Intimate examination required for HRT

[Jubbly2841]

I’ve been on hrt for a while. I’m prescribed patches and pesserys for vaginal dryness. Today I had a hrt review with a nurse instead of the gp, and she asked me why I had been prescribed the pesserys. I explained I was dry and sensitive and she said she would need to examine me before she could prescribe them.

I queried this and told her she would not be able to tell if I was dry or not, and she was insistent that she could not prescribe them without an examination because I could have a particular skin condition that she needs to rule out. I left without my prescription feeling very upset. I’m not willing to be examined for a condition I know I don’t have and it was made clear no examination, no pessaries.

AIBU to complain?

That sounds very odd. I have been prescribed the pessaries for 8 years and have never been examined since the first exam to diagnose vaginal atrophy.

There's a few possibilities but no one can be made to prescribe a medication they're not happy to.

• Nurse might not have been a prescriber and instead working from a PGD which could have required said examination for the medication to be issued?

Or it might have been the nurse has been involved in a complaint/case where examination wasn't undertaken leading to a missed/incorrect diagnosis and now they're extra cautious and wanting to physically confirm certain things before prescribing.

I had a quick look online and can’t see any reference to an internal being required to rule out other conditions. Perhaps that particular nurse has had a previous experience of missing the condition she was thinking of and is now extra cautious? If so she should have explained this and offered you the option.

You don’t have to complain, how about asking for a second opinion at your surgery? An email would probably be sufficient. You can also buy products OTC ( assuming you’re in the U.K.) and bypass the surgery altogether.

I wonder if they don’t have a record of it being confirmed as vaginal atrophy? And maybe need to be sure you are being treated correctly? I’m having horrors at the moment and am so sick of people fiddling with my fanny so I hear you.

I'd just book an appointment with a gp, I've found them to be more practical prescribing hrt. The nurse probably wants to check for lichen sclerosis, but if you're certain that you dont have that then I can't see that she needs to examine you. I just asked for cream and was given it no questions asked by the gp.

As someone else has said you can buy it online if you're desperate.

Stickytreacle yes it was lichen sclerosis she wanted to check for which I don’t have any symptoms of. Atrophy has already been diagnosed by a gp.

I’m a bit annoyed at the implication that I don’t know my own body and I have to expose myself to prove it. The younger me would have meekly been examined but I’m sick of being fiddled with when it’s not necessary.

The nurse probably wants to check for lichen sclerosis, but if you're certain that you dont have that then I can't see that she needs to examine you

I'm not sure you can be certain you don't have something if you haven't been examined. The problem with vaginal atrophy is that it shares the same symptoms as about a dozen other conditions (most of which become more common in middle age).

If the diagnosis was made with out an examination I can see why she might be hesitant to continue prescribing.

Anecdotally, I have a friend who specializes in gyno/urinary diseases and she sees patients who present with very advanced LS who either didn't have a clue anything was amiss or dismissed their symptoms as chronic thrush or atrophy. It does happen.

I have a friend who is very unhappy that her Lichen Sclerosis remained undiagnosed for several years. I had never heard of it before and know many women of similar age are also ignorant. My friend is being quite vocal trying to educate everyone she knows. I can understand the practice nurse wanting to rule it out before prescribing.

To be fair to the nurse, she's probably not desperate to carry out intimate exams on patients on a whim and is only wanting to do this because it's best practice, which is in your best interests as the patient.

It's a faff and the sort of thing I'd want to be mentally prepared for, so if it was me I'd make another appointment with her and go back.

@Delphiniumandlupins Yes, the current thinking is that LS is under diagnosed and not a "rare" disease. And it often doesn't present with the classic symptoms you see online.

I'm definitely not implying that the OP has LS! I do think there is more awareness among doctors/nurses now though ( hence wanting to rule it out).

I have both lichen sclerosis and vaginal atrophy and was undiagnosed for years and suffered a lot of pain and discomfort.

However, if you don’t have any of the symptoms, it’s unlikely to be LS so I don’t blame you for refusing the examination. 🤷🏻‍♀️

I was prescribed oestrogen cream for vaginal atrophy - which is a lot more severe than a bit of dryness. GP wanted to take a look before prescribing the cream and it took literally seconds, no speculum, no internal anything, just a quick peek to see what the tissues look like.

YANBU op, women get treated like dairy cattle, it's shameful.

Depending how you described it she may well be worried re lichen sclerosis as you know.

Imagine she doesn’t offer the exam, and 5 years from now you have vulval cancer but have been treating ‘atrophy’ instead for years. It would be her neck on the line and career.

you can decline the exam absolutely, but our nurses can only prescribe to strict guidelines so she won’t prescribe. As a GP I can go outside these but I’ll damn we’ll be documenting exactly how many times I offered it, the reasons I’m concerned and that you’ve been told in no uncertain terms the risks.

What are the symptoms of LS? What pain too?

What's the problem being checked out?
I would appreciate her diligence.

I don't see that at all in this scenario.

If a woman is having genital discomfort then how exactly can a proper diagnosis be given without actually examining the genitals? It's not a gratuitous examination.

Conversely the OP can self-diagnose and purchase medication online or see if a GP will prescribe without an exam. Those are the choices.

You are being ridiculous frankly. Also what's the big deal? Things change
My gp won't prescribe pessarries on repeat either.

OP, it looks like a lot of people have remained undiagnosed for Lichen Sclerosis so if you weren’t ready for an examination, you could just say that and then reschedule. It’s better to be safe, than sorry.

I’d have thought that since you’ve already been using the vaginal pessaries then you wouldn’t need to be examine. Although I was examined by the gp to check for vaginal atrophy before they would prescribe Estradiol.

Exactly. And if something was to go awry a few years down the road, OP could be saved from a lot more headache so I don’t see the reason to avoid a physical examination.

I was examined by my (female) GP before being prescribed Ovestin, yes it’s awkward and I would want to be prepared (fresh pair of knickers!) so can understand you were caught off guard.
However I don’t think it’s unreasonable to have an occasional examination for a prescription - as long as it’s not every time!
It’s not being treated ‘like cattle’ it would be the same for any other condition, DS gets eczema flare-ups and I have to send a photo to get a hydrocortisone prescription, obviously you can’t send a photo for VA!

Although it was embarrassing I felt reassured that I had been checked and that if there were any other issues e.g. LS it would be picked up.

I am on a repeat prescription and I have had to fill in a questionnaire about my symptoms but have not been asked for another examination, I would do it, but would definitely want some warming.

As a PP said, it wouldnt have a been an internal exam..it would have just been a quick look at the vulva tissues to check for inflammation, skin cracks in the groin etc. A 3 second look is all they done with me.