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.

It definitely should be the specialist prescribing it imo - the GP has done nothing wrong. Why isnt the consultant prescribing it??

Exactly. So a practice-wide refusal to prescribe testosterone citing lack of competence, familiarity and lack of evidence through the normal process, for all menopausal women, regardless of clinical history, but who are willing to offer testosterone to even some men, that's discriminatory. If there is genuinely no GP who feels competent out of the twenty or so in the practice, train one. It's not a massive undertaking. If there is evidence, guidelines and a licensed product and they are unaware of them, that's incompetent and if they are disputing current guidelines and evidence or clinical skills of a specialist with no equivalent expertise, that's unprofessional. Especially is it is one senior GP's opinion resulting a blanket decision for the whole practice. (Which I am led to believe is the case)

And how many women have been fobbed off with this? Look at how many women on this thread think the GP is correct. And how many would take the time and have the skills to review the NICE guidelines, MHRA licensing, BNF prescribing guidelines, IBC formularies and clinical evidence? A few might discover you can get Superdrug to prescribe it privately. It's medical misogyny.

If the consultant prescribes it, it means you have to go to the hospital for follow up blood tests and monitoring which need to be done when you are on T, which could otherwise be done with local community blood tests if the GP prescribed. For me, I have to travel to the other side of the borough to get to the hospital so it makes a huge difference.

You can buy it over the counter nowadays.

Yes, you can get Superdrug to prescribe it privately. The doctor who signs the prescription is legally responsible for that prescription, so must be able to justify why he or she prescribed it.

Unless I’ve missed it, why hasn’t the consultant prescribed the medicine? I don’t think you’ve answered this question.

YADNBU the GP is hugely unreasonable. Your consultant has prescribed it and it is the duty of the GP to issue repeat prescriptions. I would be making complaints to the practice manager, CQC and my MP frankly.
We have put up with piss poor service from GP practices for far too long. I would be furious if my practice acted in this manner and would move practices if necessary.

Yabu to say “loose” tbh.

This.

I'm not an expert but there are defo instances where the GP can refuse. However, there is often still a duty of care and this can fall with the specialist. However, IME it can often fall between the cracks if you don't chase them.

For example, I wanted to go back on my ADHD meds having not taken them since my teens and had to be reassessed as per the guidelines. Got referred to an NHS partner through the RTC pathway as NHS waiting time was five years and the partner was two months.

Got a positive assessment and was prescribed the same meds I used to take. However, after the partner had managed the initial three months period as usual, my GP refused shared care. However, they didn't state this outright. They just ignored the letters.

It was a shitshow because my provider had told me that they'd continue prescribing indefinitely at NHS rates if shared care was rejected so I didn't need to worry. However, when I suddenly realised I should've had my prescription dispatch notice a few days prior and was running out, it turned out that the provider hadn't prescribed because they didn't know whether my GP had taken it over and needed this confirmed in writing/email.

This resulted in me going almost a week without and crashing hard as you're not meant to just stop stimulants without tapering off. I was on a work course that week being trained on driving a new heavy plant vehicle and it was horrible. I had really bad brain fog, lethargy, and was driving a 25 ton loading shovel around a quarry having to do dangerous manoeuvres whilst feeling rubbish.

It took both the consultant and myself pestering my surgery for a couple of days before they wrote a proper letter saying they were refusing shared care due to not feeling they had the capacity to manage my treatment. Soon as I had that my consultant took over my care permanently and I must say they've been a thousand times better than the NHS. I can usually get through to the team in under five mins and they're really good and quick at sorting any issues.

I completely agree. It’s their registration on the line if anything goes wrong. The clinic should prescribe it.

It is not the duty of the gp to blindly issue repeat prescriptions. Consultants are not Gods that GPs have to bow down to. They’re all doctors, but have just followed different professional routes. Consultants advise and recommend in their field, but it’s up to the individual GP to decide whether they accept this recommendation.

"Loose my shit at them" does kinda sound like OP is going to storm into the surgery and sling a bag of poo at her doctor. 🤣 Maybe they deserve it!

No it isn’t, especially not when the medication isn’t licensed for this issue.

so say if I’d heard that mounjaro helps with my adhd symptoms and a private dr agreed with me and wrote to my GP to tell them to prescribe it. Should I get it on the nhs prescribed by my GP?

What is not factual?

Of course I am angry at being discriminated against and having to do my GP's job for them. Why shouldn't I be? I shouldn't be rude - and haven't been. Women are allowed to be angry if they at treated poorly, no?

I know Androfeme was only licenced in August. And so does my Gynae. But the GP, who feels they have the right to make withhold this medication for all women in the practice, doesn't. And while the testosterone has only recently been licenced, the NICE guidelines have said doctors should consider prescribing testosterone for HDSS for TEN YEARS. There IS evidence that it is safe. There IS evidence of it's efficacy for HDSS. Meds in general and HRT in particular ARE usually prescribed like this. But one doctor is keeping the entire practice from prescribing it for menopausal women at all, even within the guidelines, even with specialist advice, without knowing the patient's clinical history, because they feel their knowledge is superior, while using the fact that is isn't as a reason not to. When that is out of date now and was wrong before anyway? Which proves my point they are not competent to make the decision.

The fact they prescribe it for men IS relevant. They have said it was unfamiliar. It is not. If there are clinicians who are able to prescribe it for men, it is hardly a great feat of medical skill to review the evidence and guidelines on prescribing for women, is it? I've done it this afternoon. And even if it were never prescribed for men, that is no excuse not to have the skills in the practice to be unable to provide a fairly basic medication half of the population may need if they live long enough to reach menopause. Medical misogyny is not imagined. And women are absolutely entitled to be angry about it.

This is true, but it's also open to abuse. My mate's GP apparently told him that in an ideal world everybody would be treated but they had to consider costs. This was for about £20 of testosterone a month and a yearly blood panel. For a 35yo who hadn't been able to have sex in seven years and had hoped to one day have a family.

Can't you get it privately?

You still haven’t answered why the consultant hasn’t prescribed it?

I don't think it helps to make it a battle of the sexes though, OP.

Men have a tough time getting prescribed steroids too. Specifically because of the negative stereotypes associated with men abusing anabolics. If a man who looks like he lifts weights/has a rugby physique asks his GP to test for low testosterone/enquires about TRT, he'll often be given the third degree and treated with suspicion. Probably even more so by male doctors.

This was defo the case with my ex training partner who is a pretty muscular guy. The doctor actually commented that he'd be surprised if he had low testosterone going by how strong a beard he had and by his physique.

Didn't ask any questions about whether he'd ever had a head or groin injury etc, or if he'd ever taken anabolic steroids. When he saw the private doctor the first thing they did was test his pituitary gland and look for symptoms of a thyroid problem etc.

But it sounds like the clinic (consultant) have prescribed it in this case and asked the GP to continue to issue scripts. This is commonplace. My psychiatrist has prescribed me Lithium which requires an alert card and careful monitoring. She has also requested that the GP continue to prescribe and manage it accordingly with blood tests etc

OP - Why aren't you angry at the specialist who wont prescribe it?

Also, I have 1 GP who can prescribe - but our practice policy is NOT to prescribe as 1 GP is not enough. What happens when they are off sick or on annual leave?

We have a policy that is equitable. It is not misogynistic to not prescribe off licence. We also do not prescribe and monitor ADHD meds or transgender meds as we are not experts in these areas. Not sure why some think this is misogyny or discrimination - its equitable treatment.

Also, please think about all the people saying, "but what about me..." if a GP practice did all of secondary care work when would we actually see patients we are contracted to see?

We cannot do hospital and GP work but we still have this pressure and posts like this show a deep misunderstanding of what your GP is actually paid to do.

Be angry at your consultant who CAN and should prescribe it - not your GP.

Most GP practices are funded to do this as part of a Local Enhances Service for medicines management, which is why you are prescribed and monitored by your GP and there is a formal shared care agreement in place which is criteria based.

Is that shared care between the local nhs hospital and gp? Or does it also stand for any private drs someone may have seen? I don’t think the OP has said but I wonder if the gynaecologist is private?

Because that's not (as most people are assuming) normal practice. My schedule two controlled drugs were initially given by the hospital, but once I was stable, they wrote to the GP with the dose and the GP prescribes from then on. The consultant reviews annually, usually after anything like bloods or obs are done but the GP. That means if different consultants are prescribing a myriad of things one doctor holds all the information. And you can't say, get two lots of controlled drugs from an NHS and a private consultant. Or two scripts a month. A GP is NOT expected to be competent to prescribe all meds from scratch, but to oversee them between consultant reviews. They are generalists. They keep a broad eye on how much you are taking and how often, monitor side effects as indicated by the consultant, and flag any glaringly obvious (to a doctor) drug interactions. No one would be able to sue a GP for prescribing in the community something as directed by the consultant. The GP would rightly point out they were acting as local provider and within the expertise as directed by the consultant, unless it were something really obvious that 99 percent of GPs would know, or they varied the dose or prescribed something that interfered with it and didn't check. They do this all the time with unfamiliar and off label drugs. so why single out with testosterone specifically for menopausal women only? Against NICE guidelines. Against BNF guidance. Against BMS information. Which they include in an incomplete and misleading manner. And are only one of three practices in the county that refuse?

Hello, you can ask for your gynaecologist to give you a private prescription. Short term solution whilst you work it out with the GP.

I have a private allergy doctor in London & GP practice didn’t get it re: off licence meds. Even with the letters from my consultant. I pay privately cuz it’s not worth the hassle & it’s online so a company send me the meds by post. But you can collect a private prescription at your local pharmacy.

mines not forever though, for a year or so.

Hi there, gp here. I’ve seen some horrible, irreversible side effects from testosterone. So I’m very very cautious about prescribing it. And it’s my name on the paperwork, so it’s me that’d end up in court if it all goes wrong. This is the case for anything I prescribe, even if it’s on other medical advice.

also. We are consultants in general practice (we all hold a CCT qualification) and are expert generalists. Lots of us do have special interest in women’s health & will want to support you. But we will have had experiences which frame how we work.

Honestly, if you don’t like your GP surgery’s policy, maybe look to register elsewhere?

I was cross with them, but unfortunately being cross doesn’t get you the vaccine. Paying for it privately was the only option.