These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
Findings from the senate inquiry into issues related to menopause and perimenopause released last week highlighted the limited and variable coverage of menopause in medical school curriculum, noting a lack of awareness across all specialties – and recommending explicitly including the topic in graduate outcome statements and increasing funding for CPD, among other strategies to improve care for women experiencing symptoms of menopause.
In light of all this, we asked immediate past president of the Australasian Menopause Society and Hobart GP Dr Karen Magraith and Jean Hailes CEO Dr Sarah White to help dispel some of the most common misconceptions they see among their colleagues.
“Of course, we should manage their risk factors as best we can, but many of these women can have MHT, usually starting with low dose transdermal oestrogen and a suitable progestogen such as micronised progesterone,” says Dr Magraith.
Confusion over MHT risks persists
Dr White says many GPs remain “concerned about using menopausal hormone therapy from risks that have been overstated and poorly reported in the past.”
Dr Magraith notes the nuance around breast cancer risk.
“GPs are still concerned about breast cancer risk with MHT. It’s complex. We can’t say that there is zero risk. The fact remains that there is a small increase in breast cancer risk associated with long term use of MHT. Based on observational data it appears to be lower for patients using micronised progesterone rather than most synthetic progestogens. It is lower again (or possibly not increased at all) with estrogen only MHT, given to patients who have had a hysterectomy,” Dr Magraith says.
“To put it into perspective, lifestyle and health factors such as alcohol intake, exercise and obesity may be more important for breast cancer risk than whether women use MHT,” she says.
“Another misconception is that there’s an arbitrary length of time women are allowed to have hormone therapy for, or an arbitrary age at which they need to stop,” Dr Magraith says. “That is not correct.”
“For each woman, it’s an individual assessment based on her personal circumstances, and based on a sort of discussion of the risks and benefits as they apply to that woman. So there’s no age or duration that we need to cut off or stop, providing that they haven’t developed a contraindication such as breast cancer.”
“Menopausal symptoms often start during perimenopause as estrogen levels fluctuate, and treatment can start then if patients need it,” Dr Magraith says.
“Some GPs are not aware that topical vaginal estrogen can be safely prescribed for the majority of patients with genitourinary symptoms related to menopause,” she adds.
“Symptoms such as vaginal dryness, dyspareunia, urinary urge, frequency and sometimes urinary tract infections are caused by low estrogen levels, and worsen over time. These symptoms are very common, but women may not bring them up with their GP.”
She recommends asking about these symptoms as a routine part of a menopause assessment.
“Some women will not need systemic MHT for systemic symptoms, but may benefit greatly from topical vaginal estrogen.”
“Topical estrogen can treat genitourinary symptoms effectively and can be used long term. It has minimal systemic absorption and is a very safe treatment. The only group we really have concerns about are women with breast cancer who are taking aromatase inhibitors,” she adds.
A recent Healthed survey found lack of time was the main barrier to discussing menopause symptoms for 80% of GPs.
To this end, the inquiry has recommended a review of MBS item numbers related to menopause and perimenopause to assess whether they are adequate, and consider if a new MBS item number or expanded criteria for the mid-life health check is needed.
Dr Magraith agrees it is a major problem.
“It is impossible to do a comprehensive menopause consult in a standard 15-minute appointment. GPs need to ask about current symptoms, review medical history, think about updating screening and discuss health promotion, and that’s even before the decision-making process about treatment options for symptoms.” – Dr Karen Magraith
“In practice, if a patient comes in to discuss menopause in a standard consult, I suggest gathering information about their primary symptom or concern, validating their symptoms, giving basic information such as an AMS information sheet, and inviting them back for a longer consultation. I suggest to patients that it might take two or three long consultations to deal with all the issues,” she adds.
“I hope that improvements are made to the resourcing for general practitioners to conduct the longer consultations that are needed for menopause. Because it’s not just about education, it’s also about access to longer appointments.”
Her preference would be for better funding for longer consultations more broadly, rather than making it menopause specific.
“How do I know how much of my consult is mental health and how much is menopause? It’s ridiculous. So I just think proportionately more funding for longer consultations would be in the interest of women’s health.”
Dr White agrees time constraints are a challenge, and probably help explain why some women feel their GP does not take their concerns seriously enough.
She suggests having patients fill in this symptom checklist before an appointment, to help focus the discussion “so it can be efficient,” she says, and you can use it to track whether symptoms are resolving.
Although the Senate inquiry made “eminently sensible recommendations,” one thing it didn’t address was the impact that online disinformation and misinformation Is having on women’s expectations, and the challenges that presents for their doctors, Dr White adds.
“The thing I think they missed was the misinformation and disinformation and commercial determinants in this space. And I think those commercial determinants are actually making challenges for our very good group of GPs out there,” Dr White says.
“There are celebrity influencers, including doctors, who are probably raising expectations of the treatment that they might be provided and then when the GP makes the considered assessment, sometimes we have patients going away feeling like they haven’t been heard because they’re not getting the treatment they thought they were going to get,” she says.
“So that’s another challenge for doctors in a time-constrained environment, having to take the time to explain why they’re not recommending treatment X, but rather treatment Y.”
If a woman requests treatment that may be inappropriate, she suggests focusing on their unique situation.
“It’s that conversation around ‘I’m here to work with you and your very particular individual history’,” she says. “Here’s the pros and cons of what I’m talking about. No woman’s health history, personal circumstances and individual journey with menopause is the same and I am tailoring it to you, based on the best evidence we have.”
Based on this educational activity, complete these learning modules to gain additional CPD.
Listen to expert interviews.
Click to open in a new tab
Browse the latest articles from Healthed.
Once you confirm you’ve read this article you can complete a Patient Case Review to earn 0.5 hours CPD in the Reviewing Performance (RP) category.
Select ‘Confirm & learn‘ when you have read this article in its entirety and you will be taken to begin your Patient Case Review.
