‘All GPs should be able to manage menopause’ – but can they?

Evelyn Lewin

7/07/2020 4:23:27 PM

Barriers related to time, education, and the risks of some treatments mean GPs need more support, a menopause expert has said.

GP discussing health issue with patient.
GPs should advise patients they may need multiple consultations, and long consults should be encouraged.

‘There are some GPs who find it all too difficult.’
That is GP Dr Karen Magraith, Clinical Senior Lecturer at the University of Tasmania and president-elect of the Australasian Menopause Society.
She is talking to newsGP about the management of menopause in general practice.
Due to the breadth of knowledge needed to manage the condition, Dr Magraith says there are anecdotal reports of GPs who prefer not to manage menopause at all.
‘There is so much information that we have streaming at us that it is difficult for GPs to be up to date with every subject, ’ she said. ‘It’s very tempting for GPs to just say there are some areas that they don’t do.’
When GPs decline to treat menopause, Dr Magraith wonders whether they are instead ‘too nervous’ to prescribe Menopause Hormonal Therapy (MHT), also known as Hormone Replacement Therapy (HRT).
However, she says such concerns should not stand in the way of care.
‘All GPs should be able to manage menopause, at least to a certain extent,’ she said.
Dr Magraith is quick to note menopause is not an easy condition to manage and that there are a lot of barriers to effective care.
‘The first barrier is that general practice is not structured to support long consultations, and menopause needs a long consultation,’ she said.
The second is a lack of education and support.
‘That stems right back from medical school – medical students really don’t receive a lot of training in menopause – right through to general practice training. There is a lack of education,’ she said.
There are also challenges in keeping up to date with current information including around treatment options, especially relating to MHT.
In fact, Dr Magraith believes issues surrounding MHT pose a significant, and often under-recognised, challenge for GPs.
She said the topic is ‘confusing and controversial’, with many perceiving MHT as an unsafe treatment, especially with respect to breast cancer risk. 
‘It is difficult for many GPs to understand what that all means for them and their practice,’ she said.
‘The reality is that there is a potential increase in risk of breast cancer, and some formulations may be safer for the breast than others. We need more information about this.
‘The discussion about risks and benefits for an individual woman also needs to include symptom severity and the potential beneficial effects of MHT on bone and cardiovascular health.
‘In the end it is a shared decision making process.’
Dr Magraith believes there are a number of steps GPs can take to help overcome these barriers.
‘Just like with any other patient presentation, the first thing is to take a history and to find out what the woman’s symptoms and concerns are,’ she said.
Dr Magraith says every woman has a different experience of menopause, so it is important to establish what each specific patient is seeking. 
‘The next thing is to address those needs,’ she said.
That mainly involves educating patients about menopause and the options available to them if they have symptoms.
Dr Magraith says a discussion about menopause provides an opportunity for assessment of cardiovascular risk and bone health, and for promoting healthy lifestyle choices.
These consultations are also a good opportunity to discuss and offer the recommended screening tests such as cervical screening, mammography and bowel cancer screening.

Dr Karen Magraith says most women with symptoms of menopause can be offered hormonal therapy.
Meanwhile, women with premature menopause or menopause due to cancer treatments may have special needs and some of these women may benefit from specialist involvement.
For women being managed through general practice, Dr Magraith says there are a lot of helpful resources for GPs on menopause, including through the Australasian Menopause Society and the Jean Hailes Foundation.
Tailoring such education for each specific patient is key.
‘Any efforts to help women understand menopause need to include women of culturally and linguistically diverse backgrounds,’ she said.
Dr Magraith says GPs should also advise patients they may need multiple consultations, and long consults should be encouraged. This extra time allows GPs to break down key information into ‘manageable chunks’ to avoid overwhelming the patient.
When it comes to potential therapies, Dr Magraith says the message needs to be that MHT can be prescribed in the majority of cases, as long as the patient does not have any contraindications to treatment.
For those who have contraindications, or don’t want hormones, non-hormonal options can be considered.
‘It should be a shared decision making process and often you do need to spend some time discussing the risks and benefits of hormone therapy,’ she said.
‘But I think that’s a take-home message: that most women can be offered MHT.’
Despite this, Dr Magraith says many GPs are still wary of prescribing hormonal therapies due to potential risks.
‘I think GPs are worried if a woman develops breast cancer that they’ll be blamed,’ she said.
‘That’s really a significant issue.’
Another major issue lies in addressing the pervasive belief that menopause is merely a constellation of symptoms, rather than an important physiological process with other effects.
‘Menopause is not just about symptoms,’ Dr Magraith said.
‘It also has ongoing consequences for all women, whether they’re symptomatic or not.
‘For example, after menopause, women have an increased risk of cardiovascular disease, osteoporosis and genitourinary symptoms.
‘Some women and possibly GPs think that menopause is just a stage you go through and then you reach the other side and then things go back to normal, and that’s not actually the case.’
Dr Magraith hopes to see better education on menopause throughout the medical curriculum, but says GPs can always improve their knowledge by staying up-to-date with current recommendations.
Despite reports of certain GPs preferring not to treat menopause, Dr Magraith believes GPs are well placed to help manage it, and that the majority want to do just that.
‘I think GPs want to manage menopause well,’ she said.
‘But it is difficult.’
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Chester James-Smith (Med V)   9/07/2020 8:28:40 AM

Certainly a topic of great mystery and confusion for me. Thank you for your words of wisdom Dr Magraith.