulatory pathways of evaluation by the MHRA as conventional pharmaceutical products. For these reasons, the BMS does not recommend cBHRT products )
- Testosterone gel: Although testosterone is better known as being a male hormone, women make it too, and most of it is produced in the ovaries
Oestrogen and why you could have problems getting it
Body identical oestrogen, made of root vegetables and yams, is as as close to what your body would produce, so the risk profile of taking it is lower because it by-passes the liver. Applying it as a gel (most commonly Oestrogel) – the most widely used way for it to be prescribed – which is done on the parts of the body with the greatest fat density, the thighs and upper arms, means it’s also well away from the breasts, reducing the risk of breast cancer. Self-dispense pumps give a woman control of the amount she uses, which she can adjust according to her need and the guidance she is given from her doctor.
Sandrena Gel, also applied transdermally, comes in sachets which are more fiddly to use, can’t be adjusted (each sachet comes with a pre-measured amount) and involve more plastic waste, so it isn’t as frequently prescribed.
Oral oestrogen is made in a lab with synthetic hormones which come with a low risk of side effects – the possibility of blood clots, and increased breast and ovarian cancer risk – which means it’s less prescribed.” Although the risks with the oral pill are slightly higher, they are still small” says Dr Arif.
If you still have a womb, you will need to take some sort of progesterone as well as oestrogen in order to reduce your risk of womb cancer (see below).
The issues with oestrogen gel availability are almost entirely down to supply. There is only one factory that makes it in Europe, and what with a combination of Brexit and the fact that gel carries fewer risks so it’s much more widely prescribed by GPs, plus the increased demand for HRT generally following calls for menopause to be recognised and properly treated, spear-headed by Davina McCall, all of which means demand currently considerably outstrips supply.
This can mean women either being unable to get their prescriptions at all, or having to swap the sort they’re using, which is unsettling for them and time-consuming and fiddly for GP’s because they may have to reassess and re-prescribe the dosage.
Because it’s so much less widely prescribed, similar supply issues don’t apply to oral oestrogen.
Progesterone and why you could have problems getting it
As with oestrogen, there are different forms in which progesterone can be prescribed (see above)
Because women have the most oestrogen receptors in the lining of the womb, this can increase the risk of cancer. And because some women going through peri-menopause may still need contraception, an intrauterine device – or coil – is the most effective and protective way of delivering progesterone as part of the HRT mix, protecting against cancer and providing contraceptive protection.
Mirena coils are the most widely used intrauterine devices in the UK with good safety and efficacy records.
The problems with Mirena coils are multi-layered. Mirenas are fitted by some, but not all, GPs under an enhanced service (they obviously have to be specially trained). They’re also fitted at sexual and reproductive health clinics. The clinics can have waiting lists for six months to a year in some areas.
And although the GPs qualified to fit them are funded, in some areas that’s only if the coil is used specifically for contraception. Easier to argue for a 45 year old, less straightforward for a 55 year old. Each coil costs £88, and requires the allocation of 2-3 ten minute appointments, and the provision of fitting equipment. Each of those elements costs money and for some surgeries that means they’re actually losing money on each fitting. Which, when they’re being run as independent businesses, isn’t sustainable.
Testosterone and why you could have problems getting it
Testosterone is the least prescribed of the HRT therapies. This is down to a combination of cost, understanding and awareness of its importance to women and a lack of data and research into its efficacy. “The only hard evidence is that it helps libido, but I don’t agree,” says Dr Arif. “Its other benefits are to brain function, tackling fatigue and energy loss and improving muscle strength and bone density. And it has been shown to help women who have had hysterectomies with their ovaries removed, and women suffering from primary ovarian insufficiency.”
Testosterone can be given in one of two ways. Using the male preparation, but in smaller doses, which is just as safe but means it’s being used off licence (unlicensed drugs are used quite often and very safely throughout the NHS). And the specially prepared female version – Androfeme – which is only available privately.
“Menopause is still not a compulsory part of GP training,” says Dr Arif. “Don’t forget you can also ask to be referred to a menopause clinic at a local hospital if you think you need more specialist expertise. You should push to get the treatment you deserve. Life is short, and HRT can give you your life and joy back.”
By Diane Kenwood
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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