5 tips for success: consider these before seeing your GP about MENOPAUSE…

With a lot to cover in a little time, it can be daunting to see your GP to talk about menopausal symptoms or to ask about treatments such as HRT.

A little preparation can really pay off, making you feel more confident, ready and in control.  This checklist guides you through 5 things to consider before seeing your GP about menopause. By doing this, you can do to prepare your thoughts, so you can get the most out of the consultation. It includes links to useful references. These things are tagged just in case it’s helpful to have some professional source material to hand. For example, you’re definitely not expected to know the NICE guidelines inside out when you go, but you may find them interesting.

1. Choose how to book your appointment.  Consider an online consultation or ask for a healthcare professional with an interest in menopause
2. Gather your symptoms
3. Note your medical history and family history. If possible, note your height, weight and blood pressure. Consider if you need contraception as well, as this will influence your choice of any treatment.
4. Consider what you want from the consultations – advice and guidance or treatment? You don’t have to know what treatment you want, but many people like to research their options beforehand
5. If you are unhappy with the outcome, don’t be afraid to go back, or write a letter to the practice. Be polite and clear about your position. Seek support from family, friends, colleagues, local menopause groups or online communities if you’re feeling alone.

1. Choose how to make your appointment.

Phone, in person or online? Nowadays, most surgeries offer different ways for people to access appointments.  You can telephone or alternatively, go to the surgery website to complete an e-consultation (also known as online consultation).

An online consultation system presents you with a series of questions relevant to the issue for which you’re seeking help. Online consultations can help the surgery route your request to an appropriate health professional, when you get to speak to them, they already know what’s on your mind and what you’re looking for from the consultation. It may also have flagged up important information about your medical history that will be useful in deciding what to do next.

For many people, it’s helpful to be able to go through the questions without feeling rushed. Many women tell me they find the experience of a 10 minute appointment stressful and either forget to mention things or feel they’ve run out of time. Completing the information in advance can give you the breathing space you need. You can also say whether you would prefer to be seen face to face or via a telephone call. Some people like the convenience of a call and menopausal symptoms can often be safely managed without an examination.

If you choose to telephone to make your appointment, when you get through to book the appointment don’t be shy about letting the receptionist know that you want a consultation for menopause.  Ask whether there is a doctor or nurse in the surgery with a special interest in its management. They won’t share this information with anyone who isn’t involved in your care.

2. Gather your symptoms

There are 32 recognised symptoms of menopause. Most people have heard of hot flushes, night sweats and changes to periods but many women experience other symptoms which at first glance aren’t obviously thought of as being hormone-related.  These include anxiety, difficulty concentrating, palpitations, itchy skin or joint pains. When diagnosing menopause and perimenopause, it’s really helpful to be able to put all the symptoms together. If you can think about your symptoms in advance and gather them into one place, this provides a really helpful summary for your doctor. There are lots of good symptom trackers available now, either paper-based or as apps. To read more about the symptoms of menopause, see my article here:

https://onewomanhealth.com/what-are-the-symptoms-of-the-menopause/

You might be surprised at some of them!

3. Take note of your personal and family history

This checkpoint covers all the other important medical questions in a consultation, after your symptoms. Your doctor will also need to ask questions about your medical history. If it’s your regular NHS GP surgery, they’ll have your medical record which should contain a comprehensive summary of all important medical events in your life, but they may want to check that nothing has been missed. Common questions could be:

• What is you’re bleeding pattern and how it has changed?
• Checking whether you have ever had breast cancer, a blood clot or stroke
• Whether you’ve had surgery to remove your womb (hysterectomy)
• Do you get migraine?
• How you’ve got on with other hormone-based medicines in the past, such as the contraceptive pill (if you’ve ever used it)
• If you’ve had a Mirena coil fitted somewhere other than your surgery, it may not be on your notes.

Family history

It’s likely that you will be asked whether you have a family history of breast cancer too, as this is unlikely to be on your notes unless it’s cropped up before. Breast cancer is a very common illness and a family history doesn’t automatically mean you can’t have HRT, but your doctor needs to know who it may have affected in your family and how old they were when they found out. Women with a strong family history of breast cancer may be referred to the specialist breast doctors for further analysis so that their risk can be better understood. The infographic linked below is helpful for putting the risks of HRT into context with other lifestyle factors that affect risk such as drinking alcohol regularly and smoking.
https://www.womens-health-concern.org/wp-content/uploads/2019/10/WHC-UnderstandingRisksofBreastCancer-MARCH2017.pdf

What else?

If you can take along a recent blood pressure measurement (from a home monitor or the machines in the surgery waiting room) along with your height and weight, this will be really helpful. The doctor will want to gather this information to ensure they can prescribe safely and to look after your health more generally.

Do you need contraception? HRT is not licensed as contraception.  If you need it, this may influence your choice of HRT. The professional medical bodies such as the Faculty of Sexual and Reproductive Health recommend that all women who are sexually active have adequate contraception up until the age of 55 UNLESS a woman is clearly post-menopausal. This is defined as being over the age of 50 and 12 months with no period OR under the age of 50 and 2 years with no period. Many women with coils or no-bleed contraception may not be able to know this information, in which case blood tests can be helpful.

4. Research your options

Many women come to the doctor feeling they need help but not knowing what options are available..  Some women come to the doctor knowing they would like to start HRT but not being sure what kind.  Wherever you are in your thought processes is completely fine. The doctor should be able to guide you through some options to help you make an informed choice. However, if you would like to consider the options in advance, take a look at the following pages:

https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/

https://www.menopausematters.co.uk/what_to_do_at_menopause.php

https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/

The number of preparations and combinations can be bewildering. Some general principles are:

• If you still have your womb (uterus), you will need progesterone as well oestrogen. This can be given combined with oestrogen (e.g. in a combined patch or tablet), or given separately (e.g. in a Mirena coil or as utrogestan tablets with separate oestrogen via patch, gel or spray).  In general, oestrogen tends to deal with the menopausal symptoms, but the progesterone is needed to stop the lining of the womb (endometrium) from thickening. This can cause bleeding and more serious problems, so the progesterone is really important.
• If you have had a total hysterectomy (removal of womb and cervix), many women will be able to have oestrogen on its own without additional progesterone. However, it is important to discuss this with your doctor as in some cases progesterone is still recommended. For example, in cases of severe endometriosis where there are deposits of endometrium outside the womb, or in some cases of sub-total hysterectomy where the cervix has been left behind.
• Many women are choosing to have oestrogen delivered through the skin either as a patch, gel or spray rather than in tablet form. Taking oestrogen by mouth is known to increase the risk of blood clots and stroke, and is not recommended for women who have a history of migraine. Studies show that delivering the oestrogen through the skin does not increase the risk of stroke at standard clinical doses. That said, for women who are low risk, an oral tablet may be a reasonable option if it’s your preference.
• Consider vaginal treatment as well. Dryness, soreness and itching is extremely common and becomes more common as women get older. This can be managed with non-hormonal skincare products such as the use of emollients rather than soap for washing, vaginal moisturisers (for comfort) and lubricants (for sex). However, many women benefit from oestrogen delivered directly to the vagina, to improve the condition of the vaginal skin. Please don’t be afraid to mention this during your consultation. I encourage every doctor to ask specifically as this can get lost in dealing with all of the above, and women are often embarrassed. Don’t be, you are definitely not alone with this!
• The choice of treatment depends on your current symptoms, background medical history, whether you need contraception, your personal preference and indeed, what is in stock – HRT shortages have been affecting supply for years and what is available can change. However, don’t let this deter you as there are often equivalent or similar alternatives.

5. Don’t give up

If you’re unhappy with the advice you’ve received for any reason, what should you do? Polite persistence and clear communication is usually the best bet. This can be difficult in the moment, especially if you are feeling at the end of your tether. Things can escalate. Better to step back and take a moment to regroup. You can ask for a second opinion from another doctor in the practice or you can write to the practice manager setting out your query. There may be good medical reasons why advice has been given but we also hear from many women that they are not being offered the up to date options such as those contained within the NICE guidelines. Online communities can provide support if you’re feeling alone. If you wish to, you can also consider seeing a private menopause specialist who will have time to talk through symptoms and options, risks and benefits with you. See https://onewomanhealth.com for more details.  I