Expert advice to get the most from your appointment
She has extensive clinical expertise as a menopause specialist, regularly seeing and advising women on all issues relating to menopausal health. An independent prescriber with a Masters in Community Gynaecology and Reproductive Healthcare, Kathy is immediate past Chair of the British Menopause Society, the professional society for healthcare practitioners.
She’s also the director of ‘The menopause course’ an educational initiative for nurses, designing and running study days, courses and events relating to menopause, and director of menopause services at www.peppy.health.
Henpicked: In this session we want to remove any hurdles people are facing in getting the right support and help from their GP during menopause. One worrying trend we’re seeing is women saying they’ll wait until Covid-19 is over before making an appointment. Why shouldn’t they wait?
Kathy Abernethy: Yes, I hear this too, but you could have a long wait if you wait for Covid-19 to be over and the NHS to be back to normal. But GPs are saying they are now back to service and offering consultations on zoom or over phone. It’s quite likely you won’t get a face-to-face appointment for menopause. But that doesn’t mean it has to go on hold. In fact, this is a good time to be thinking about our health, so I’d encourage women not to wait.
The sooner you get help the sooner you’ll start to feel well. GPs don’t want you to wait either – they’re there to help.
Henpicked: There’s often a misunderstanding around diagnosis, with some women thinking they have to have blood tests or blood pressure tests. Can you explain how menopause is diagnosed so we’re all really clear on that?
Kathy Abernethy: We’re so used to blood tests for other medical conditions. But as a clinician I would listen to a woman’s experiences and put together the pieces of the jigsaw. If some bits are missing – perhaps she’s not of classic menopause age – then a blood test may be necessary. But for most women, if you tell a practitioner what’s happening with your periods, how old you are and any other symptoms, it’s generally very easy for them to diagnose menopause.
Henpicked: In fact, the NICE guidance says for a woman over 45 otherwise presenting healthily a blood test isn’t required.
Kathy Abernethy: That’s right, because it would be so unreliable. As we go through perimenopause our hormones are fluctuating wildly. A blood test could be doing you an injustice as it can be very difficult to interpret. You can end up with a test that neither confirms nor denies you’re in menopause, when your body is telling you that you are.
Henpicked: The other thing we’ve heard from women is you need a blood pressure test before doctor can confirm menopause, but you can’t get into surgery at the moment. What’s the guidance on that?
Kathy Abernethy: This is really interesting as it has changed through the Covid situation. Six months ago it was absolutely routine to have a blood pressure check before you had HRT. But this was less about the HRT, more of a well-woman check. A good thing to have done, but actually HRT isn’t going to affect blood pressure. Recommendations from professional bodies is that we can still prescribe HRT as long as blood pressure is normally good. If it’s been high in the past you may still need to have a check-up.
Henpicked: So don’t wait, but you can also help yourself by doing your prep beforehand. Appointments are usually only ten minutes, so we recommend that people keep a list of their symptoms and understand any changes in their body. Also, have a think about what your philosophy to treatment might be, based on your medical history. The conversation with the GP can then be “this is what I’m experiencing, this is how it’s affecting me, this is how I’d like you to help me.”
Kathy Abernethy: Absolutely, and the one thing I’d add to that is right at the beginning of consultation be clear in your own mind and with your GP what the purpose of the talk is. It’s very easy for a GP to be sidetracked into talking about risk when, for example, all you want is a diagnosis to find out whether you’re in menopause. Your opening sentence should be the reason you want the consultation. For example, “I’m talking to you today as I want to start HRT. “Guide the conversation down the right direction from the start and get best use of the few minutes with your practitioner.
Henpicked: One thing we know that puts women off HRT is they think it’s too risky.
Kathy Abernethy: This whole risk picture has been built up over past 20 years when there was an important US study which showed there may have been some association with HRT and breast cancer risk. This is good data but has been exaggerated and misapplied. We need to move away from the big data study and look at individual risk.
If you’re low risk generally and healthy but menopausal and taking HRT to relieve symptoms, there’s a very small risk of breast cancer. As with anything it’s measured. The risks are very small and the benefits much greater. It can make you feel better, get rid of your symptoms, protect your bones, protect your cardiovascular system, perhaps improve your memory functions. Whereas the risk may be similar to having a glass of wine every day or being overweight.
Henpicked: Many GPs are superstars. But what if a woman isn’t getting the help she needs?
Kathy Abernethy: It’s such a shame menopause has become so subjective rather than objective. If you go with any other medical condition you’ll be told what your options are and what do do. But with menopause healthcare practitioners have developed opinions about it and it’s become a very moral debate. I think we need to move away from that, and I’d suggest if that’s the direction your doctor is going down, see a different GP in the surgery.
It’s often a good idea to speak to the receptionist as they know which doctors are open to discussions around menopause. We need to think about seeing a GP with a specialist interest rather than being fixated on seeing a female GP of menopausal age. This doesn’t necessarily mean they’re the right person for you to speak to.
Henpicked: What’s my course of action if I can’t get the right support from my doctor?
Kathy Abernethy: If there’s no joy from the receptionist or a different GP then you can write to the practice manager. Tell them your experience has been disappointing and ask who they can you direct you to. Hopefully then you’ll be directed to a GP with a special interest in menopause.
Henpicked: We know some cases will be more complicated than others. Is there an option to be referred if this affects you?
Kathy Abernethy: If there’s a true contraindication that you can’t have HRT, nobody should simply be told they can’t have it. They should have opportunity to speak to someone in a specialist clinic like I do. We work beyond the NICE guidance sometimes, which is easier for us to do than for GPs. We treat each person as an individual and weigh up their options.
Henpicked: There are over 70 HRT preparations. Why are some women being told ‘it’s this one or nothing’?
Kathy Abernethy: This is such a shame. Women often have to try two or three combinations before they finally find one that suits them. It could be a tweak in dose, or it might be a complete change of HRT. If the first one they try is perfect I’d be astonished, as that just doesn’t happen. This is why you have follow ups. If you’re meeting resistance from your GP, there are other options to try. Do your research and see whether you might need a dose change or to start again with different HRT.
It’s about change in a way that makes sense, not just switching brands. You need a practitioner to look at what you’re on and make an intelligent switch.
Henpicked: Can women take HRT if they’re still having periods?
Kathy Abernethy: One of the biggest myths surrounding HRT is you need to wait until periods have stopped. But the time you may most need treatment can be when you still have periods. It doesn’t matter if you’re still having periods, if you’re struggling and in perimenopause it’s time to start treatment.
Henpicked: We’ve had a few HRT shortages recently. How is the supply now?
Kathy Abernethy: The brilliant news is almost every HRT is in stock. There are a few postcode variations but there’s general availability around the UK. It’s a much prettier picture than it was.
Henpicked: What if a GP says you can only take HRT for a certain length of time, so you need to wait until things are really bad?
Kathy Abernethy: The time to take HRT is when your symptoms are particularly bothersome, may be early in perimenopause or later on. I would suggest people don’t need to worry about when to stop. Some only need it for a short time, others can safely take it longer. Guidance from professional bodies is that there is no arbitrary length on the time you can take HRT.
Henpicked: Can a GP advise on non-HRT treatments?
Kathy Abernethy: Yes GPs can help women manage symptoms without HRT if they have medical reason not to take it. It’s trickier with herbal treatments and supplements, as GPs are told to only recommend things with a strong evidence base. Some of the supplements and dietary things you might do will have an effect but we can’t say there’s a strong evidence base. But NICE guidance is clear that things like black cohosh and red clover do have a degree of evidence. So your GP should at least discuss that with you.
Henpicked: If women are really not getting what they want can they seek private support?
Kathy Abernethy: The first thing to do is see if another GP or nurse practitioner can help. But failing that, if you go privately check the BMS register of specialists. Be aware that some may use compounded bioidentical treatments, which are not recommended by the BMS.
Henpicked: How do women know when to move away from contraception onto HRT?
Kathy Abernethy: If you’re not on HRT you can stop your contraception when you haven’t had a period for a year if you’re over 50 or two years if you’re under 50. If you go on HRT when you’re having periods you won’t know at what stage you’re becoming menopausal. Most women use contraception alongside it, until they’re about 55
Henpicked: Can HRT be started if a woman doesn’t have symptoms?
Kathy Abernethy: There can still be benefits to cardiovascular and bone health but this is not side step from other things you need to do. This includes weight management and exercise – HRT is an extra bonus.