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.

This ^

As a retired NHS manager I'm a bit concerned that the hospital specialist would try to pass responsibility for issuing the scrip onto the patient's GP rather than do it themself.

I'd say the fault here lies with the specialist and not the OP's GP.

@Peoplecoveredinfish shouldn't be losing their shit with their GP, but with the specialist.

However, they might find the quickest way to resolve this is to ask the GP surgery's practice manager for assistance. Although it's not the GP's fault the surgery might be able to get the specialist to issue a scrip quicker than the OP herself can.

I had mine prescribed privately for the first 2 prescriptions, then after a second blood test, the menopause clinic suggested I ask my surgery to take over the prescribing, as it does cost a lot privately. Luckily, my NHS surgery have a menopause expert and she was happy to prescribe from then on. I have a yearly blood test, and it has massively helped with libido.

I had this issue - the gynae insisting the gp could continue the prescription and the gp saying they couldn't for menopause

In the end, The gynae diagnosed me with Hypoactive sexual desire disorder, and that seemed to be the magic label to allow the gp to prescribe it under the local guidelines.

It made me furious, as if I said I was trans it seemed much easier to get hold of it.

I think you are being unreasonable- I do not want my GP prescribing something that is not in their sphere of competence, this is quite specialist stuff and actually many GP’s won’t prescribe it, alongside a list of other medications some adhd drugs, anti-psychotics, chemotherapy medications etc - these are all consultant and specialist led prescriptions- which once someone is settled on the drug can often be transferred over to the GP.

GPs cannot be specialists in everything- it’s in the title ‘General’ Practitioner.

Annoying, but it’s not expensive to get privately, I think it would cost roughly £90 a year (2x tostran canisters) plus a consultation.

However, there needs to be a wider discussion about licensing testosterone for women. The current product for men, tostran, would be perfect if it was one pump per day instead of one every second day so really just need a half strength version.

The whole thing is just bloody frustrating so I feel your pain. I've lost count of the number of face to face, telephone and other interactions I've had with numerous GPs over the last year or so. I got so unwell at one point that I was suicidal and my marriage nearly ended. I finally managed to talk to a more clued up GP (totally pot luck also a relief) who started me on Estradiol gel and progesterone. I later asked for testosterone to be added, citing the many benefits and was told they'd only prescribe it for lack of libido. Funnily enough my libido waned shortly after.

You would be unreasonable to lose your shit.

You would not be unreasonable to go to your GP about your HSDD, if that should happen to be one of your menopause symptoms though...

OP would you be happy for a GP to remove your appendix if you needed it doing? Or perform a coronary artery bypass?

If your job involved driving a car, would you be happy to have a go at driving a bus with people in it?

Your GP’s letter is perfectly reasonable. In the past 20 years, more and more work that was traditionally done by hospital doctors has been pushed into general practice. GPs have accepted this additional workload and responsibility, if they feel clinically competent to do so. But they have to draw the line somewhere. GPs can’t be expected to take clinical responsibility for treatments that they are not licensed to prescribe.

In a few years time testosterone will probably have been used enough for the risks and benefits to be established, and it will be licensed for GPs to prescribe. But until then, it should be prescribed by doctors who have the expertise to defend their actions. GPs don’t have that expertise, as they’re generalists.

I’ll also say - I knew about the need for a HSDD diagnosis to get TRT on the NHS. Although I wanted TRT for many reasons including mood it was lack of libido that I presented as main symptom to the BUPA menopause specialist, and as a result the only symptom that went onto his letter to the GP.

The issue is the lack of studies into testosterone for women. Why hasn't this been done? Because why spend money on a study to help old, pointless women, that's why.

I'm on testosterone and for me it has been amazing. I was unable to have an orgasm before I started taking it. So that part of my life would be over without this drug. It has also increased my energy and drive ( but this part is in my head apparently, it doesn't work for that)

I hope it's working out for you?! I think I'm finally on the right combo and I feel like a new woman. Full of energy, thinking much more clearly and I actually want to have sex again.

Its not fair for women to be caught between this sort of admin battle. Its really distressing when you are just trying to get your symptoms dealt with.

A male friend of mine is prescribed testosterone after having tested with levels in the 85-100yo bracket in his mid 30s. The NHS are really really cagey about prescribing it for some reason, even to men whose levels are far below the cutoff used by industry associations like the British Society for Sexual Medicine.

He had to go private (used a guy that is a nationally regarded expert and also an NHS consultant). Guy wrote to his GP and the surgery weren't having it one bit. His GP said "every man feels better on testerone". Wouldn't address the issues of no sex drive, lack of energy/apathy, and the fact his levels were those of somebody 50-65 years his senior. My mate hadn't had sex in about seven years despite being slim and otherwise healthy.

He eventually managed get prescribed it through the NHS from the niece of his childhood GP after moving home for a few months while buying a house. Ironically, he said this woman was far less dismissive than the three male GPs he'd seen. However, upon moving back to the city his original GP tried to take him off it. He just refused and said he'd continue administering himself if need be and they'd still have a duty of care to monitor his bloods etc, at which point they grudgingly relented.

Their level of treatment is an absolute joke. Obv private care is usually the gold standard, but the NHS are decades behind here. They still recommend three week intervals between shots rather than weekly, or even twice weekly, which gives massive peaks and troughs compared to the latter. You have high blood pressure at the start and are way deficient by the end.

And they don't even check estrogen which is one of the key hormones that can become elevated on TRT and cause erectile dysfunction etc. My mate has to pay for his own blood tests and buy Anastrozole. I don't know what it is about testosterone. Whether it's the stigma from anabolic steroids misuse or just that they're scared of opening the floodgates (in America testosterone prescriptions have risen by something crazy like 400% over the last decade or so I think it was).

British Society for Sexual Medicine says that a young person with levels under 12 nmol should be considered for a trial of TRT but most GPs won't even look at you unless you're below 8 nmol. Meanwhile, a 'good' level for a 45yo bloke is 21 nmol.

I know this discussion is about women but I think across the board there is a weird stigma to prescribing testosterone. Unless you want to take it for gender reassignment reasons. My mate's private doc said a young woman wanting to change sex would be more likely to get a prescription than a deficient male.

£90 if you're careful where you take your private prescription. I was careless and went to Boots where I was charged over £76 for a canister.
And that's on top of the £145 fee to see a private menopause consultant in the first place.
What really annoys me if that my DH could have the very same medication prescribed online and at a fraction of the cost. Just a quick survey and they'll pop a can of Tostran in the post. It encourages dodgy behaviour

Misogyny is rife

Yes. Totally unfair that men can get it online without the prescription cost.

They all feel confident prescribing viagra though, don't they?

You lost it with the wrong person, the specialist should have prescribed and be
monitoring you.

And if the GP doesn't feel comfortable prescribing it he should refer it to an endocrinologist. Although certainly for men urologist often seem to be a better bet. My mate's private GP said that endos were often the most obstructive and that many have zero experience in treating hormone deficiencies as they usually tend to specialise in diabetes.

The guy that was being dismissive towards my friend had a specialism in metabolic medicine and didn't seem very up to date on TRT at all.

Is this actually true?

Yes, it's easy to buy off the black market. That's what bodybuilders do. But anybody can order it that way. Usually you need to go to a TRT clinic and they charge big £££. Most men use injections as gel often doesn't get absorbed well into the thicker skin of middle aged men.

Gel also carries a significant risk of transferral to your partner and possibly children as it rubs off on clothing and bedsheets etc. Much better to do a weekly injection. For example, you need to shower before applying the gel and it needs to be on your skin for something like eight hours.

So if you want to go to gym before work or do sports on the weekend you either need to wait eight hours or go before applying which would mean training with low energy as it will have worn off by the morning and you'll have almost zero testosterone as natural production shuts down over time when on TRT due to the feedback loop. If you sweat it will ruin the absorption.

@Bulbsbulbsbulbs it took a long time. When viagra was first invented it was only for a very limited number of people with very specific medical conditions. But it’s been around for decades now, and its safety is long established.

What are you implying in your comment? Are you aware that a lot of GPs are women?

Do they?

YANBU. GPS frequently issue prescriptions for medication originally prescribed by specialists, and which they are not necessarily familiar with. Eg Parkinson’s, types of dementia. This sounds to me like a commissioning wrangle - it’s not in the GP contract to monitor this and it’s become common enough that they are pushing back

Yes - if they have low testosterone, at many online pharmacies. Just the gel. Bodybuilders are using higher doses injectables.

I reckon it's less misogyny and more 'Pay for it from your budget, not ours'.

In either case, though, losing your shit at the GP isn't going to be remotely productive in any shape or form.

I think a lot of people on this thread don’t understand how prescribing works. The clinician who signs the prescription takes ultimate clinical responsibility for any adverse outcomes.

I’ve been a GP for nearly 30 years, so I’ve seen a huge number of new drugs and treatments appear, and also seen many changes in the way medical care is delivered.

I want my patients to get better, and I want to be able to help them. But I also don’t want to face a disciplinary hearing, or face judgement by the GMC. I have a family to support, and I don’t want to lose my job. So, like most people at work, I follow the rules. And if I know I’m not qualified or licensed to undertake a particular form of treatment, I’m not going to do it. That’s not me being difficult or obstructive. It’s just working within the parameters of my knowledge and expertise. It saddens me to think that people want to “lose their shit” with me, just because I’m doing my job.