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.

You would be massively unreasonable to “lose your shit” at your GP. That’s never appropriate. There are lots of medications GPs don’t prescribe. You need to understand how much they are responsible for their own prescriptions and the consequences for them if it goes wrong. If you can’t get it through the GP, then you’ll need to keep getting it through whoever prescribed it to you first.

The gp's letter seems fine to me. Their argument seems reasonable.
I guess you need to contact the hospital and ask them what they will do now.

Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy, and musculoskeletal health.

This is correct but they haven’t added that at present the nhs can only prescribe testosterone as HRT for loss of libido. So asking for any other reason won’t be accepted.

The GP argument about not being trained to prescribe hold no water, you have been assessed by a menopause specialist who thinks you may benefit. GPs could never have specialist trading in every medication. That’s why a specialist makes the decision and asks the GP to prescribe and monitor.

If you want to pursue this with your current practice then I would write to the practice manager in the vein that of course you understand that the GP may have not been trained but the gynaecologist has and is recommending it so how best might we move this forward? Within any practice there will be one or two doctors who are more willing and interested.

If they absolutely refuse it might be easiest to go privately or move practice (ask around).

But remember you want it in order to improve your libido, nothing else.

I wouldn't sign my name to something or expect someone else to that didn't feel comfortable doing so.

It's honestly not worth pursuing. The consultant needs to prescribe it for you if they feel it is the right medication.

I was a physio, and would get various requests from doctors that I perform certain procedures that I did not agree with because of the dangers or lack of evidence. I was therefore obliged to not do them.

Had I 'followed instructions', as you want your GP to do, and thus caused harm to the patient, then I would have been held responsible. More so than the requesting doctor, because as a physio, I should have known the problems with the procedure.

Your GP is in the same position, hence the letter.

I know one of my local practices has started doing this as well. Won't take over private prescriptions (for hormonal treatments or for mental health even if very normal) and won't even do shared care with NHS consultants. I don't even know how the latter is lawful.

My DH has eye drops that were originally prescribed by the hospital. According to a lot of people on this thread (and the other local surgery, thankfully not ours) the GP should not prescribe them because they are not eye experts. That seems bonkers to me. I can't see why a GP can't follow the instructions of a specialist unless they actually think it would be actively harmful to the patient, in which case they should contact the said specialist and talk to them and then decide whether to prescribe.

Yes & Sometimes general uselessness in numerous other concerns too💚😥

I think you should have contacted the GP to say why you weren't doing it and to educate them.

Losing your shit is the best way of being without a gp.
They shouldn’t have to tolerate abuse.
Why don’t you lose your shit with your consultant?

Not comparable as Viagra is not an off-licence drug when prescribed for erectile dysfunction.

So a totally different scenario to the OP?

I also guess different areas may have different rules regarding whether it’s the responsibility of the gp or the consultant, or even what the condition is/what oversight is needed might make a difference.

Dh is on steroids for a rare autoimmune disorder, literally 2 in a million people worldwide get it. All his care is at the hospital, regular appts, blood tests, the consultant prescribes the steroids. Which are a licensed/recommended treatment for the condition. But the GP will have never seen it before, he won’t be the best person to manage dh. A friend is on the same steroids for a different condition, much more run of the mill and the same GP prescribes them and oversees care.

Our GP surgery has recently sent a letter to all patients saying something along the lines of medications recommended by hospital specialists need to have the prescription filled by the hospital clinic. I have no idea how the ongoing care works but it seemed to me to be something to do with budgets. And it definitely wasn't limited to women's health.

Take it up with your gynae. Your GP has a procedure in place that you don't agree with. You're not the expert. Why would you want to take a medication with no proven scientific research that it actually helps? If you want it then pay for it yourself via a private gynae.

Funny that. I'm sure women's health will be prioritised similarly as soon as they hear about the menopause and what proportion of people are affected.

My GP wants me to have bloods every six months, but in reality I have to remember to send myself off for bloods every 9-12 months! I don't think they particularly care as I've been on it for 2yrs and my levels have stayed low (though my libido has gone up massively).

I feel for you op, that's absolutely rotten. My consultant (private) wrote to GP to tell them to give me 4xtubes estriol each prescription and my GP was very happy to do so.

My GP was also v happy to give me testosterone off her own back, no consultant involved. It does seem that some GPs are amazing at this stuff. My surgery is all female partners which really helps.

Please don't lose your shit at your GP. They are only working within the guidelines. Campaign for change or ask the specialist to prescribe it if she is so happy for you to try it.

I understand your frustration, and I 100% sympathise with your predicament - you should be able to access the treatment you need as determined by a specialist consultant. However, reading between the lines of that letter, it appears to me to be a massive arse covering exercise RE the prescribing off license. I'm not sure on the dynamics of it, you would think that if a GP was questioned over it, they could refer the 'powers that be' to your consultant's letter, but maybe it doesn't work that way 🤔. The only other thing I can think of is that they are part of a different trust, and don't want to open the floodgates by facilitating these prescriptions because of the cost. Either way it's absolute shite for you - can you get your testosterone from the hospital instead, or go private? (I know you shouldn't have to, but it's an option).

This is nothing to do with your GP not fulfilling their obligations as your Primary doctor. They are actively refusing because they disagree with the prescription. They have stated that there is insufficient evidence to support the drugs use off-label for your symptoms. If your consultant knows otherwise then they will be able to furnish the GP with relevant evidence. Thats all that needs to happen.

I hope to achieve a change in the sexist and regressive blanket policy that my GP practice will not prescribe testosterone to postmenapausal women AGAINST modern medical guidelines, clinical evidence, national trends and current best practice when requested by their specialist. AND has requested that the specialist does not ask them to as per normal practice. I am not throwing my toys out of the pram because they won't prescribe it to me specifically.

I'm still collating my response, but so far the NICE guidelines say 'should consider' the BNF says 'administer under expert advice' 24 out of 42 ICBs say under expert guidance and only one says should not be prescribed. Three practises county wide are obstructive. The rest are on board with this process. Which is the accepted process for providing specialist meds from consultants. There IS now a UK product licensed for women and the British Menopause Society is incompletely quoted. They are wrong and out of date. Which is not in itself an issue - because they are 'unfamiliar' and yet refuse to prescribe in the advice of the specialist who IS. Which is an issue.

If they don't have a single GP (out of twenty or so) competent or willing to become competent to prescribe under expert advice according to NICE and BNF guidelines requested by a consultant when it's clearly a national practice and when they prescribe it for men with no issues, then they need to address their skill set and recruit one. NOT ignore the patient and ask the consultant to stop treating them appropriately. That's not a clinical decision. It's either a personal bias or cultural misogyny. It's not professional and it is not about competence.

I’m with the gp. A gp is legally responsible for any prescription they write and also are under no
obligation to prescribe what a consultation recommends (Nb. It’s a recommendation, not an order). If you want to loose your shit with anyone, loose it with the consultant for not giving you a prescription.

Seems fair. They’ve asked the specialist to prescribe for you because it is outside the GPs competency, that’s safe practice. You are unreasonable to “lose your shit”.

Just read your latest post, have you had any from the consultant at all? Some gps will issue it once it has first been issued by the consultant, but will not issue the first prescription. Is there a shared care arrangement?

Why can't the specialist prescribe it for you?

Is there a particular reason why you can't write to them in a calm way instead of 'losing your shit'?
It looks as if Androfeme was licensed only 2 months ago. Prior to that, testosterone was not licensed for women in the UK. The fact that they prescribe for men is irrelevant and so is your imagined bias against women. You need to calm down and present the facts.

I've had a stroke & my GP won't even look at anything menopause related 🥲