Sex, drugs and general practice

Breaking the chains of medical hierarchy: a plea for progressive perimenopausal and menopausal care.

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This is a call to my GP colleagues to stand up and challenge new draft NICE guidelines for managing the menopause, which have the potential to seriously damage the progress we are making in women’s health.

Last week newspaper headlines led with CBT not HRT for menopausal flushes, insomnia and low mood. The guidelines themselves start strongly, recommending we consider “each person’s circumstances, needs and preferences”, but sadly as I read on phrases such as “normal life transition” and “troublesome symptoms” set the patronising tone for what can be described, at best, as a disappointing update.

Once again, the focus is on an outdated breast cancer risk – mentioned 150 times, based on the now refuted WHI study and various meta-analyses that continue to use that data – and the long-term health benefits of hormones are actively denied.

There is little consideration of the heterogeneity of progestins, notably that most of the research has used synthetics rather than body identical micronised progesterone. For a diagnosis of perimenopause under the age of 45, women will need to have flushes and irregular periods to be considered, and women under 40 will need to demonstrate elevated FSH twice, even though bloods only show menopausal status not perimenopause, irrespective of your age.

Women with POI do not fare better. Despite overwhelming evidence showing early loss of hormones has a significant negative effect on long-term health, the guidelines suggest they too will be at risk of breast cancer if they brave HRT. Even vaginal oestrogen is to be restricted to expert use for women with a history of breast cancer, despite good evidence showing how little is absorbed and its benefits for well-being and reduction of urinary tract infections.

As women globally call for their doctors to be better educated about menopause and to offer hormone therapy, I am not optimistic these guidelines will answer that need in any way.

I wanted to be a fashion designer growing up, certainly not a GP, “just like my mum”, that is until Trish came for tea. Trish was my godmother’s trainee in Accident and Emergency, over for a year in Belfast, which sadly at the time was the place to learn about gunshot wounds.

Whatever she said that night piqued an interest that growing up surrounded by doctors had not, and lead me to here, loving life as a GP and practice owner in Sydney.

And just like that encounter with Trish it was in a consultation with a patient two years ago that I felt the world shift again.

“Listen,” she said. “You really need to upskill in menopause. Please do Dr Louise Newson’s Confidence in the Menopause course.”

I could not believe how poor my knowledge was in an area that affects 51% of the population, and as a female GP, most of my patients. That course and Louise’s podcast patient stories really ignited a new passion and marked the start of my wonderful journey into hormones.

As a GP trainee in 2005, despite the aftereffects of the WHI study, I was lucky enough to have the guidance of a great GP in Dr Lynsey Myskow, whose HRT cheat sheet I often referred to over the years.

But I know that I only really prescribed it for hot flashes and night sweats, maybe some tibolone if they also complained of low libido. I am pretty sure I never checked if the dose was correct. I would have always insisted that they stopped it at 60 and I certainly never considered it for mental health issues.

One of my greatest regrets to this day is not understanding the complaint of “all over body pain” that women of a certain age from India often reported. I now regard this as the most succinct description of menopausal transition, covering every symptom from headache to joint pain to vaginal burning and cystitis.

I have read updates on the WHI study and new advice about breast cancer risk with HRT over the years but never really delved beyond the headlines. And of course, the devil really is in the detail.

Reading the latest update on the scandal that was the WHI study makes me wonder what else I have thought to be so true that was in fact the opposite. Rather than HRT causing breast cancer could it also treat it?

There are four types of oestrogen: E1 oestrone, E2 oestradiol, E3 placental oestriol and E4 foetal oestetrol; and at least 3 types of oestrogen receptors. Not surprisingly the interactions between these oestrogens and their receptors exert quite different effects. When women transition through menopause E1 becomes the dominant oestrogen as ovarian E2 falls away. There is currently a trial using oestradiol to suppress tumour growth in triple negative breast cancer, and studies that show that oestradiol can oppose the tumorigenic effects of oestrone.

Therefore, we cannot say that all oestrogens are dangerous in all breast cancers. And what if a woman who has or has had breast cancer chooses to take hormones because her quality of life is so much better with them than without, and it also reduces her future risk of heart disease and osteoporosis? Is that not her decision to make with us instead of us making it for her?

So why did nobody teach me properly about sex hormones at university or in my hospital jobs or in primary care?

All doctors look after women at some point in their careers, yet it seems the majority, like me, only have a cursory understanding of the impact of sex hormones on our body’s physiology, namely their effect on reproductive function.

Essentially all living things are designed to live long enough to reproduce, explaining why sex hormone receptors exist on probably every cell in our body, from the quality of our tear film to the effect of progesterone as a neurotransmitter in our brain. And you cannot escape that women’s health acutely deteriorates in menopause transition when we lose the potent anti-inflammatory and anabolic effects of oestradiol, progesterone and testosterone, when our reproductive capacity ends.

And I as a perimenopausal woman am not taking that sitting down!

There is currently a very polarised debate about the medicalisation of menopause, a natural stage that all women will experience if they live long enough. For others it can be induced by surgery, chemotherapy, or radiotherapy years before it should have occurred. The majority of what I treat is “natural” whether that is diseases of ageing such as hypertension and heart disease, normal life events such as pregnancy, birth and death, infectious diseases or hormonal imbalance.

And while optimising nutrition, exercise, sleep, breathing, and social connection are all extremely important for healthy physiology, we cannot escape the fact that women have good levels of oestradiol and progesterone before menopause and after menopause they have almost none plus only 50% of their pe-menopausal testosterone at best. And rather than hormone therapy being a miracle cure I find that optimising someone’s hormones gives them the passion for life that makes making good lifestyle choices so much easier. (Try going to the gym if you have been up half the night ruminating about the apocalypse.)

I find it hard to hear doctors argue against a treatment which both improves current quality of life and reduces the risk of cardiovascular disease, osteoporosis and much more, yet happily prescribe a multitude of other drugs or the occasional vaginal laser, that neither offer the symptom relief or the risk reduction that body identical hormone therapy does.

What is particularly concerning is that these views seem to dominate, and patients are left to suffer.

As a GP who is trying her best to proactively screen for hormonal issues and to offer good hormone care to as many patients as possible, I find it frustrating and disheartening to see those who have the ears of many of my overworked GP colleagues continue to downplay the benefits of hormone therapy. I listen to friends, patients, and colleagues, and I read the comments on social media from thousands of women who have seen their GP to ask for HRT but have been told they are too young or too old or too at risk for hormone therapy and why don’t you just try this antidepressant instead.

As GPs we are at the forefront of patient advocacy. So I would ask you to re-evaluate your knowledge of menopausal transition and treatment thereof. It is time for us break free from the shackles of a hierarchy that says we are “just GPs”, challenge incorrect and outdated advice, even when it appears in globally respected guidelines, listen to our patients, friends, family and colleagues, and embrace the opportunity to offer truly holistic care to women.

And as my godmother, once a bullet-removing trauma surgeon, spends her days confused in a care home due to Alzheimer’s when she physically can still climb mountains, I cannot help but feel we have let her and many other women like her down. Alzheimer’s affects twice as many women than men, and not just because women live longer.

With a recent meta-analysis suggesting reduced incidence of all neurodegenerative diseases in women who used hormones, I know if my godmother could speak to her 45-year-old self she would be right on to those hormones, if there was even a small chance that she might still be able to summit that mountain.

Dr Ceri Cashell started her career in general practice in 2004 in Edinburgh, Scotland. Since 2012 she has been working in Avalon, Sydney, where she is practice principal and owner. She enjoys all aspects of general practice and has a special interest in women’s health, including menopause transition and hormone-related mental health disorders. Dr Cashell is a passionate advocate for increased awareness of the effects of hormones on physical and mental health and is a member of the RACGP and AMS.