Please help me with my GP, she's not listening

[GlomOfNit]

I'm 46 and have had odd symptoms that could be related to perimenopause for about 3 years now. Mostly things have come on gradually, to the extent that now when I look at a checklist on a website entitled something like 'could you be in perimenopause?' I can tick most of them.

I know it's a tedious litany but I'll list the ones I can think of here:

-cycle length shortening and no longer predictable and regular (after childbirth, it was as if I was reset to factory settings and my painful, often long cycles set to 28 days and very little pain). I can have anything between 33 days and 18 (those are both outliers though) but it's mostly around 23-27 days.

-Sore breasts at the sides and some cycles at the nipples, reminiscent of first trimester breast pain. Sometimes really bad. I'll get a cluster of 'bad breast' cycle and then for a few months won't get this at all.

-Pain at hip tips, quite acute. Sometimes this is the whole bloody cycle, sometimes it's worse from ovulation to end of cycle.

-General pelvic discomfort and pains, mostly from ovulation to end of cycle.

-night sweats. Not aware of daytime hot flushes as such but I'll wake in the middle of the night and have to change my PJs sometimes.

-depression and anxiety. While I think I've always been inclined this way, it's much more pronounced now. Seeing a sort of counsellor occasionally about this.

-fatigue

-weight gain in new places - the 'apple' pattern, dammit. Also thighs.

-DEATH OF LIBIDO (which was never great but it's as if I'm dead from waist down. Only on anti-depressants have I ever experienced this)

-I think my armpit sweat smells worse and stronger, and even Mitchum doesn't really work. By morning I smell like a goat. And recently I think my vulva is smelly too.

-itchy skin and vulva.

-heartbeat irregularities (I've had a couple of ECGs and an 'event monitor' and they said, yes, ectopic heartbeats, nothing to worry about. Still get them ALL the time, it bothers and worries me)

-spotting mid-cycle. Had already had the odd smear at ovulation which is normal, but in the last 4 cycles I've had two that weren't really proper cycles - they were short (21 and 18 days) and once my proper period had stopped I then had on-and-off bright red smearing in vaginal canal. Not enough to come onto pants but definitely enough to look dramatic on loo paper if I wiped up there. Smelt 'old' though was fresh red and came with lots of mucus. Ended both times with 'proper' period - slight cramps, enough to fill my mooncup etc.

I know this last one is alarming (it alarms me!) but the GP who saw me said it's probably stress, let's wait out the next two cycles and see if it's persistent, and if it is, you'll need to have a hysteroscopy. So I did - I had two clear cycles after the first one, and then it happened again last cycle. :-( That was the 18 day one, which ended on Boxing Day. What I want to know is, how usual is this sort of mid-cycle bleeding in a woman of my age displaying all the other stuff?

Sorry, I know this is tedious!

So. I've taken my symptoms to GPs frequently over last 3 years. They are getting increasingly irritated by me. They seem to think all I want is HRT - what I want is to be taken seriously and maybe referred to a local, very good menopause clinic at local city hospital.

My main GP is dead-set against HRT. She also dislikes me talking about being 'perimenopausal' and has said very firmly, in manner of admonishing small wayward child, 'Glom, you are NOT in perimenopause. I would only regard you as being in that if you had a) very irregular or missed periods, b) hot flushes and c) dry vagina'

I've since extrapolated from this that she based her criteria on the NICE guidelines for prescribing HRT (or am I barking up the wrong tree?). But as far as I know there is no NHS-used definition of perimenopause that has to tick those three particular boxes and that's been verified by a friend who's a GP. Could anyone confirm this, please?

I was also told by a more sympathetic GP that in a few years' time I might be prescribed HRT but not yet, because I'd only be 'allowed' to take it for five years and if we started too soon, I might have to come off it before I 'really needed it'...

Anyway, having had another cycle where I mostly bled, I need to see the GP AGAIN. I'm not massively keen on having a surgical procedure but I'm also shitting myself about cancers. The other thing that's worrying me is that I often have the sensation of a Thing in lower pelvic area, like something is caught or tugging at me, and pain (intermittent twinges not agony) in that area. Currently have this in lower right ovary area. I've seen a (male) GP with this in the last 2 months and he had a quick palpate and said he can't feel anything, it's probably normal and I'm just stressing, and that if it were a cyst it would probably have gone by the time I got scanned. (to add, I've had a clear smear test within the last year or so, and a blood test a year back for something or other didn't show up inflammatory markers associated with cancers.)

I do have health anxiety, I always have done. The GPs know this and I feel that when I go in with any of these symptoms, they treat my anxiety and not what I'm reporting. I'm pretty much at the end of my tether here.

I'm sorry, I'm not really sure what I'm asking here. I need to see GP again about the most recent cycle of bleeding, and again about the pain/feeling in my lower right pelvis. I want to be taken seriously. I'd like a referral to this clinic at the hospital, I suppose, but I'm entirely expecting them to say no because I'm not ticking their boxes.

@JinglingHellsBells
I'm not a GP I am a oncologist with a special interest in hormone dependant cancers.
You are obviously very knowledgeable about HRT my points on this thread are there to highlight how complex the situation is and there is not one size fits all in HRT.
It is untrue that conjugated equine estrogen makes are the only HRT that can cause or worsen exsisting hypertension .They are however the only ones contraindicated in clinical guidelines .The most commonly used estrogen is called estradiol 17 B which is the predominant estrogen variant in premenopausal non pregnant women .It is linked to hypertension in chronic exposure by mechanism of superoxide production.

Oops posted too soon
There is an article by the American physiological society published in 2011 on this and many more subsequent can't link as I'm on my phone .
In most cases there is no issue with extended family BC but in some genetic mutations a patient is known to or likely to have ,the use of HRT vastly increases the chances of activating these mutations.Therefore second degree relatives are relevant in the prescribing of HRT in some women's cases .
Again migraine with aura increases the baseline risk of stroke ,HRT increases baseline risk of migraine with aura ,and HRT increases baseline risk of stroke therefore there is risk .Risk where it may be outweighed by benefit but none the less risk .
I do think there is a reluctance among clinicians to prescribe HRT in the uk and you shouldn't be refused without a valid reason.However occasionally there are valid concerns.

Again migraine with aura increases the baseline risk of stroke ,HRT increases baseline risk of migraine with aura ,and HRT increases baseline risk of stroke therefore there is risk .Risk where it may be outweighed by benefit but none the less risk .

That’s actually really helpful, @Thismeanswarfarin. Thank you.

@Thismeanswarfarin I accept your comments on genetics and breast cancer, but your comments on migraine are at odds with what the Migraine Trust says, and also UK top meno specialists (I'm a health journo and interview the top meno consultants for articles) as well as having personal HRT experience with them.

I have migraine myself and it's never ever been discussed and I do not for one minute think this is an oversight by my consultant who is one of the most renowned in the UK and trains other medics.
Transdermal estrogen is not associated with blood clots or migraine.

This is from the MT website

What are the risks of HRT for women with migraine?
There is no research based evidence to suggest that women who have migraine and are using HRT have an increased risk of having a stroke (ischemic CVA).

Now I’m confused again.

@JinglingHellsBells I apologise as I have been vague in my first post and should have specified that it is migraine with aura that increases stroke risk .Migraine without aura is not associated with this . I believe migraine with aura accounts for about 25% of migraines .

www.ncbi.nlm.nih.gov/pmc/articles/PMC4540227/

So in migraine with aura where estrogen is a trigger for said migraine this increases risk of stroke.So therefore it stands to reason that HRT would increase the risk of stroke in that cohort .
However they have been no studies to date directly studying the stroke risk in patients with migraine on HRT.I believe many clinicians are cautious in this cohort as in theory risk is increased even without data .
As for migraine in general I agree that a full clinical picture has not yet been developed .The most recent systematic review I came across in the IJWH suggests that migraine triggers in women are predominantly hormonal .It concluded the effect of HRT on migraine is unpredictable and may worsen migraine in some women and some may be left unaffected .

I think it is often forgotten that “no evidence of risk” is not the same as “evidence of no risk”.

There are very many situations in which there is a theoretical risk, but well-designed studies to evaluate the clinical significance just haven’t been done (or for various reasons, can’t be done).

Those are useful posts, Thismeanswarfarain. Thank you.

OP I have been on HRT for over 30 years. My consultant is one of the top specialists in the country and is one of the authors of the "NICE guidelines on the menopause".
Please Google this phrase, read and re-read the guidelines until you can almost recite it by heart. Print out a copy, then, once you really know your stuff, make an appointment with your GP.
The NICE guidelines are the NHS up to date recommendations to medical professionals on "best practice" . Clearly your GP has not been keeping up to date on advances in the treatment of the menopause.

I have advised many women to do just this. Once you offer her a copy, (one friend delivered a copy addressed to her GP when booking her appointment stating in an attached note that her appointment was to discuss the guidelines) most GPs accept that they are not up to date but if she still won't budge then ask for a referral to a menopause clinic.
Under no circumstances accept pills. There are numerous transdermal options - patches, gels, implants etc.- all of which are effective at much, much, lower doses than pills which have to be stronger to survive the first pass through the liver.
HRT is a replacement of the hormones your body produces naturally but have now been used up. Nobody suggests to a diabetic that because their body no longer produces insulin they should tough it out.

HRT is life changing and I am on it for the rest of my life. I do so hope your doctor ups her game or you get a new one. Good luck.

I believe you can self refer to nick panay’s clinic at Chelsea and Westminster.

The whole issue of breast cancer and HRT is still very controversial especially as regards which women can or cannot have it . And even whether it causes BC or not.

There is no controversy over HRT & migraine and the advice of the Migraine Trust is surely not one to challenge?

@Thismeanswarfarin I wonder if you've come across the work of oncologists Avrum Bluming and our own lovely Prof Michael Baum and their opinions on it all?

Bluming does not believe that HRT 'causes' BC and both his wife and daughter who had BC are now on HRT.

Likewise, Baum was interviewed recently on TV discussing HRT and says his daughter uses it, in spite of his mother and his sister having had BC.

Current thinking in the UK is that HRT may not cause BC at all but promote an existing cancer to develop faster than it would have otherwise. (This is discussed on the website Menopause Matters by Dr Currie.)

I agree it's helpful to have a discussion on this but at the same time it's important to cover both sides of the 'argument' (for want of a better term) . Many meno specialists are more concerned about quality of life for women.

Nick Panay in an interview available on the Liz Earle website says 'longevity of life means nothing without quality'.

@Thisiswarfarin The link you left does not reach the same conclusion as you posted. It mentions that more women than men have migraine (so we assume there could be a hormonal link) but it does not say that this is specifically caused by estrogen. Many women's headaches are triggered by the reduction of estrogen at the end of a monthly cycle not the surge around ovulation.

This, is exactly what my consultant says, and it's certainly not a reason to deprive women of HRT.

.It concluded the effect of HRT on migraine is unpredictable and may worsen migraine in some women and some may be left unaffected .

I appreciate you are an oncologist but your comments on HRT are not in line with current thinking of most meno specialists.

You said there were many common conditions that would prevent a woman having HRT. There aren't - some may represent a cautious approach and use of transdermal HRT, but the true no-no conditions can be counted on one hand.

I believe you can self refer to nick panay’s clinic at Chelsea and Westminster

Not sure about that @Doryhunky. You may be right but last time I looked for someone (it's all online- just google C&W menopause clinic and read 'referrals') it needed a GP letter.

That bloke Michael Baum is happy to be a maverick.
He feels that DCIS should not be treated as pre-cancer, that routine mammograms do more harm than good, and that women self examining their breasts is a waste of time --they shouldn't be encouraged to do it.

Thisiswasfarin, I think that there are a lot of factors that can trigger or activate genetic mutations, as alcohol, stress, psychological trauma, obesity, even pregnancy!
We just don’t know for sure if hrt is more or less dangerous!
As for migraines, I always have migraines and they worsen when my body need estrogen.
My gyn doesn’t think that having migraines is a contradiction for taking hrt. The opposite actually, that taking estrogen is helpful.

That bloke Michael Baum is happy to be a maverick.

LOL!

Maverick or genius?

Have you read anything about him and his work? He's a professor and one of the UK's top breast oncologists.

DCSIS- in 50% of women it never becomes cancer. Women who are treated for it through chemo often die/ become ill from chemo or radiation which can damage heart and lungs.

Mammograms- across the population there are no better survival rates with mass screening than not (though it's personal choice is you want to have or not have screening.)

Self examination- his comments are now in line with NHS advice. That is to be breast aware, not be obsessive about prodding your breasts.

If migraine is possibly linked to stroke risk (possibly) then hrt ought to help.

All the research shows that using some types of estrogen keeps the arteries flexible and reduces the build up of plaque by 50%.

Surely this is a good thing?

This could be useful, alongside the NICE guidelines @GlomOfNit

Once on HRT, my fastest-resolved symptom was palpitations - happened with in the first week. The physical symptoms cleared up pretty quickly and the emotional symptoms took a little longer

Discontented that's really useful and easy to absorb, thank you!

Would love, above all things, for palpitations/ectopic heartbeats to bugger off. They're unsettling and try as I might to relax about them, I can't.