BMS Vision for menopause Care in the UK;is implementation achievable?

So what has been achieved so far?

The first statement is beyond doubt, but remarkably that word “Menopause”, is still seen by many as a scary taboo word, the attitude then hindering further discussion. A variety of forms of education are increasingly available for women and at Menopause Matters we are investigating the possibility of providing Menopause Matters magazines to be sold in retail stores, increasing access to information. To my surprise and disappointment, discussions have centred around the need to change the name in the belief that women may be too embarrassed to pick up a magazine with the word “Menopause” on the front! I find it incredible that this was raised when most other areas of health have now been demystified and destigmatised. To change the name would only add to the view that this word should not be spoken. The name is not for turning!! The tide is turning though and we regularly hear of magazine articles, television programmes and advertisements, radio features, educational and support events about menopause but clearly there is much work still to be done to get to a time when there is no shame, no embarrassment, no taboo, no stigma around a physiological process which affects all women.

While educational meetings are well attended, our annual scientific conference being a sell out in 2018, and BMS membership at almost 700 at the time of writing, we are nowhere near the state of all HCPs having a basic understanding of menopause. There is an urgent need to include menopause sessions in educational programmes of other specialists, primary care teams, allied healthcare professionals, pharmacists to name just a few. It is often at specialist level where menopause symptoms may be missed and the wrong information given. A recent example is a patient with migraine which worsened around the perimenopause and severely affected her quality of life and ability to work. She was advised by a Neurologist that she should absolutely not take HRT because of significant increased risk of stroke. Seeking information herself she found that this was not the case, and commenced transdermal HRT which was life changing. You will all be aware of similar stories. For many women, advice given by a specialist is perceived as being that it must be correct and is very difficult to challenge. In the News in this issue, “Fear and loathing persist” reveals shocking information that hormone therapy continues to be underused with many women still being denied treatment, especially younger symptomatic women. ² We must ensure that consistent messages are given across the UK with more widespread menopause education. Not least is this relevant than to gynaecologists who may be expected to be well educated in all things menopause, which will affect ALL their patients, but this is not always the case. We continue to work with other specialist societies including Royal College of Obstetricians and Gynaecologists, to improve education starting at trainee level. To encourage interest at an early stage of training, we hope to include a section for submissions by students or trainees in each issue of Post Reproductive Health, commencing with the June issue.

Women’s usual first contact with a healthcare professional when seeking help with menopause symptoms is primary care, and we believe that many practices do have a member or members of the team who have a special interest in menopause care. However, women themselves may not have identified that their problems are hormone related and may not know to ask for an appointment with a specific HCP. Better education of women from the whole range of resources increasingly available will lead to appropriate first appointments.

BMS recognised Menopause Specialists are increasing, with around 140 registered at the time of writing. The register of specialists was launched online on World menopause Day 2018 and is a fantastic resource. However, there are still regions where no specialist service is available. To become a BMS recognised Menopause Specialist the BMS/FSRH Advanced Menopause Certificate, or RCOG/BMS ATSM in menopause care or equivalent must be completed. Attendance at our theoretical courses for the BMS/FSRH certificate in Menopause care has increased dramatically in recent years with all 4 courses per year being fully, and sometimes, over subscribed. For those who then want to complete the practical training, there can be difficulties and long waiting times in accessing a Trainer to complete practical training. We desperately need more HCPs to register as Trainers through FSRH and hope that those of you who are eligible will do so.

Resource is then needed to develop Specialist Menopause services in regions where these are lacking. As noted in a previous editorial of this journal, the resource for improving care is within the system ³ and research has shown that allocating extended time for menopause specific appointments leads to reduced number of subsequent appointments. ⁴ Women with menopausal problems are being seen already and, if referred inappropriately are often subjected to unnecessary investigations and clinic appointments, and offered inappropriate treatments. I will finish with a summary of a case report which clearly demonstrates that we have not yet everything in place to achieve the BMS vision for menopause care, and confirms that our resources can be so badly wasted if we do not get this right, yet some pieces of the jigsaw are starting to fit together.

The patient is a 65 year old lady, generally fit and well. She had been taking low dose estrogen patch for many years which suited her well. She had had a hysterectomy in the past. A routine appointment with her GP led to her being advised to stop as she had “been on HRT long enough”. She then developed sweats and her GP performed many blood tests and a Chest X ray was ordered. There was an abnormality on the chest X ray which led to her seeing a physician and having a CT scan – all of which were normal. Meanwhile the patient was still having sweats and her quality of life was suffering. She saw a programme on Menopause on the BBC by Kirsty Wark and asked GP to refer to a menopause clinic as she thought “this was her”. She was seen by a Menopause Nurse whose first question was “when did the sweats start?” Reply was “on stopping HRT!” The option of restarting HRT was fully discussed and the patient chose to restart a low dose patch again as she “wanted her life back”. A telephone follow up with her 3 months later confirmed that life was back to normal and that she felt great.

In conclusion, the vision has not been fully implemented yet but is achievable and we are on our way!