GP refusing to prescribe HRT

[PinotPony]

My friend is 48 years old with symptoms of peri menopause... anxiety, lack of sleep, raging temper...

She has pre-existing depression, linked to bereavement, and has been on citalopram for several years. She has young children and physical disabilities.
It's been evident for the past six months that she's just not coping.

She has been to see her female GP a few times to ask for HRT but was refused. At first they prescribed sleeping tablets. At another appointment, when she broke down crying and told the GP she was hurting her children, the GP recommended anger management classes..!

She has been sent for a scan and the radiologist seemed to think she was referred for PV bleeding. My friend clarified that she just had menopause symptoms and the radiologist confirmed that her ovaries were no longer ovulating... no surprise there!

She was suicidal last week, calling me for help as she had a knife at her wrists following an argument with her DH. After lots of tears and cuddles, she calmed down and has spent Christmas with her family.

I am hoping to accompany her to a GP appointment tomorrow so I can advocate for her. I'm looking at the NICE guidance so we can present this to the GP. My understanding is that GPs should offer HRT to women of this age with these symptoms but I cannot find the wording to support that. Please can anyone highlight the appropriate NICE guidance to quote? I am determined that she should get some proper help. I'm very concerned for her and the children.

www.nice.org.uk/guidance/ng23/chapter/Recommendations#diagnosis-of-perimenopause-and-menopause

Given your friend has an established history of depression and a stressful life, it may be hard to put the blame for her current mental ill-health on the menopause alone. Does she have any "physical" other menopause symptoms - hot flushes, period changes etc? they might help clarify the role of menopause for her?

I don't often reply on threads but this hit home. There is an amazing group on Fb called The Irish Menopause. Full of guidelines, lots of specialist podcast links etc. set up by women who were going through it with no support. Have a read, maybe get your friend to read. Yes it's an Irish group but Menopause is Menopause wherever you are based. Best wishes to your friend - & she's so lucky to have you in her corner x

No, as far as I know she doesn't have any physical symptoms.

I just find it astounding that a woman presenting with new psychological symptoms at 48 isn't seen as a candidate for HRT. Within our friendship group, all of us have easily accessed HRT when we've told our GP that we've become anxious, grumpy and aren't sleeping. Yet the one person who really needs it is being fobbed off.

Thank you for this information. I'll pass it on. X

They should at the very minimum do a blood test to check her FSH levels before assuming that all her symptoms are mental health-related.

Davina McCalls book Menopausing is full of data and information that may help. Amazon will do a quick delivery time.

@pinneddownbytabbies Nope :) Blood tests are only done on women under 45.
During normal peri ages (45 onwards) NICE advised, from 2015 Menopause Guidance, no blood tests.
They are not reliable. FSH can vary from day to day and month to month.
A diagnosis is made on symptoms.

@Onynx Is the OP and friend in Ireland?
Ireland has a different take on a lot of medical issues, including the type of HRT available. There are women who pop along to this forum and discuss various types of HRT and they are not available in the UK.

@PinotPony Your friend just needs to stand her ground.
If HRT helps, then she needed it.
Most GPs would at least offer her a 3-month trial to see if she felt better.

Yes, there is the slight chance it could be a placebo effect, especially if she already has MH issues, but they can't be sure of either (pre existing or peri menopause.)

If she doesn't get any joy, see another GP or - if she can afford it- access a private specialist.

This is awful, the poor woman. It makes me so cross that so many GPs are either totally unaware of the guidelines or just think they don't apply.

She's lucky to have you OP, she needs to be assertive and just keep repeating that she wants to try HRT.

Thanks all. She has an appointment this afternoon. I have printed the NICE guidance and will ask the GP why she is so reluctant to prescribe HRT to a patient where it appears to be clearly indicated.

We're in England so it really shouldn't be this difficult!

This makes me so grumpy – she shouldn't have to beg for HRT like this. I suggest she also prints out and fills in this checklist of symptoms to reiterate how she's suffering.

menopausesupport.co.uk/wp-content/uploads/2019/11/MENOPAUSE-SYMPTOM-CHECKER.pdf

Without wanting to comment on your friend's situation specifically, I find it quite disturbing that symptoms of depression and anxiety should be seen as grounds for prescribing HRT, especially in someone with a history of depression. Mental health care in the UK has been ground away to almost nothing. And it can only make things worse if the new focus on menopause results in mental health problems being rountinely 'treated' with pills without proper evidence of their relevnce.

I'm old enough to have seen several pro- and anti- cyles around the prescription of HRT. Decades ago they were handed out too readily to women of menopausal age, then there was significant concern. Seems we are heading back the same way. Menopausal women are more than just the menopause. Their distress shouldn't be ascribed to hormones without evidence.

@Random789 I understand what you are saying but the NICE guidance does cover the various scenarios of HRT/depression/ anxiety and other possible causes (and treatments.) It asks drs to consider existing MH issues and consider HRT as a treatment if symptoms coincide with period changes or other symptoms.

It's decades since HRT was handed -out, as you describe it, and it was stopped mainly as a result of the flawed WHI trial, based on US women. Most meno specialists now agree that was a disaster for women's health as many were refused HRT, and developed other illnesses that can be prevented with HRT.

Do you agree that for decades, psychological symptoms that were attributable to menopause were not recognised?

I do, because my Mum's generation (women now in their late 80 and 90s) seemed to suffer from 'nerves' and were medicated with tranquillizers (benzo type drugs) and sleeping tablets for years.

These 'nerves' were anxiety and some women I knew developed agoraphobia, and anxiety over all sorts of stuff, but it was never linked to menopause. I know close friends of my Mum and my MIL who were part of that group.

Thankfully, the pendulum is swinging the other way but there are still only around 10-15% of women on HRT.

@PinotPony Let us know how your friend gets on.

The thing is @Random789 is that the OP says her friend has been on antidepressants for several years, and has only been not coping for the last six months. So what's changed? Yes it could be that her current depression and difficult circumstances have got worse and what she needs is a higher prescription of anti depressants, or a different drug. But it could also be that she has menopausal symptoms ON TOP of her pre-existing depression and it is the job of the GP to consider that as a distinct possibility. Dismissing her request for HRT out of hand is just wrong.

I also agree that women in the past were just prescribed heavy duty tranquilisers - my grandmother lost her husband when she was about 55, and was on diazepam until she died 30 years later. And of course some women didn't cope, the highest suicide rates in females are between 45 and 55 years of age.

www.itv.com/news/2021-11-16/suicide-rates-in-women-of-menopausal-age-rise

Thank you @Inkpotlover , this checklist was incredibly helpful. She ticked almost every box!

Thankfully we saw a different GP who was very understanding and prescribed a 3 month trial of oestrogen patches and progesterone tablets. She talked about patches being a steady release to avoid peaks and troughs which might worsen migraines. My friend has endometriosis and the coil didn't work when she tried it several years ago so GP has recommended 2 weeks on / 2 weeks off progesterone.

My friend has a prolapse and urinary symptoms so hoping that will improve too but is going to use the NHS Squeezey app in the meantime.

The GP suggested my friend keep a diary of her symptoms and also re-do the checklist before her 3m review to see what has changed or improved.

My friend said she feels better already just having been heard and not dismissed.

I'm so glad she got her prescription! And that the checklist was helpful. It's so crazy that she was denied it before, so thank god you saw a different GP this time.