Diagnosis of peri menopause between 40-45

[apwilson1980]

Would appreciate help understanding NICE guidelines for diagnosis of peri menopause between 40 and 45.

I'm 42, periods have been getting increasingly irregular for about six years, and I've been having loads of symptoms the past 6-9 months. Now haven't had any bleeding at all in 3 months... I want to see if HRT will help with my symptoms (bad sleep, brain fog, irritability, etc.) as I'm starting a new, much more demanding job, in a month.

Went to the GP and was told I'll need to do a blood test for FSH despite symptoms and fact that my mum and maternal grandma both had early menopause (done and dusted by 42 for my mum). I told the GP that I thought diagnosis was to be done on symptoms alone and that the blood test is not reliable marker but she just fobbed me off, told me to get the blood test done and not to worry--also to look for black cohosh🙄 ... Anyway, have looked up NICE guidelines to try to have another go at the conversation about the blood test vs. symptoms-basis. The guidelines say no need for blood tests for those above 45, but it is recommended for those between 40-45 but then doesn't say anything else that I can see.. In other words, how is peri menopause diagnosed in women in that age bracket when the blood tests aren't a clear marker? From what I can read, FSH levels are all over the place during peri and plenty of women will be in that phase in early 40s, so what is the guidelines aside from recommending a blood test? What is to happen if someone in that age bracket has symptoms but blood test is 'normal'?

I haven't got time to read your long rant but we don't receive "formal training" in many things because it's not possible for every single possible area of medicine to be covered in that way. We have standard gynae training and educate ourselves (in our own time) about everything else. Same for all specialties. Plenty of GPs have never worked in paeds or gynae or ENT or dermatology etc. We would have to live to be 500 to formally train in everything to expert level.

My point is that if this dialogue was occurring 5 years ago it would be very different. Medical fashions come and go, but from a GP perspective the risks and benefits remain largely unchanged. Just because HRT is fashionable now does not mean it's without risks. Just because it was unfashionable 10-15 years ago (when the million women study was at the forefront of everyone's mind) it didn't mean it was without benefits.

Everything has to be seen in context. Going to the GP armed for strategies for getting HRT is not necessarily the best thing for everyone. Hence my objection to your plan.

@Sarahcoggles I may have mentioned in my post

GPs being patronising and acting like an almighty beings.
Maybe you should rejoice women are talking about their issues - and realisng it is OK to do so rather than not daring to face patronising and dismissive GPs?

And if you, as a GP, do not think it is appalling that GPs are not trained in something all women (if they live long enough) do through, then yes, maybe us plebs will speak about GPs in a way you do not like.

HTH

I thought it was Paroxetine that was the best ssri for hot flushes?

With the long view, and I credit Gussie grippers and oestrogen matters for my education with this, better management of the menopause in a way that's right for the woman reduces the need for medical interventions later on as well as death (from falls from urinary urgency).

Bones, heart health, urinary urgency and incontinence, mental health, ability to stay in work, maintaining relationships etc

@Sarahcoggles Wow! Are you aggressive like this to your patients?

I find it hard to believe you really are a GP writing the way you are here. (Anyone can say they are anything on a forum).

I don't like the way you talk about GPs as if you know exactly what we're all thinking and what you have to say to bend us to your will.

Bend us to your will? So you treat a consultation like a battle field or a confrontation?

The essence of NICE meno guidance and the BMS is that dr and patient are equal partners. You as a GP are supposed to listen and advise women of the risks of HRT, then they make up their minds. Unless there are sound medical reasons to refuse HRT, (and very sound reasons, not your own bias) then you are supposed to offer what women want.

I think GPs should be trusted to know what they're doing and prescribe appropriately

But many don't.

Spend a week on this forum and you will find most (and I mean that!) GPs who women here are seeing, do not know much about HRT. Why should they? They don't get any training unless the sign up for it as CPD. It's not covered at med school.

There are cases on this forum daily of women being given the wrong type, OR just as often, being told they can't have HRT for the wrong reasons (often migraine is quoted, or high BP, or they are too young, too old).

They are given continuous when they need sequential, they are given Oestrogel to use on their vulvas (FGS!), they are told they can't have systemic HRT and topical estrogen,.....and the list goes on.

And I've not even started on the sheer scandal of medicating women with ADs instead of HRT. Yes, ADs have a place but they are not first line treatment as stated by NICE. They are for women who cannot use HRT for very sound medical reasons.

I'd also suggest that if you have a lot of your own patients who don't get on with HRT, maybe your prescribing is not quite what it could be. IME here, many GPs lack the knowledge to tweak doses, try different types, whereas specialists do and get better results with their patients.

Out of interest, how has your own menopause training developed over 25 years?
Do you attend the annual BMS conference? Do you update you knowledge on their courses? Do you read the latest research papers or talk to menopause experts like Prof Nick Panay?

@Sarahcoggles It's not that HRT is now 'fashionable'. It's that women are becoming more educated and assertive about their own health. They are seeking help for something that for decades was ignored.

If anything was a fashion, it was (and is) the inappropriate prescribing of ADs for menopause symptoms. That is a disgrace and in years to come will be seen as that.

I'm afraid all your posts here do are confirm the rather arrogant stance of some GPs who treat women as inferior with the 'I know best' attitude, when in fact many simply don't.

we don't receive "formal training" in many things because it's not possible for every single possible area of medicine to be covered in that way. We have standard gynae training and educate ourselves (in our own time) about everything else.

@Sarahcoggles GPs are no different to many other professionals who have to access CPD and do it in their own time. It's depressing that you try to defend your lack of training rather than see it as a need to seek out better training, so you can serve your patients better.

The British Menopause Society runs courses on meno and HRT every single month. Their annual conference is always a sell-out (so some doctors clearly see the benefits of listening and learning from world-class experts.)

The BMS is constantly striving for more GPs to attend their training as the menopause is a neglected area of medicine, yet affects 51% of the population.

It's worrying how you appear not to be able to see that your posts here simply confirm the negative image and experiences that women have when consulting a GP about menopause. You appear brusque, angry, defensive and a little biased, unwilling to even acknowledge the benefits of HRT and the NICE guidance.

Thanks @PantyMcPantFace , I think this was really solid advice. Sorry for my absence in the conversation -- for some reason, I quit receiving notifications about the conversation and had no idea that there were all sorts of replies (!).

To follow up, here's what happened in the end... I got my blood test results back and, as I suspected they would, they showed 'normal' (i.e. not-fully-menopausal) levels of FSH. The Dr who assured me that she would 'absolutely' not fob me off, but text me as soon as she got the results so that we could continue the conversation, etc., etc., did NOT text or call. I had to call and get results from surgery reception and I have heard nothing in the days since. Presumably, since it was 'normal', she decided there was nothing to be done despite my concerns. I generally am quite trusting of doctors and respect their training and desire to genuinely help, but I also know that human bias is real and that medical practice unfortunately is often skewed against taking women seriously -- if anyone doubts this, I highly recommend the book Invisible Women by Perez (who writes on a host of issues not just medicine).

I was decided I didn't have time to keep messing with it and was lucky enough to be able to afford it, so I just called a private clinic. They were able to get me in within two days, reviewed my symptoms, medical history etc. and the Dr there is putting me on a trial period of oestrogen gel and progesterone mini-pill for my uterus. According to her, family history such as mine is a quite reliable indicator of early(ish) menopause and with my symptoms, etc., she felt no need to even look at the blood test. I also learned that HRT might have benefits for my bone health. My grandmother and mother, who both had early menopause and were fobbed off of HRT in their time, have, respectively, osteoporosis and terrible bone density. Both have had broken bones and complications because of it. I was entirely unaware of this benefit of HRT and making that link between the issues my mum and grandmother currently have and HRT was a real lightbulb moment. So I'll be trying the gel and progesterone pill and looking forward to possibly breaking fewer bones in the future and being stronger to play with any grandkids and get up and down steps for longer!

Thanks for all the advice everyone!

My gyn made the diagnosis of my early meno at 42 based on my symptoms. Blood tests aren’t very accurate.