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As doctors, one of our ethical responsibilities is to ensure we maintain our professional competence, keeping up to date with clinical guidance, as well as reflecting on and learning from adverse patient events.
In 2022, as an important part of our “Supporting doctors through menopause” campaign,1 Medical Protection surveyed its UK and Ireland medical members to understand the impact of the menopause on their wellbeing and careers. Additionally, respondents were asked how comfortable they were in managing and supporting patients experiencing menopausal symptoms. We received responses from 261 members in the UK and 354 members in Ireland. Around a quarter of doctors surveyed (26% in the UK and 25% in Ireland) reported feeling uncomfortable supporting and managing these patients – 72% of UK respondents and 69% in Ireland said they would welcome more training.
In both jurisdictions, these figures have likely improved, with press interest in the menopause having increased in recent years, patients potentially being more informed, and professional guidance being widely available, such as the UK National Institute for Health and Care Excellence (NICE) guidance2 and the Irish College of General Practitioners (ICGP) guidance.3
However, with the above survey results in mind, a detailed analysis was carried out of Medical Protection’s cases from recent years, to see if there were any lessons from these cases to be learned regarding the management of the menopause in primary care.
Over a ten-year period, 548 menopause-specific cases were identified, including claims, complaints, regulatory investigations, incident reviews, and inquests. The majority of cases (82%) were UK cases. The remainder of cases were in Ireland, South Africa, Australia, New Zealand, Asia, and the Caribbean. Of these cases, 78% involved GPs and 15% involved gynaecologists. The small remainder comprised of various other specialties, such as psychiatry, rheumatology, and emergency medicine.
Three main themes emerged, reflecting closely what we tend to see as core issues within many areas of medicine – prescribing, diagnosis and management, and communication. This article will focus on the diagnosis of menopause and its potential pitfalls.
A total of 79 cases (14%) of the 548 cases reviewed related to concerns about the diagnosis and management of the menopause. While most (81%) of these cases related to primary care, 19% occurred in secondary care. Several themes emerged from analysis of these cases, and detailed below are some of the common areas of diagnostic challenge relating to the menopause.
A large proportion of cases (16%) related to failure to diagnose early menopause or premature ovarian insufficiency. The NICE guidance makes reference to the following definitions:2
Early menopause is the cessation of ovarian function occurring between the ages of 40 and 45 years, in the absence of other causes of secondary amenorrhoea.
Premature ovarian insufficiency (or premature menopause) describes definitive loss of ovarian function before the age of 40 years.
In many of the cases, patients presented with typical menopausal symptoms, but the diagnosis was either not expected as the patient was young or there was no apparent effect on the patient’s menstrual pattern. There are certainly challenges for doctors, and the diagnosis is not always easy to make, with many symptoms such as fatigue, insomnia and mood changes being common in a range of conditions. However, it is important to keep an index of suspicion in younger patients and consider: “Could this be the menopause?”
In some cases, patients were dissatisfied that doctors had not undertaken hormonal blood tests or referred them to a local menopause clinic.
Another significant category (9%) involved the menopause being misdiagnosed as depression, either involving a delay in diagnosis and treatment of the menopause or patients receiving SSRI medication which was ineffective for them. It is well-known that low mood and anxiety can be symptoms of the menopause, often presenting in this age group for the first time. These symptoms may be related to fluctuating hormone levels. It may therefore be challenging to determine whether a patient is suffering from the menopause or a mental health condition. Additionally, it should be kept in mind that patients with existing depression and anxiety may also have worsening symptoms as they experience the menopause. It is important to keep an open mind.
A concerning statistic is that the 45–54-year age group has the highest rate of suicide in women.4 Three of the Medical Protection cases reviewed did involve a patient’s death by suicide.
The Royal College of Psychiatrists has an e-learning module on menopause and mental health.5 Doctors may want to review this informative resource.
In several cases, there was a delay in the menopause being diagnosed, due to another physical diagnosis being made. Patients may receive a diagnosis of fibromyalgia, but it is important to keep in mind that the menopause may present with muscle and joint pains and lack of energy. Similarly, patients may experience migraine, brain fog, difficulty with word finding and loss of memory, and may be worried that these symptoms have a primary neurological cause. However, these are symptoms that can present in the perimenopause and may respond to hormone replacement therapy.
In the perimenopause, patients may remain fertile, and it is important for doctors to discuss contraceptive needs with their patients. Menopause is not considered to have occurred until one year after the patient’s last menstrual period. Medical Protection has seen cases where pregnancy was missed in a patient, as the amenorrhoea was presumed to be the menopause.
Members of the transgender and non-binary community may experience menopausal symptoms if they are taking hormonal preparations.6 It is important to recognise that if patients come off hormonal medication, they may experience menopausal symptoms. Similarly, if they restart particular hormones, adverse symptoms may occur. Menopausal symptoms can also be experienced naturally in some trans and non-binary people.7 While it is likely that patients will be attending a specialist gender clinic, it will still be essential that they receive support from their GP. The National Institute for Health and Care Excellence (NICE) will be including advice on trans and non-binary patients in its next update of its menopause guidance.8
Notably, in 17 cases (3% of all menopause-related cases identified), concerns over the doctor’s manner and attitude were the primary cause of a complaint or dissatisfaction. Some patients felt the doctors were dismissive of their symptoms or uninterested in the menopause as a potential factor in how they were feeling. In other cases, the patient felt the doctor was not appropriately trained in the menopause or up to date with the latest HRT preparations.
In conclusion, providing good, patient-centred menopause care is a challenge, but a very important focus for patients. Whenever a patient appears dissatisfied, or something goes wrong in the provision of their menopause care, try to work out why and how this happened and discuss this within your team. Learn from adverse events and take part in any review process. If in doubt, contact Medical Protection or your medical defence organisation for advice.