Managing the menopause in primary care

Awareness of the effects of menopause and its treatment options have been the subject of recent media attention.
Dr Rachel Birch discusses lessons that can be learned from analysis of Medical Protection’s case files

As an integral part of our 2022 Supporting doctors through menopause campaign, Medical Protection surveyed its members to understand the impact of the menopause on their wellbeing and careers, and additionally how comfortable they were in managing and supporting patients experiencing menopausal symptoms. We received responses from 354 members in Ireland and a quarter (25 per cent) of respondents reported feeling uncomfortable supporting and managing these patients. Some 69 per cent said they would welcome more training.

It is likely that, if the survey were repeated now, these figures would have improved, with the ICGP having published its Quick Reference Guide – Diagnosis and Management of Menopause in General Practice in October 2022. The ICGP has also updated its menopause training course, which is available to its members online. 

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

Over the last 10 years, 548 menopause-specific cases were identified, 5 per cent of which were from Ireland. The majority (82 per cent) were UK cases, with the remainder made up of cases in South Africa, Australia, New Zealand, Asia, and the Caribbean. Some 78 per cent of the cases involved GPs. A further 15 per cent 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, communication.

1. Prescribing HRT

This was by far the largest category, making up 61 per cent of all cases, and most of these cases involved GP members.

Unopposed oestrogen

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

In most of these cases (73 per cent), the patients developed post-menopausal 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 a 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.

Other prescribing issues

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.

Potential actions that GPs may wish to consider

• Be up-to-date with the ICGP guidance on the diagnosis and management of menopause.
• 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 learnings within the practice if there are any adverse incidents or ‘near misses’.

2. Diagnosis and management of the menopause

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

Early menopause

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

“Early menopause is defined as a menopause between 40 and 45 years and occurs in 5 per cent of women.”

“Premature ovarian insufficiency (POI) is when menopause occurs before 40 years. It affects about 1 per cent of women.”

In many of the cases, patients presented with typical menopausal symptoms, but the diagnosis was either not expected as the patient was young or there was no apparent effect on the patient’s menstrual pattern. There are certainly challenges for GPs and the diagnosis is not always easy to make, with many symptoms (such as fatigue, insomnia, mood changes) being common in a range of conditions. However, it is important to keep an index of suspicion in younger patients and consider: “Could this be the menopause?”

In some cases, patients were dissatisfied that doctors had not undertaken hormonal blood tests or referred them to a local menopause clinic.

Mental health

Another significant category (9 per cent) involved the menopause being misdiagnosed as depression. It is well-known that low mood and anxiety can be symptoms of the menopause, often presenting in this age group for the first time. These symptoms may be related to fluctuating hormone levels. It may therefore be challenging to determine whether a patient is suffering from menopause or a mental health condition. It is important to keep an open mind.

A concerning statistic from the UK is that the 45-to-54-year age group has the highest rate of suicide in women. Three of the Medical Protection cases reviewed did involve a patient’s death by suicide.

The HSE has published useful guidance on the mental health impact of menopause and peri-menopause.

Transgender patients

There were several complaints relating to transgender patients, some relating to communication and the GPs attitude, but also regarding the monitoring of hormonal effects and side-effects. Members of the transgender and non-binary community may experience menopausal symptoms if they are taking hormonal preparations. It is important to recognise that if patients come off hormonal medication, they may experience menopausal symptoms. Similarly, if they restart particular hormones, adverse symptoms may occur. Menopausal symptoms can also be experienced naturally in some trans and non-binary people. Whilst it is likely that patients will be attending a specialist gender clinic, it will still be essential that they receive support from their GP. The National Institute for Health and Care Excellence (NICE) will be including advice on trans and non-binary patients in its next update of its menopause guidance.

3. Communication

Notably, in 17 cases (3 per cent of all menopause-related cases identified), concerns over the doctor’s manner and attitude were the primary cause of a complaint or dissatisfaction. Some patients felt the doctors were dismissive of their symptoms or uninterested in the menopause as a potential factor in how they were feeling. In other cases, the patient felt 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.

Potential learning points for GPs

• Keep your knowledge of menopause symptom recognition, diagnosis, and management up-to-date.
• 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.
• 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.
• Try to maintain or develop clear lines of communication with specialist services.

In conclusion, 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 team. Learn from adverse events and take part in any review process. If in doubt, contact Medical Protection or your medical defence organisation for advice.

References on request

Dr Rachel Birch, Medico-legal Consultant and member of Medical Protection’s Menopause Network