The Role of GPs in Menopause Management - Dr. Karen Magraith
It is said that nothing is certain but death and taxes. For women, provided they live long enough, another certainty is menopause. Most women have their last menstrual period between the ages of 45 and 55, though there are women with early menopause who have unique needs.
Although menopause is a natural event it is not necessarily easy for women. Women can experience a range of symptoms in the perimenopausal and postmenopausal years. In addition to changes in the menstrual cycle, symptoms include hot flushes, mood changes and anxiety, sleep issues, and genitourinary symptoms. Some women experience few symptoms, but others have severe and debilitating symptoms. Whether symptomatic or not, menopause has important and ongoing consequences for all women, including an increase in risk of cardiovascular disease and osteoporosis.
In spite of improvements in education and understanding about women’s health, menopause still remains a poor cousin and is the subject of embarrassment and stigma.
How can GPs help perimenopausal and menopausal women?
We hear that GPs are ‘well-placed’ to do all sorts of things, often said by ‘experts’ who exhort GPs to squeeze more and more into our already crowded consultations. The reality is that menopause cannot be addressed adequately in a typical ‘standard’ consultation.
Women presenting to their GP with concerns around the time of menopause need:
A comprehensive history including a menstrual history, family and personal history of medical conditions and risk factors. An important part of this is an exploration of the women’s individual needs and concerns.
An exchange of information. What is menopause? What can be expected? Is her experience normal? What health checks should be considered at this time? How can a healthy lifestyle set her up for healthy aging in the years ahead?
A discussion about options available for treatment if she has symptoms. The most effective treatment for relief of symptoms is menopausal hormone therapy (MHT) and should be offered to symptomatic women who do not have contraindications. Other, non-hormonal options can also be offered, and can be helpful for women who can’t or don’t want to use hormones.
A discussion about the benefits and risks of MHT. This can be a challenging conversation and needs to be tailored to the woman’s personal circumstances and concerns. A decision to prescribe MHT needs to be a shared decision-making process.
The offer of further discussion and follow up, as with any other health issue.
For many GPs the management of menopause is challenging and sometimes feels too hard. GPs are pressed for time, and time is what is needed. GPs are concerned about the potential risks. In particular there is controversy, confusion and misunderstanding about the risk of breast cancer associated with MHT, both in the general community and amongst GPs. This leads many women (and their GPs) to dismiss MHT as an option. Some GPs even state that they don’t deal with menopause. (Would a GP say that they don’t deal with asthma? Hypertension?). When GPs are not providing menopause management it risks leaving women without the support they need, and they suffer needlessly, or they may turn to inappropriate or unsafe options.
The Australasian Menopause Society (AMS) aims to provide evidence-based information on all aspects of menopause. As a starting point, the Australasian Menopause Society advises that MHT is safe to use for most women if started in their 50s or for the first 10 years after the onset of menopause.
The reality is that GPs are in the perfect position to manage menopause. This does not normally need to be the domain of specialists but can be where GPs come in to their own, balancing and managing multiple aspects of physical and mental health in a holistic fashion. Discussing whether to use MHT is challenging and requires GP to manage a nuanced conversation about risk and uncertainty. But dealing with uncertainty is a core part of GPs’ business and in the right circumstances they can provide excellent care and information to menopausal women.
How can barriers to more effective and comprehensive GP management of menopausal women be overcome?
Removal of the structural barriers to long consultations, where funding incentivizes short consultations and penalizes holistic care. GPs should be encouraged to offer several long consultations to these women, funded by appropriate Medicare rebates for patients.
Enhanced education of medical students and GPs about menopause. This will help defuse the anxiety that some GPs have, particularly about prescribing MHT.
Education of women. This is particularly needed for women from culturally diverse backgrounds, and those who have poor health literacy or are marginalized, who often have poor access to health services.
Improved PBS listing of MHT products. Currently the one of the MHT options that is widely considered to be associated with lower risk is not PBS listed.
Women with early menopause have complex needs and many of them may benefit from a specialised multidisciplinary approach. Similarly, women with a history of breast cancer and some other conditions may benefit from specialised services. But for the majority of menopausal women, their GP can provide comprehensive care.
The Australasian Menopause Society and other women’s health organisations aim to promote health practitioner and community education about menopause. More work is needed to clarify and communicate the benefits and risks of MHT and enable GPs to proceed with confidence in these complex but important consultations.