GPs caught in media menopause spotlight

“T” and “wonderdrugism”

Central to GPs’ gripes are the “wonderdrug” narratives that have arisen around HRT as well as off-licence testosterone use in women. Irene Redolat-Castella is a GP who has also seen a rise in patients presenting to her Redcar surgery requesting GPs prescribe these hormones.

“We’re hearing condescending comments to clinicians, demands for testosterone off-label, as well as unrealistic expectations of HRT being the panacea for total happiness and bliss,” Redolat-Castella tells The BMJ.

For Harrogate GP Chris Preece, such patient presentations are troubling. “I’ve got lots of patients suddenly asking for an off-licence drug,” he says, “a proportion of whom are coming into the consultation primed with the view that any reticence to prescribe it on my part reflects either ignorance, misogyny, or both.”

Obstetrician and academic Susan Bewley, who has an interest in overmedicalisation, believes the testosterone vogue—the synthetic androgens are dubbed “T” in commercial market parlance—smacks of wonderdrugism. “There are myriad voices saying its use is ‘safe.’ But safety is always relative to a drug’s use,” Bewley says. “Insulin, for example, can be safe if you have diabetes, but fatal if you don’t.”

Bewley adds that we also lack information about potentially damaging effects of testosterone use in women, pre- and postmenopausally. “We don’t know if it has lasting effects on atrophy of the uterine lining, vulval skin, and urine infections, or whether it impacts pregnancy health or babies’ outcomes,” she says.

Preece sticks to British Menopause Society guidance, making sure that patients’ oestrogen levels are sufficient (with HRT) to prevent grave side effects before contemplating off-label testosterone prescription, and stressing that testosterone is a limited treatment for low libido only. He warns patients that long term risks, including side effects such as acne or hirsutism, are poorly understood.

Davis says that while testosterone supplementation is useful for “a small subset of women,” she is concerned that the synthetic hormone is being touted as an “elixir.”

“There is irrefutable evidence that testosterone therapy may improve sexual interest and reduce sexual distress in postmenopausal women with low desire and distress not caused by other factors (such as hypoactive sexual desire disorder), with efficacy being low to moderate for the majority,” she explains.

By contrast, Davis says, the prescribing of testosterone as a treatment for fatigue, brain fog, and low mood is based on testimonials and anecdotes and not evidence.7 She is concerned that patients with depression will not be treated, and relationship problems that might require counselling could be overlooked, as a result of this “golden pillism.”

Redolat-Castella has prescribed testosterone to women, but has discontinued the prescription in many cases. “My experience is that it hasn’t been that helpful in improving symptoms and I have discontinued in these cases because of lack of effect; additionally, some forms are now out of stock,” she says.

Disease mongering

Ash Paul, a public health doctor interested in evidence based health services commissioning, believes that positioning menopause as a “long term female hormone deficiency” is a “classic case of disease mongering.”

“Disease mongering describes a process of widening the boundaries that define medical illness in order to expand markets for those who deliver treatments,” Paul says. He points to the overuse of the argument of the “risks” of natural menopause onset in view of the paucity of data around natural menopause onset.8

Margaret McCartney, a BMJ columnist and vocal advocate for evidence based medicine, tweeted on 18 June: “OK. Fed up of this now. If you are a doctor commenting on HRT and how useful it is/is not, and on the role of testosterone, please can you make sure your financial relationships with pharma are easy to find and with enough detail to enable an informed judgement on their impact.”

Louise Newson, a Warwickshire GP who regularly appears on This Morning as a menopause specialist, is a leading proponent of the theory of menopause as a female hormone deficiency9 and champions the use of testosterone by menopausal women for improved concentration, sleep, libido, energy, and stamina.10 She appeared on the Davina McCall programme, and has previously declared accepting financial payments from pharmaceutical companies including HRT and testosterone manufacturer Besins. Her declaration says, “At no stage has any company with which I have had a financial relationship with ever influenced the medical advice I have given to patients or others. Nor has any such company had any control over the content of any lectures, articles, or any other work I have done nor over the content of my website.”11

Newson declined to be interviewed by The BMJ, providing a statement: “Whilst Newson Health clinic has been open, neither the clinic nor Dr Newson have received any funding from any pharmaceutical companies. Any outside funding that Dr Newson has received in the past has been declared in the correct way.” The BMJ makes no claim to the contrary, although others are not quite as clear in their financial declarations as Newson.

Regarding the prescribing of testosterone, Newson cited the 2015 NICE menopause guidance and its recommendation to “consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective.” Newson added, “Patients in our clinic are assessed for various menopausal symptoms including low sexual desire. We follow this NICE guidance when we prescribe testosterone for our patients.”

Towards better treatment

The joint position statement on the menopause welcomes political and media interest in the menopause as well as “the increased understanding of patients.”

Similarly, Haitham Hamoda, immediate past chairman of the British Menopause Society, celebrates the erosion of stigma that’s come from increased media representations of women going through the menopause, particularly in the workplace. Hamoda tells The BMJ that he would like to see individualised care and an end to the “postcode lottery” that some women face when it comes to quality of care in general practice.

The recent APPG report also expressed concern about the postcode lottery of menopause treatment. The group called for the creation of a national formulary for HRT to ensure that doctors can access the most accurate guidance on prescribing, for menopause to be incorporated in the GP Quality and Outcomes Framework to improve diagnosis and treatment, and for updated menopause training to be provided for GPs, other healthcare professionals, and medical students in training.4

Hamoda says that menopause is an area in which he would expect most GPs to be up to date on patients’ options. “In fact, most GPs offer good advice: telling patients what to expect in terms of symptoms and management options,” Hamoda says. “Though you do have a small group of GPs who may not be aware of all treatment options who are anti-intervention and another small group who think that HRT is the answer to everything,” he says.

Menopause and the Workplace, a 19 July report published by the House of Commons Women and Equalities Committee,12 recommends that training on menopause should be a mandatory aspect of continuing professional development requirements for GPs and that until then, “all GP surgeries should ensure that at least one member of their clinical staff has received specific training around menopause,” with a menopause specialist or specialist service in every clinical commissioning group area by 2024.

Wetherell believes the current surge of demand in general practice could be alleviated if HRT moved to being managed by online pharmacies. Pressure might be alleviated, too, by the arrival of new NICE guidelines—to be published in August 2023 and to focus on managing urogenital atrophy, the long term benefits and risks of hormone replacement therapy, and cognitive behavioural therapy for managing menopausal symptoms. Also potentially helpful will be the arrival of a wider variety of treatments for menopause, including non-hormonal treatments for hot flushes.13

Redolat-Castella believes the overemphasis on HRT’s global benefits obscures the fact that for some women such treatment can be beneficial and “make them feel like themselves again.” She says, however, that HRT is not guaranteed to “cure” tiredness, irritability, or emotional lability in postmenopausal women and “expectations should not be so high.”

Menopause revolution aside, Preece would like to see a cooling of the media stoked antipathy towards GPs as menopause gatekeepers. “It is not our role as GPs to block necessary treatment or be obstructive and any media narratives that claim that this is our intention are damaging—for both GPs and patients,” he says.