To loose my shit at my GP?

[Peoplecoveredinfish]

I was prescribed testosterone by gynaecologist on 16/9. I have chased this three times, and had no response. I’ve still had no response, but I see from my record that the practice has written to the gynae. They’ve been pretty good about menopause, but this is a shitty misogynist policy.

TLDR: We don’t prescribe testosterone for women because it would be off licence. We prescribe off licence medication all the time, but we won’t prescribe this one, because we aren’t familiar with it and we don’t think women really need it. We think women need counselling for their made up symptoms. Even though we are not specialists and the specialist has asked us to do this, we think we know better.

The actual letter…

We have recently been receiving an increasing number of letters from the menopause clinics requesting us to prescribe testosterone for patients who are menopausal but have an intact uterus and ovaries and feel their menopausal symptoms are not being fully controlled on Oestrogen replacement therapy.
As you are aware, this medication is not licensed for women in the UK, so a clinician can only prescribe it off licence.
While there are many drugs that GPs do prescribe off licence, these are medications that we are familiar with, and there is known evidence to prove their efficacy and safety.
The GMC guidance around Good medical practice clearly states that “14 You must recognise and work within the limits of your competence. 16 In providing clinical care you must: a) prescribe medicine or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the medicine or treatment serve the patient’s needs, b) provide effective treatments based on the best available evidence.”
Also “You are responsible for the prescriptions that you sign. You must only prescribe medicine when you have adequate knowledge of your patient’s health. And you must be satisfied that the medicine serves your patient’s need.”
The British Menopause Society states “Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy, and musculoskeletal health. Further better designed studies are required with these health issues as primary outcome measures as some individuals report improvement of these symptoms. Until these data are available, the primary indication for testosterone should therefore be for HSDD following a biopsychosocial approach.”
We are thus unable to continue issuing testosterone prescriptions to our patients whom you have seen in clinic and advise they need testosterone. We expect you as the secondary care specialist in this area to manage these prescriptions and continue to issue and monitor their safety in those patients.
We would kindly request that you avoid telling our patients to contact the surgery for the GP to continue the prescriptions for testosterone. Furthermore, any letters we receive requesting this, will be returned with a TCS letter.

I used to be prescribed it but the GP practice has recently stopped it.

AARRGGHHHH!!!

Fucking doctors and their general uselessness over the menopause!

YANBU.

The GP’s response seems fair enough to me. If a specialist wants this drug prescribed, then they should do the prescribing, and all monitoring etc as required and/or prudent.

Shouldn’t GP’s get trained and educated in this treatment that could be needed by a significant chunk of their patients?

'Losing your shit' at your GP is an excellent way to end up with no GP, not to mention it will probably be a minion you are yelling at.

A calm complaint to the Practice Manager will get you much further but it sounds like this is fixed policy.

Yes. 100%.

I'm very lucky that my GP is an expert in women's health, and happily prescribes anything necessary.

This is a fair and valid response from the GP surgery.
If the specialist clinic/consultant recommends it, let them issue it under their specialist area of practice/knowledge.

You wouldn't want to be issued medication the prescriber isn't confident about or aren't familiar with surely?
They are simply asking the specialist service to take responsibility for it as it's their area of practice.

GP here. If an unlicensed medication is commenced by a specialist, it has been reviewed by said specialist and patient is benefitting from it without any problems then there isn't a reason why I wouldn't continue it if got the appropriate letters from clinic etc

Infuriating though this is I’m with the GP. My understanding is that GPs only prescribe testosterone off-licence for loss of libido. I’d be pissed off if some specialist kept sending me letters saying “prescribe this off licence for Ms Olderbutwiser because I think she needs it, despite it actually being your responsibility to make prescribing decisions”.

My gp happily prescribed it for me for loss of libido after my mood changes had been addressed with an increase in my oestrogen dose.

Although I completely understand your frustration do you really want dr prescribing medication they don't feel they have the knowledge to prescribe. Its their signature on it which means it falls back on them if a problem arises. The consultant should be the ones prescribing it if they're the ones that want you on it rather then passing the buck to the gp. Im on medication that is consultant prescribed and it makes absolutely no difference to me who prescribes it I still get it either way. This is between your gp and consultant

Well yes, in an ideal world.

But pop over to the menopause board and see the sheer number of us who are on the bog standard estrogen or estrogen and progesterone and have had the most almighty battle with GPs to take the hot flushes, anxiety, itchiness, sleep disturbance etc etc seriously. (In my case, fobbed off twice with a prescription for antidepressants and once with a prescription for folic acid).

Testosterone is one of those things which is restricted in females and does have side effects. It is not licensed for women and yes, prescribing off-licence means that the GP could be personally liable if anything goes wrong. It is not unreasonable that they say they are not prescribing and that the specialist has to do it.

There needs to be massive re-education of all GPs around menopause but let's start with the very basics please! No point educating them on testosterone when women falling to bits at 47 or 50 are told the GP will not prescribe basic HRT patches or gel.

I think your GP is within their right to refuse, tbh, if they are uncertain about if/how it will help you.
Why doesn’t your gynae prescribe it? They want you to have it, so why pass the prescription responsibility on to someone else?

The GP is right, and it should be the specialist that prescribes it.

Some GPs do take on additional training, but it's not within the remit of general practice, this is a specialist issue.

The specialist is basically offloading their workload to the GP, and the GP is saying they don't have the capacity to prescribe and also do the follow up care.

In an ideal world - but I’m under gynae for the next year (open access) who have requested a testosterone blood test
gynae wait list is now 2 years to be seen. If they’re tied up doing the drugs too, the wait list is going to be even longer for those who need surgery

That is absolutely the correct response from a GP who is unsure of what is being requested. An off licence prescription is at their discretion. The consultant can prescribe if they feel you need it.

Thank you.
That seems to be a very reasonable response.

Nobody expects doctors to be experts on everything. All HCPs are very good and knowledgeable at some things, and less so at others.

If a consultant advises a GP that their patient requires X medication, surely that ought to be prescribed.

The message the OP's surgery is sending out is very unhelpful and obstructive IMO.

But thank you for being a reasonable, helpful GP @Matsukaze

Prescribers only prescribe within limits of their competency. If they don't feel competent, they shouldn't prescribe. They should refer you to (or back to) someone who is/feels competent. They are personally responsible for what they prescribe.

YABVU. Although I do understand your frustration. I would feel the same.

The GP has explained why they are not allowed to prescribe it. You need to get in touch with your consultant.

Is there a financial element of who's budget does it come out of, the GP surgery or the clinic?

It does sound reasonable that if the clinic wants someone to have a drug which is not licensed for use by the GP they should supply it, particularly if the GP then takes on responsibility for it being safe and effective. Can the GP avoid responsibility by just saying they told me to prescribe so I did, I rather doubt that would wash in a court.

That's a very common and not unreasonable approach. It isn't hugely expensive, you can continue to get it from the private provider. Lose your shit and you'll have to add finding a new gp to your jobs list

Not sure why anyone should "lose their shit" at a qualified professional who is behaving in a responsible manner. If they are not confident/familiar/convinced re this medication then they are correct to refuse to prescribe it.

GP - General Practitioner.
Not specialist.
They cannot be specialists in every medical area. That is why there are specialists, that is why there are hospital drugs/off licence drugs.
Don't lose your shit at a GP who has trained for 10 years to help you to a high standard on 99% of things a specialist cannot help you with. Specialists only know the remit they specialised in.Try asking your testosterone specialist to prescribe the drug THEY recommended. Lots of lazy specialists instructing GPs to do something they are neither funded nor qualified to do. Bet your specialist could not help you with an urgent suspected cancer pathway for lung cancer, or treat necrotising fasciitis or tongue cancer or skin lesions.
People really need to understand how bloody amazing GPs are.
Don't get me wrong and dont jump on me, I know there are shoddy ones out there but I work with 8 amazing humans who happen to be GPs.

I went to the GP last week hoping for a discussion about testosterone. She said no, it would need a referral to the Menopause Clinic. I agreed to try the Blissel (sp?) gel in the first instance :(

However, I would love, love, love to lose my shit at the GP receptionist who has to be the nastiest woman I have ever met.

YABU. GP’s policy is reasonable; it’s not within their remit to prescribe an off-license medication or monitor the effects. This might change if the evidence becomes available and NICE guidelines are updated. Could you write to the gynae and ask for the prescription?

Not if the treatment isnt evidence based.