The authors categorised the barriers to, and facilitators of, menopause care into three key themes:
The context of contemporary care in England
This first section outlines the broad context in which HCPs provided menopause care and the experiences of women who sought support for symptoms; it also recognised that many women did not seek menopause care in general practice at all.
Participants discussed awareness of menopause and how that impacts patient presentation. They talked of their patients’ increasing awareness of menopause and HRT as a treatment option. All mentioned the impact of celebrities raising awareness of menopause and increasing information in the news and on social media. As one HCP commented:
‘More recently, they've come particularly because they're so aware of menopause symptoms in the general population. I think you'll probably hear it across your interviews, but the Davina McCall programmes are strongly influencing people to come.’ (HCP01)
Participants understood that patients perceived access to GPs to be challenging and suggested that some women experienced symptoms for a long time before accessing support:
‘Most of them have been suffering with symptoms for at least, sort of, three to four months before they come, and many substantially longer.’ (HCP01)
All participants stated having seen many women who had self-diagnosed; this was felt to be a change evident in the last 5–10 years, reflecting greater awareness and understanding about menopause:
‘I had a patient the other week who came with, like, she had all those little notes in a booklet, that she'd read. You know, she’s very well informed, and patients will be very well informed about their symptoms, and they'll be tracking — [using] those tracking apps and things — with their periods and things like that.’ (HCP14)
In spite of this, participants recognised that there were still some women who presented with typical symptoms, but were unaware that they could be menopause related:
‘The people that I tend to see, because of the socioeconomic class, the vast majority of people come in with a whole list of stuff. And I just think, "Oh, this sounds like you're perimenopausal or menopausal." And then they're like, "Well, I did think maybe, but then, actually ..." Or, or it comes as a complete surprise.’ (HCP11)
Some participants noted this as a cultural difference.
Several participants also reported some cultural differences in presentation:
‘I would say most of the women we deal with are women who are, kind of, in their late forties, fifties, who are still generally working and maybe struggling with that. But it’s predominantly, sort of, late forties, fifties, up to sixty-plus. But they generally tend to be White British.’ (HCP08)
This indicated that the increased awareness driving appointments may not have been spread evenly across communities.
HCPs also recognised the risk of making assumptions about how women with menopausal symptoms might present:
‘Am I beginning to expect that everyone who wants to talk about menopause is, themselves, going to introduce it and, themselves, going to talk about it? And, actually, if that’s not the case, then if we don't, kind of, maybe if I don't actively recognise that, might I be missing opportunities? And then maybe some inequalities could come up in that way.’ (HCP03)
Participants recognised that there were still many patients who lived with menopause-related symptoms and did not present to primary care:
‘I think a lot of women probably don't just present because they just feel it’s something that they should be tolerating or just going through as a part of ageing.’ (HCP02)
Current menopause care
This second section focuses on the experiences of HCPs who provided menopause care in areas of deprivation, within the context outlined in the first section. They focused on delivering safe and satisfactory consultations to women, with recognition of different cultural needs and identification of the systemic barriers to providing care.
Participants agreed that taking a good history was vital to understanding whether a patient was experiencing menopausal symptoms and devising a management strategy. They discussed the importance of differential diagnoses when advising women with potential menopause symptoms. GPs discussed potential overlap with physical health issues:
‘If they're complaining about night sweats, but they're heavy smokers, [you might be] thinking [...] “Could this be a cancer?” Don't just assume it’s menopause.’ (HCP08)
GPs also discussed potential overlap between menopause symptoms and mental health issues:
‘There’s a big, sort of, crossover with mental health problems, and anxiety in that age, anxiety and depression in that age group. And whether to attribute that to menopause, or whether that is just anxiety and depression, and needs treating as such, I think is quite difficult. And so, I've certainly seen anxiety as a result [...] of menopause being misdiagnosed.’ (HCP10)
Due to difficulties with diagnosis, some participants had seen women who had not had a discussion about menopause, despite previously having presented to other clinicians on multiple occasions with symptoms that were potentially menopause related. All participants agreed that:
menopause care should focus on understanding patients’ needs and expectations;
women’s experiences and symptoms could vary greatly; and
those experiencing health inequalities might not anticipate menopause or might experience other overlapping morbidities and communication issues that added barriers to presentation.
All participants agreed that a good consultation about HRT includes a discussion about its risks and benefits. Several participants suggested that many patients had very high, and unrealistic, expectations of how HRT could help them:
‘I saw more and more of these people, who, ultimately, were disappointed with HRT because it didn't deliver what they were hoping it was going to deliver. And, therefore, I got a little bit more savvy doing the consultations to try and see what it was that was bringing them for the consultation [...] But they weren't coming with acute presentations. A lot of it was social situations and emotional situations. And, you know, HRT was not [beneficial], and, and in a way, that was very disappointing for me and very disappointing for them, because [...] it was, like, their last-chance saloon for happiness, and then it didn't materialise.’ (HCP08)
They noted that patients had to be counselled to have realistic expectations. Several interviewees reported that, in most cases where expectations were managed, HRT had had a positive impact:
‘I think for the ladies that are on HRT, as long as they’re told it’s not an immediate fix, that sometimes we’ll have to tweak things, it might take a little bit of time to get them where we want them to be, [as long as we] temper their expectations immediately, I think, I think it’s [HRT], it’s really great, and I think the vast majority are delighted with it, to be fair.’ (HCP09)
Participants reported that patient safety factors determined the treatment they offered, including the form and dose of the HRT prescribed, but some felt that there were a lot of HRT options and updates of which they had to keep abreast. Many participants reported having received requests for testosterone and some said they had been asked to prescribe off-licence doses of hormones:
‘The other thing that we've had highlighted at one of our meetings is requests from private doctors to prescribe quite high-strength preparations of oestrogen, which we've had a, had a discussion about, and, and made a policy that we're not comfortable to prescribe off licence. And we'll make that clear to the patient, and the private doctor as well.’ (HCP04)
Dealing with these requests was felt to present an increasing stress on clinician capacity. Variance was reported in relation to approaches to testosterone based on geographical location and clinical experience:
‘I mean, at the moment we haven't got a licensed preparation for women for testosterone so I think that has to be a barrier, because you have to tell people that it’s not a licensed thing when you prescribe the meds and you have to explain all that.’ (HCP07)
‘I don’t start patients on testosterone a great deal of the time. I can count on my hands the amount of times I’ve done it.’ (HCP11)
‘We've recently been able to start prescribing testosterone for low libido, with some guidance about how to do the bloods, and how to follow these patients up. I guess we have more clarification about when to do blood tests, and things. So yes, in that respect, that has really grown.’ (HCP14)
Participants agreed on the importance of continuity, and some attempted to schedule ongoing monitoring after HRT had been prescribed. In a context of overstretched resources, however, most suggested that they found continuity and personal follow-ups unachievable. As one HCP stated:
‘The only thing is, sometimes we don't get to follow up with the same patient.’ (HCP02)
Participants accepted that some women would not choose to take HRT and wanted to discuss alternatives, such as over-the-counter medicines and lifestyle changes:
‘For whatever reason — might not just be a contraindication, might be that they're happy to go with, you know, conservative lifestyle measures, herbal remedies — and for whatever reason [... patients] don't want to use HRT or something prescribed. Just, again, anecdotally, I just remember one lady saying, “Well, yeah, it’s the menopause, it’s gonna happen. And happened to my mum, and she got through it. So I’m sure I'll be fine.”’ (HCP04)
Limitations of the current model of menopause care
In this final section, the limitations of providing care, and why the current care model does not work for many people, are considered. Participants explored the needs of those experiencing health inequalities, and the barriers and facilitators to providing care to these groups.
Resource implications of meeting the needs of diverse and deprived communities were discussed; this included the provision of interpretation services:
‘About thirty to fifty per cent of our consultations are in a foreign language so, we've got three interpreters in the practice at all times.’ (HCP15)
Some participants suggested that women presented and discussed menopause differently, depending on their cultural background. Difficulties in having meaningful conversations through an interpreter, which was sometimes a family member, were also highlighted:
‘I have definitely spoken to patients who've talked about not having words for “menopause” or how it wasn't something that gets talked about. So there may be groups where there is stigma or a taboo.’ (HCP03)
When asked about the ethnic groups of women presenting for help, multiple participants reported that, in their experience, non-White women were less likely to present with symptoms:
‘I can't remember the last time I spoke to anybody Black or Asian about HRT, which is interesting.’ (HCP10)
Participants also reported that they saw an overlap between affluence and awareness/understanding related to menopause, with more affluent women being more likely to self-diagnose and advocate:
‘From the more deprived area, it tends to be something that you suggest to them, I think. You, sort of, say, “Could this be menopause?” And they say, “Oh, yeah, well, yeah, I am fifty. I suppose that could be what’s happening.” It’s like, so, we have a chat about it, and then that leads on to a chat about HRT. So, certainly, certainly [there is] a difference in, in the approach to seeking HRT between the two demographics, I’d say.’ (HCP11)
Participants reported that there were many patients with low levels of menopause awareness/understanding and that it was easier for the GP to support patients with higher levels of menopause awareness. When asked about this barrier, interviewees suggested that written information might not reach everyone and misinformation still exists; however, several also proposed that outreach and advocacy work in communities could help, and gave practical examples from their own work and networks. Examples of best practice are shown in Supplementary Box S1.
When asked about barriers to care, many participants recognised that access to GPs can be problematic:
‘Can you get past the front desk? Do you have the, kind of, social capital, the confidence to get past the front desk to get into an appointment? Does the type of consultation make a difference? Is this something where, if it’s all remote, you might not feel [heard]?” I don't know the answer to that. But I guess those are things that I wonder about.’ (HCP03)
All participants suggested that time and capacity were the largest barriers to providing good menopause care:
‘Time. So, the people I work with are brilliant. Primary care is so stretched at the moment. Stretched to capacity, stretched financially. We’re seeing our, our income reduce year on year, over the last few years. Particularly since COVID. I have not asked for more than ten-minute consultations [for] menopause, but I know that they [GP partners] would say “no”. Because it’s core GP work, it’s standard GP work. But you try and do a menopause consultation, even a follow-up, in ten minutes. It’s absolutely impossible.’ (HCP05)
More time and, often, multiple appointments were considered necessary to be able to provide good care to patients from minoritised ethnic groups; this was seen as a barrier in an environment with limited capacity:
‘We haven't got the resources or the time to back it up. ’Cause, effectively, what we're doing by doing that is saying, “Oh, let’s just have a load of double-length interpreter consultations with our most experienced senior female staff”, who are already in demand. So I think we would, anything that we did, sort of, along these lines, would have to be really well financed.’ (HCP01)
‘I mean part of the beauty of being a GP is that you develop that rapport with the patient and you can figure out what it is that they will most benefit from. But you need to have the luxury of getting to know the patient and the time to do that [...] so I think it comes back to the time.’ (HCP07)
Some participants reported receiving good support from secondary care for complicated cases. In contrast, others found it difficult to access the support needed from secondary care and suggested that the time required to access secondary care is a barrier to good menopause care:
‘They [Some patients] should be under the care of a specialist in, in menopause. But then it’s so hard to access that, you know, you don't know when they're gonna be seen. It could be a year down the line, and patients want, want things done now, you know.’ (HCP04)
Participants made a range of suggestions based on their perceptions of the current context of menopause care and why the current care model doesn’t work for everyone. They suggested that general practice should have female GPs and nurses with a specialist interest in menopause care, and offer continuity of care where possible. Participants identified an increased need for menopause and HRT training, and awareness for all practice staff in order to facilitate the best care for all. They reported a need for up-to-date research and evidence, and targeted knowledge about specific communities:
‘I’m a fan of continuity, so I like to see the ladies again … I like them to be able to come to me and say, you know, sorry doctor but the [medicine] did nothing and you need to do something more.’ (HCP01 )
‘The conversation about wider education that is specific to communities … then, there probably is something about training and expertise for people working in these areas, but very specifically targeted at, “Okay, how do you have a conversation with someone who’s really reluctant to have HRT? Or doesn't even understand it?” So, it’s not just generic training for menopause, it’s actually a bit more targeted, to say, “When you're working in these groups, and these areas, these are things that can be helpful. And these are the resources you can direct people to.”’ (HCP15)
Participants suggested that, in contrast to the current climate of awareness, there is a clear gap in public awareness and education about the menopause in deprived communities, and suggested that women with greater understanding and awareness of menopause and HRT were more likely to receive good care. They described some of the resources to which they had signposted women, but also identified a gap in good-quality resources in different languages or those aimed at different communities and in easily digestible formats, such as video and audio, which would be effective alternatives to written resources. It was recognised that more-accessible information was needed in a range of languages and styles that are culturally relevant, authentic, and co-produced. Participants expressed that specific guidance on how to work with sub-groups of women might facilitate improvements in menopause care.
Many participants suggested that community outreach was important to reach specific groups, and several had evidence of existing positive work in this arena, including the benefits of learning in community groups. Some examples included working with specific minoritised community groups, and using mechanisms — such as family learning — to share education with, and through, multigenerational families. These were individual cases of excellence, and not linked to any projects working at scale; examples are outlined in Supplementary Table S1.
