Can the GP refuse to prescribe HRT?

[thedayismine]

My Dsis has been having awful menopause symptoms for a few years now - low energy , hot flushes , aching joints , brain fog ,disrupted sleep etc - we also have osteoporosis in the family.
She saw a GP and was advised it wasn't suitable as she smokes and was overweight.
She has lost some weight but still hasnt been back as she feels she will just be sent away again as she is still overweight and still smoking.
As she says though the symptoms themselves make exercise and other positive action harder as everything is a slog!

Where does she stand - can she insist on giving HRT a go if it's not specifically contraindicated ( and she is aware of the risks ) or is she right in thinking she will be sent away again ?

Of course a GP can refuse to prescribe something on medical grounds. There are a number of reasons why HRT might be contraindicated. BUT I'd be back to GP and asking for advice from consultant about why in her particular case they say no. GP can ask for this by email and you do not need to use up a hospital appointment for something 'trivial'.

If I were her, I would educate myself as much as possible before the next appointment. This is a great place to start.

HRT is really the business. Good luck.

Yes. 'Cos being overweight and still smoking make it risky.

Jay maybe read the thread? You don't seem to have picked up the points about smoking/ weight and HRT risks.

Actually if she starts doing a decent amount of exercise she might not need HRT. It’s not the menopause that’s making exercise hard, it’s being fat and smoking. Exercise and weight loss will improve menopausal symptoms.
Good on the GP for resisting.

According WHI research that is not trustworthy anymore, the slimmer women on hrt are in increase risk for breast cancer! I don’t know how researchers can interpret this paradox result...just a comment about how unrialable can be a research!

When you suffer from insomnia, brain fog and body aches exercise is impossible! Body fat makes the symptoms less severe cause estrogen stores at fat cells and it helps body to find estrogen. The slimmer and younger women in meno suffer from estrogen crush, that means that their body lose almost immediately the estrogen it has with severe consequences at their health.

Actually if she starts doing a decent amount of exercise she might not need HRT. It’s not the menopause that’s making exercise hard, it’s being fat and smoking. Exercise and weight loss will improve menopausal symptoms. Good on the GP for resisting.

Good grief! Only people who don't understand menopause or HRT would offer judgy comments like this.
Have a logged into the Daily Mail by mistake

Could you tell me how I had bad symptoms with a BMI of 19, an extremely healthy diet, no booze, hardly any sugar, walking 3 miles 5 days a week?

Exercise can help but it doesn't replace estogen.

PollyPerky,
That is not to say slender women don’t have a menopause but obesity exacerbates symptoms.
No use going “There, there” when actually there is a cheaper, safer solution that doesn’t involve drugs. It would be negligent of a GP not to,discuss excess weight and impact on menopausal symptoms.

www.sciencedirect.com/science/article/pii/S1521693414002582

I think you are mistaken.
For the record, fatter women can have fewer symptoms- they may be unfit but fat cells produce estrogen. That is why overweight women have a higher risk of breast cancer.

You are also mistaken about saying that there are 'safer' solutions. HRT has many many heath benefits, including reduced cardiovascular disease, reduced bowel cancer, stronger bones, less dementia...I could go on.

The risks of HRT are minute for most women.

A good dr would have prescribed HRT so that his patient felt better and this would enable her to take a more proactive and positive approach to her lifestyle factors like being overweight and smoking. If you feel crap all day, every day, you are not going to be motivated to tackle weight gain and an addictive habit.

Wow thanks for all the replies I don't think I realised how contentious this topic might be!
Dsis has lost over two stone and we try to swim when we can but she does struggle to be more active in other ways .
I guess I can see both perspectives here but I just would like her to get some help .
The Last GP definitely just made her feel bad about herself and a bit hopeless !
I think she should at least go back for another conversation.

I don't really go there on the smoking - can't see her giving up anytime soon !

Polly Perky I think your last paragraph is what I feel would be an ideal approach

There are as many research papers showing fatter women have fewer peri symptoms than slimmer women. for example

www.medscape.com/viewarticle/749030

Graphista she doesn't have any contraindications for HRT. Have you not read the thread? It's not that hard to understand Smoking and being overweight are not contraindications.

OP what I would say is that unless she stops smoking, doing anything to make herself feel better is a waste of time. She has to at least try to give up. Smoking is the No 1 worst thing anyone can do for their health. HRT will be a sticking plaster. She may feel a bit better but longer term she will get ill.

Thanks Polly for the understanding and advice. I just want her to have the best treatment she can.
Totally understand the comments about what is in her control and the smoking.
To be honest this has given me a bit of a nudge asi don't always manage the healthiest choices and this will all be happening to me soon

This link's good on exercises for prevention of osteoporosis

www.nhs.uk/conditions/osteoporosis/prevention/

The problem with relying on HRT is that the benefits are gone as soon as you stop taking it - most women won't be taking HRT when they are older and in need of bone protection.

this again from the NHS:

HRT can help to maintain bone density and reduce the risk of osteoporosis.

However, it's not recommended as a way to maintain bone strength for most women around the menopause.

One reason is that the beneficial effects of HRT on your bones wear off when you stop taking it (usually before the age of 60). So your bones won't have protection when you're older, which is when they really need it.

HRT also carries some risks, including a slightly higher risk of stroke. This means it's not suitable as a bone treatment in older women, whose risk of stroke is already higher.

Paris What you posted it not correct. If it's NHS stuff it's out of date.

The problem with relying on HRT is that the benefits are gone as soon as you stop taking it - most women won't be taking HRT when they are older and in need of bone protection

NICE guidelines- there is no time limit on use of HRT You can take it till the day you die. ALSO there is new research that shows bone protection may last much longer. If your bones are improved and are normal with HRT it doesn't suddenly decrease. You will still have more bone than if you hadn't used HRT.

this again from the NHS:

HRT can help to maintain bone density and reduce the risk of osteoporosis.However, it's not recommended as a way to maintain bone strength for most women around the menopause.

Yes it can be for women who have menopausal symptoms AS WELL.

One reason is that the beneficial effects of HRT on your bones wear off when you stop taking it (usually before the age of 60). So your bones won't have protection when you're older, which is when they really need it.

If this is from the NHS site it is old information. If it's your opinion, it's not right. You can use HRT forever.

HRT also carries some risks, including a slightly higher risk of stroke. This means it's not suitable as a bone treatment in older women, whose risk of stroke is already higher

Between ages 50-60 benefits outweigh risks.
60-70 benefits and risks are equal
Over 70 for some women there may be a risk. The risk of stroke applies only to pills not transdermal estrogen.

The NHS link isn't out of date, it was updated last summer.

Their point that most women won't be taking HRT when they need bone protection is perfectly true, regardless of whether they would be allowed to or not.

Could you give links on protection lasting longer? This would surely mean that women not taking HRT would be protected past the date of their menopause too, from their natural oestregen? Would be interested in reading this.

As for benefits and risks - this varies very much depending on individual circumstances and isn't just down to age. Women should be talking to health professionals about that balance. For me at age 50, risks would outweigh benefits because of my particular circumstances. There is no one size fits all.

Lots of information on the NHS website is out of date because they haven't embraced new research. One prime example is their advice to people at risk of diabetes: several diabetes charities and experts have criticised NHS dietary advice which is outdated now re. fat in diet as opposed to limiting carbs.

This would surely mean that women not taking HRT would be protected past the date of their menopause too, from their natural oestregen?

You don't have any after the menopause (or only the minutest amount - hence osteoporosis occurs post menopause.)

In terms of research yes, here is a link which I hope is helpful.

www.thebonejournal.com/article/S8756-3282(03)00479-4/abstract

Post menopause, women lose up to 5% of their bone each year rapidly for 5 years then the loss slows down a little.

It used to be thought that the rate of bone loss after using HRT was the same- a rapid fall. The link shows otherwise.

The other point is that for someone who has osteopenia and uses HRT for maybe 5 years, her bones are going to be better for some time compared to if she'd not used it. It can keep someone in the osteopenia range rather than the full osteoporosis range for longer and give them a window to build bone through exercise and diet at the same time.

There are also some consultants who prescribe tiny doses of estrogen 0.25mgs - to prevent osteoporosis as shown in this paper by Panay.

nickpanay.com/Papers%20pdf/Low%20Dose%20HRT%206th%20IMS%20Workshop.pdf

He says that there is even no need with ultra low doses for progestogens (which are shown to possibly increase breast cancer.)

if you are one of the very, very few women who have special risks, then you must do what your consultant advises. For women who do not have special risks this is what consultant Dr Currie shows on her website.

menopausematters.co.uk/balance.php

Hi folks. We've had a few reports from Mumsnetters concerned about this thread so just wanted to pop by to say that while we're daily amazed by some of the excellent advice and support offered on Mumsnet, we do just like to remind people that experience is one thing but there's no substitute for advice (or a second opinion in this case) from a qualified doctor, and that we can't check the qualifications of anyone posting on Mumsnet. Thanks!

Polly, you misunderstand me. If you say that taking HRT provides bone protection for longer than you take it, then your natural oestregen which you have before menopause should give protection afterwards.

Going to stop here because I'm taking on HebeMumsenet's comments - none of us are experts on anything other than our own health, and we can all only do what's best for us, in partnership with health professionals.

If no-one took any notice of anything said on here (and other forums) we might as well all pack up and go home and close down all forums.

I am amazed that Mumsnetters would express concern about a normal thread about menopause and osteoporosis. Anything that is evidence based that helps to shed light on this important topic is immensely helpful to many ladies.

Absolute contra-indications to HRT are given here:

www.menopausematters.co.uk/contraindications.php

• Pregnancy
• Undiagnosed abnormal vaginal bleeding
• Active or recent blood clot or myocardial infarction (heart attack)
• Suspected or active breast or endometrial (womb) cancer
• Active liver disease with abnormal liver function tests
• Porphyria cutanea tarda

There are other conditions for which taking HRT might involve increased risk of some adverse health condition but these are to be discussed with your doctor who knows your particular medical history. However the general principles of age-related risks that Pollyperky referred to are listed here www.menopausematters.co.uk/balance.php and of course are not intended to be one-size fits all. It goes without saying that there are general broadly applied priniciples and refer to ladies who are otherwise healthy.