Abstract
Since 1972, Women's Health Concern (WHC) has been offering an independent service that provides advice, reassurance and education to help support those with gynaecological, sexual health and related problems affecting their overall health, wellbeing and quality of life. Joining the British Menopause Society (BMS) now provides a significant new opportunity for both charities to extend their reach and impact.
Forty years on, our founder Joan Jenkins - an inspirational nurse who some of the more senior members of the BMS will remember with affection and even some awe - far from turning in her grave (she died in 2002), would embrace both the principle and the practicality of a patient arm.
One of the key objectives of the BMS is to educate primary care practitioners in their understanding, awareness and competence in diagnosing and treating those with reproductive and postreproductive conditions. A glance at the WHC website www.womens-health-concern.org will show the range of work that our nurses and medical advisory panel undertake to underpin and enhance this BMS objective.
Summaries of two case studies are presented below to highlight our Helpline and Email Advisory Services. Our principal aim, of course, is to help the patient, but we emphasize that our advice should be made available to her doctor, so a helpful spin-off is to provide the practitioner with confirmation of current information.
Requests come to us through our website, Internet searches, word of mouth and, interestingly, through NHS Direct and general practitioners (GPs) themselves. Inevitably a small proportion of the women (and men too) who approach us have lost confidence in their own doctor, especially when there is a refusal to prescribe hormone replacement therapy (HRT). We consider it part of the service to foster a closer relationship between patient and surgery. To their credit, the WHC nurses and medical advisory panel achieve this aim in more cases than not.
Case 1: Menopausal symptoms
Enquiry
I am 49 and I had a Mirena IUD fitted four years ago for very heavy periods. My periods are now very light. I started to get menopause symptoms around six months ago, hot flushes all day and night, insomnia, aches and pains, thinning hair, sudden low libido, depression, tearfulness, etc. My GP started me on Elleste solo 1 mg. The hot flushes have lessened, but the other problems continue. I asked for a hormone check and had a blood test this week. My GP said the estrogen levels were normal; they were 8. I am confused by this, as checking on the net, the normal range is over 25 at lowest, but should be higher on HRT? Should I see another Dr, or ask for 2 mg of Elleste solo. I am not feeling myself, and GP has now suggested antidepressants, but I believe this is hormone related. I am feeling very low, and my poor husband cannot do anything right! I would really appreciate some advice, especially about estrogen levels (I have seen GP 3 times in last 2 weeks).
Advice
A normal estradiol level would be > 100 pmol/L (>30 pg/mL), so I do not know to what a value of 8 refers. I suggest you increase the dose to 2 mg and see what happens to your symptoms. If you still have problems after a couple of months, ask for a referral to a local menopause specialist. I would certainly avoid antidepressants.
Response
The increased dose has helped and the worst of the symptoms have ceased. I think 8 was an error and the GP agrees I should not now go on to antidepressants. Thank you very much.
Case 2: HRT
Enquiry
I am 57 and I had both ovaries removed at age 23 and therefore had essential HRT via implants until I was about 48 when I went on to patches. I tried to stop HRT at age 50 due to all the scares about it at that time. I quickly experienced severe menopausal symptoms and went back on a low dose patch, which my gynaecologist was happy to give me until I reached 55. Again, due to the scare stories I stopped at age 53 and my GP gave me a vaginal cream to deal with dryness, etc. It was not very effective. In 2009 I revisited my old gynaecologist. He did a bone density scan and said I had osteopenia, and recommended an implant to combat the menopausal symptoms, which refused to go away. I felt much better on the implant. He wrote to my GP suggesting that he prescribe estrogen and testosterone gels once the implant had faded out. However, my GP is unwilling to do this and will only prescribe the vaginal cream. I am confused about whether to seek another form of HRT. I am now nearly 58, but struggle with vaginal dryness, which makes intercourse impossible, urinary frequency, night sweats, aching muscles and am at risk of osteoporosis, particularly as there is a strong family history of it. I feel I have gone as far as I can with my GP without alienating him! But private treatment is very expensive. It is very difficult to weigh up the risks but I do know that I feel so much better with estrogen and I want to avoid the osteoporotic fractures my mother and grandmother had. I try to keep fit, walk a lot, do pilates and have a good diet.
Advice
There is no reason why you cannot continue on estrogen and testosterone by patches or by gels, and no reason why your GP should not prescribe them. There has not been any increase in breast cancer risk in women taking estrogen without progestogen, as shown by a very large American clinical trial, so the evidence is that taking estrogen by the non-oral route is very safe, and there is no time limit on how long you can take it for.
Response
It was really helpful to get a reliable view. As my GP is unwilling/unable to prescribe anything other than the vaginal cream, I will go back to my gynaecologist and obtain HRT privately. It probably only costs about the same as getting the car serviced! With thanks.
We look forward to sharing more cases with readers of the Journal and meeting you at our women's health events.