Participant characteristics
Participant characteristics are shown in Table 1.
Table 1. Participant characteristics Patients
Of 54 patients who expressed interest in participation, 34 were eligible. The most common reason for being ineligible was being on HRT at the time of the consultation. Eighteen of the 34 eligible women proceeded to interview, following receipt of the study information leaflet and consent form; 16 did not respond to their invitation for interview.
The mean age of patient participants was 48 years, and just over half (n = 10) had a graduate or postgraduate degree. Eight participants were in IMD deciles 1–5, which indicated greater deprivation. Most patients reported other perimenopausal symptoms, the majority of which were vasomotor symptoms. Subsequent to their consultation, but prior to interview, four women had started taking HRT; these women were included in the analysis as it was considered important to ensure that women whose mood changes had been identified as linked to perimenopause during or after their consultation were not excluded.
GPs
In total, 11 GPs made contact regarding the study and all proceeded to interview. There was a relatively even distribution of gender and level of practice deprivation. Two GPs were from the same practice.
Themes
Themes and sub-themes for patients and GPs are detailed in Supplementary Tables 1 and 2. The data were organised into four shared themes — uncertainty, consultation context, management, awareness — across GP and patient interviews. Five unique themes were identified for patients:
Five unique themes were also identified for GPs:
The most prominent shared and unique themes that elicited the richest data (Figure 1) will be discussed. Agenda setting was considered to be a theme for GPs due to the substantial amount of data collected; though patients also discussed agenda setting, this was classified as a sub-theme under ‘consultation experience’ as less emphasis was placed on this by patients.
Agenda setting
Both patients and GPs described patient-led agenda setting in consultations. Though GPs described this as a distinct component of the consultation, patients discussed this in the context of their overall consultation experience. Many patients reported being asked to describe why they had come, or what they wanted, at the beginning of the consultation. Some patients perceived this to be a helpful shortcut to getting what they needed; others felt they needed more support from the GP to help identify what they needed:
‘I said “This is what I want” because, invariably, most doctor’s appointments are like, “What can I do for you?”. So I was like, “Well this is the issue, this is the problem, I think this [HRT] might be the solution”, and he said “Yeah I agree, I think we should try you on a low dose”.’ Patient 16
‘She said “What do you need from me?” And I’m like, “I don’t know at the moment, I don’t know what I want, I don’t know what I need, but I know I need to do something”.’ Patient 18
GPs agreed with this and perceived their consultations to be patient led; they reported using questions to establish the patient’s expectations and to define what would be discussed as early as possible during the consultation. This was seen as important for meeting patient expectations and being efficient:
‘We generally don’t have that much time do we? So you … and I think when you’ve been in practice quite a long time you get good at getting to the shortcut and finding out what they actually … want.’ GP 10, male, GP partner
Many GPs reported that they would not routinely enquire about perimenopausal symptoms when a patient presented with mental health symptoms, even for patients in the perimenopausal age range. Most reported utilising a standardised approach to a patient presenting with a mental health symptom that was initially very open and patient led, and led onto routine mental health questions regarding risk of self-harm and suicide; this rarely changed based on the patient’s age or sex:
‘I guess I’ve seen people consider menopause as one of the causes, or I’ve seen patients just bring it up themselves. But I guess I wouldn’t say that I think about it a lot when I see people. I don’t look at their age and think “Could it be menopause?”.’ GP 8, female, GP registrar
‘In that age group, it wouldn’t be my most immediate thought that it would be perimenopausal without the patient mentioning that they think they have menopausal symptoms.’ GP 2, male, newly qualified GP (NQGP)
Though many GPs described routinely asking about some specific physical symptoms associated with mental health — including sleep, appetite, and palpitations — many stated that they would be unlikely to explore key perimenopausal symptoms, such as a change in menstruation or hot flushes, even for patients in the perimenopausal age range:
‘I think probably, honestly, I probably haven’t specifically, unless there’s something that they say that suggests to me … “I’m feeling really sweaty”. They might volunteer it. I don’t think I’ve put it as part of my checks that you do at the end, like your closed question bit … so I haven’t really been doing that, and then only if it comes up I suppose.’ GP 10, male, GP partner
In contrast, however, some GPs — particularly those with an interest in women’s health — did report asking patients about their periods and felt this also informed them about other mood disturbances linked to hormonal fluctuations, such as premenstrual syndrome and premenstrual dysphoric disorder:
‘Sometimes they’re just presenting with the mental health side of things, and even you asking where they’re at with their periods can help them think “Oh, could that be related to what’s going on right now?”. Sometimes it’s the first time they’ve made that potential link.’ GP 1, female, salaried GP
Consultation experience
Some patients reported being aware that their symptoms could be linked to perimenopause, but experienced other barriers to addressing this during their consultation. One patient mentioned embarrassment:
‘I do, I get night sweats, I get palpitations and I don’t think that’s connected to the other things. I just don’t sometimes feel in control. At the same time, despite all my health problems, I actually feel embarrassed to ask.’ Patient 11
Another felt that raising the issue was breaching the time allocated for the consultation:
‘I did go into that consultation thinking “I’m not really allowed to talk about it”, so I did, but I was quite conscious of “I don’t want to take too much time doing this”.’ Patient 17
Even when a patient did feel confident to discuss perimenopause with the GP, this was not necessarily a facilitator to receive the support they required. One patient who had discussed perimenopause with her GP had her concerns dismissed:
‘The doctor was rushed, and said “The thing is it’s just not … there is no actual evidence that this is hormonal at all, it’s very likely to be depression, especially as the fact you’ve got a history of it”, and I said “But does my age not come into this?”. And I found out my family history is menopause quite young, and he said “I don’t think that’s got any bearing on it, and we’re getting a lot of this”, he said. “There’s a lot of hysteria about it, and the media hasn’t necessarily helped.”.’ Patient 7
However, one patient whose GP did initiate a conversation about perimenopause found it helpful and, in turn, it informed their understanding on the menopause transition:
‘When I went to the doctor recently [they] said “Oh well, you can have things happening from the age of 40.” I didn’t realise that, I thought that was just in the, maybe, couple of years leading up to the point where your period is due to stop is when you start noticing stuff.’ Patient 6
Uncertainty
Patients described finding it difficult to know whether their mental health symptoms could be influenced by hormonal fluctuations in perimenopause. Most patients initially attributed their symptoms to social circumstances and recent life events. However, many felt that hormones could be an additional factor in their mental health symptoms, and that perimenopause created instability or lowered their resilience for dealing with the normal stressors in their everyday lives. Some patients mentioned that they were either using contraception methods, or had had procedures that affected their periods and, therefore, had been unable to tell whether there had been changes to their menstrual cycle. This created further confusion regarding their menopausal stage and whether it played a part in their mental health symptoms:
‘But I do think that was wrapped up with probably I’d moved country, I’d changed job, I probably … my relationship wasn’t great, so probably [I] was burnt out at some point. But I think it’s almost, if you’re informed, it’s almost a natural question when you start to hit your mid-to-late 40s: “Is this something more, is it perimenopause?”.’ Patient 10
‘So in my head there was a more obvious reason that these things were happening, and I hadn’t really joined the dots if there are dots to be joined, I don’t know.’ Patient 3
GPs noted the difficulty in diagnosing perimenopause in patients presenting with mental health symptoms, particularly for those who had other complex physical conditions and previous mental ill health. Many GPs acknowledged the uncertainty provoked by these consultations and how attaining a balance or ‘middle ground’ without a definitive diagnosis was difficult for both themselves and the patient:
‘It’s much easier if somebody comes in and says “I’m having awful hot flushes and night sweats, brain fog, and my mood isn’t brilliant”… rather than somebody who comes in and has a textbook presentation of low-level depression or anxiety, and then they say “Oh I wonder if it might be my hormones”. I’m like, “I don’t even know, maybe, I’m not sure,” and then what do we do about it?’ GP 3, male, NQGP
‘Yeah, depends on … if their presentation is more mental then it will be a mixed approach where lots of factors tie into it. If it’s very much a more menopause kind of thing then the menopause [is the] focus, rather than going down a mental health line. But often there’s in-between, which is tricky.’ GP 6, male, NQGP
GPs found it particularly difficult to hold this middle ground when patients felt their symptoms were secondary to hormonal changes, but had a more complex mental health history or other strong risk factors for a primary mental health diagnosis:
‘But it’s difficult because you get a bit of pushback sometimes to the suggestion that particularly if someone has come in with that [perimenopause] in their mind, you tend to get a pushback if you then try and explore other factors, and sometimes people feel as if you’re dismissing.’ GP 7, female, salaried GP
Awareness of perimenopause
Both patients and GPs commented on increasing awareness of perimenopause. Though GPs attributed this mainly to media coverage, patients discussed attending employer workshops and increased awareness due to the experiences of friends and family:
‘We would discuss it quite a lot at work, and we felt comfortable enough to do that.’ Patient 8
‘I discussed it with some friends, and some had already been through it, are a bit older than me and stuff, and yeah they said “It sounds like you’ve got perimenopause”, and I start to learn a bit about it, then realise what it was, yeah.’ Patient 9
However, many GPs perceived significant socioeconomic and cultural differences in patients’ awareness of perimenopause. They described how patients from predominantly White, affluent areas were more likely to have greater awareness and set the agenda of their consultation to access support for perimenopausal symptoms, whereas those from more deprived backgrounds might not even recognise their symptoms as being secondary to perimenopause:
‘I think our area it’s traditionally quite deprived. I think we’re in the bottom 15% of, in terms of deprivation in [city] with some of our wards and stuff. So I think the level of education of some of our patients is quite relatively low, and that’s not an insult it’s just a fact. So I think some of them don’t really recognise when [there are] symptoms [of perimenopause] that are happening to them.’ GP 10, male, GP partner
‘When I was in [town] we had more people of colour, people from different cultures, so I noticed people who were from different cultures might be a bit more hesitant to talk about the menopause.’ GP 5, female, GP trainee
‘So in one extreme, you might have somebody who’s watched all the Davina documentaries and really [laughs] this is definitely what’s going on, and then might be blinkered to other things. Or you might, at the other extreme, well not extreme, but you might also have somebody who goes “Well I’ve battled depression and anxiety all my life, and I know this pattern, and this feels the same”.’GP 1, female, salaried GP
One patient mentioned that their GP had been the first to mention earlier onset of symptoms. Other patients discussed their lack of awareness of perimenopause until experiencing symptoms themselves, or only finding out quite late in life:
‘One of my nephews he went to [country] as a doctor, and he was making the joke of his auntie, my sister in law, that “Oh they’re going through menopause”. So I ask my son I say “What is menopause?”. And he explain to me, and then now I start realising.’ Patient 13
‘I didn’t really know much about it before. I just thought one day you stopped and that’s it, I didn’t really know there’s a build-up to it until I started having that experience for myself.’ Patient 9
Personal experience could also influence GP awareness and subsequent interest in perimenopause symptoms, as well as awareness of mental health issues in perimenopause:
‘I literally had a conversation with a close friend last night, she’s 45 I think, and just her story, I was just like, “I think I’ve heard this story before”. So it’s more from that, that I’ve maybe gained more of an interest about it, because my peer group, and my friends, my family and things are all getting to that age.’ GP 10, male, GP partner
‘One of my best friend’s mums, when she was going into her perimenopause, had a dip in her mental health, and I remember talking to her about that before starting salaried life, and she was saying “You should always think about mental health stuff associated with menopause for women who are my age, because my GP never really linked the two of them together”.’GP 3, male, NQGP
Clinical experience
All GPs commented on a lack of training on perimenopause and menopuaseduring medical school, which affected confidence managing perimenopause. However, most had participated in some — albeit limited — during their GP training. This was particularly the case for NQGPs, many of whom had completed short modules or lectures, while others with a special interest had completed courses. GPs who had a doctor with a special interest in menopause at their practice found it to be a useful way to keep up to date and discuss difficult cases:
‘We’re very lucky in that one of the GPs in my practice has done additional training, so she’s now a qualified menopause specialist — I can’t remember what the qualification is exactly — and she’s done a few sessions for us on menopause management.’ GP 7, female, salaried GP
‘I have not become well versed enough in it to be confident to be like, ”Oh right, you’ve got a uterus but you’re still having periods, so we need to give you blah, blah, blah”, and the flowcharts and things.’ GP 3, male, NQGP
The GPs who had not undergone recent or additional training on menopause were aware of the gap in their knowledge and how this affected their confidence in managing perimenopause in consultations:
‘I feel like I would benefit from more training, because it’s something I haven’t experienced, so I need to know what happens, and what people actually… what patients’ feedback is, what they benefit from.’ GP 8, female, GP trainee
‘I feel frustrated sometimes when people bring it up, because I know that I’m not going to be as comfortable navigating the rest of the consultation, because I essentially don’t know.’ GP 3, male, NQGP
