Recently, awareness of the effects of the menopause and its treatment options have been the subject of media attention. Dr Rachel Birch, Medicolegal Consultant and member of Medical Protection’s Menopause Network, discusses lessons that can be learned from analysis of our case files.

Although the menopause is a natural phase of a woman’s life, for many women it is by no means straightforward. The perimenopause may last several years, during which time hormone levels may fluctuate until gradually falling to postmenopausal levels. For other women, the menopause may occur more suddenly, especially when brought about as the effect of surgical or medical treatments. In either of these scenarios, symptoms can be debilitating for women.

In November 2022, 1,290 adults were surveyed as part of the Department of Health’s Menopause Awareness Campaign. Results showed that 55% of women experiencing the perimenopause and menopause described it as a negative experience. One in three women reported constant symptoms with, on average, women experiencing up to seven symptoms at any given time. Common symptoms included vasomotor symptoms, menstrual changes, fatigue, insomnia, changes in body shape, cognitive issues, mood changes and joint pain.

In October 2022, the Menopause in the Workplace Survey of 1,132 women, undertaken by the Menopause Hub, reported that almost half of women did not feel confident talking with their GP about the menopause. Furthermore, 25% of respondents described their symptoms as severe, with 79% of women considering that the level of information and support for menopause in Ireland was poor. 84% of survey participants felt that the menopause had affected their performance in the workplace, while 38% of women admitted that they had considered stopping working due to their symptoms.

The numbers in both studies were small, so caution would be required in extrapolating information to the larger patient population. Additionally, it is likely that the first national Menopause Awareness Week, held in October 2022, may well have proven a success in helping women to understand the menopause. Nevertheless, it is clear the menopause may be a very challenging time for large numbers of women in Ireland.

Medical Protection and the menopause

As an integral part of our Supporting doctors through menopause campaign, Medical Protection surveyed its members to understand the impact of the menopause on their wellbeing and careers. We received responses from 261 members in the UK and 354 in Ireland.

The results of the doctors in Ireland revealed that 58% of female doctors experiencing the menopause have previously gone into work while being impacted by menopausal symptoms, and 60% were unsure where to seek support for their menopause symptoms at work. 50% of respondents were concerned about the potential impact of their symptoms on their performance at work, with 35% believing the impact of symptoms could potentially result in medicolegal issues. 37% of survey participants experiencing the menopause had considered reducing their hours as a result.

Although study numbers were small, these figures make difficult reading, especially considering the ongoing pressures in general practice due to the COVID-19 pandemic and increasing patient demand. In its policy paper, Medical Protection has made recommendations for the support of doctors experiencing menopausal symptoms and it is hoped that this has helped to further raise awareness of the importance of doctor wellbeing. I wanted to take the opportunity, in this article, to remind members that Medical Protection’s counselling service is available to any member experiencing stress or feeling under pressure; this includes support for anyone struggling with the menopause.

Patient care

At the time of Medical Protection’s survey, 25% of respondents in Ireland reported feeling uncomfortable supporting and managing patients experiencing menopausal symptoms. 69% agreed they would welcome more training. It is likely that, if the survey were repeated, these figures would have improved, with the ICGP having published their Quick Reference Guide. Diagnosis and Management of Menopause in General Practice in October 2022. The ICGP have also updated their 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 helpful lessons to be learned regarding the management of the menopause in primary care.  

Over the last ten years, 548 cases were identified, 5% of which were from Ireland. The majority (82%) were UK cases, with the remainder made up of members’ cases in South Africa, Australia, New Zealand, Asia and the Caribbean. 78% of the cases involved GPs. A further 15% 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, and communication:

1. Prescribing HRT

This was by far the largest category, comprising 279 cases, making up 61% of all cases. Most of these cases involved our GP members. This is not unexpected, since a large proportion of HRT prescribing is carried out in primary care.

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

In the majority of these cases (73%) the patients developed postmenopausal 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 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.

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

Learning points to consider:

2. Diagnosis and management of the menopause

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

A large category (16%) related to failure to diagnose early menopause or premature ovarian insufficiency. The ICGP guidance⁶ makes reference to the following definitions:

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

“Premature ovarian insufficiency (POI) is when menopause occurs before 40 years. It affects about 1% 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. The ICGP guidance⁶ may be helpful reading on the indications for blood tests.

Another significant category (9%) 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 is that the 45–54-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.

Mental Health Ireland hosted a webinar on World Menopause Day 2021. The HSE have published guidance on the mental health impact of menopause and perimenopause. Doctors may want to review these informative resources.

Importantly, there were several complaints relating to transgender patients, some relating to communication and the GP’s attitude (see below), but also regarding the monitoring of hormonal effects and side effects. Members of the trans 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 hormones, the same 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 and recognition 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

Communication was seen frequently in cases, as a contributory factor, leading to complaints and expressions of dissatisfaction from patients. This is unsurprising, since alleged issues over communication and consent are some of the commonest themes we tend to see in a wide range of case types, across the various specialties.

However, in 17 cases (3% of all menopause-related cases identified), concerns over the doctor’s manner and attitude were the primary issue. Patients’ perceptions in these cases were that the doctor was dismissive of their symptoms or uninterested in the menopause as being a potential factor in how they were feeling. In other cases, the patient felt that 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 to HRT available.  

Learning points to consider:

General practice is a challenging, wide-ranging and important specialty. Doctors cannot be specialists in all areas. However, I hope that the points below may assist GPs in providing the best care for patients experiencing the menopause and consequently succeed in avoiding complaints or adverse outcomes.

• Keep your knowledge of menopause symptom recognition, diagnosis and management up to date.

• Take an open and inquiring approach, 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 around menopause care.

• 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 – make the most of their expertise, especially in complex cases.

• As a practice, try to maintain or develop clear lines of communication with specialist services, eg through email or telephone advice.

In conclusion, it is clear that 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 practice team. The Medical Council recognises that "despite the best efforts of staff, adverse events may still arise”. However, they emphasise that it is important to learn from adverse events and take part in any review process. I hope that the analysis of the Medical Protection caseload will similarly contribute to your professional development and interest in this area.

If you have any queries relating to the subjects in this article, please contact Medical Protection’s medicolegal advice line on 1800 936 077.