My doctor won’t budge! – Shared decision making with your healthcare professional

“You’re too young to be menopausal”  “But you don’t get hot flushes”  “HRT is too risky”  “The drug is not licensed to be used in this way”  “You’re on the safest dose I can allow”

Do these phrases sound familiar? If they do, you are not alone. Many women struggle to find a healthcare professional that will not only listen to their concerns about menopausal symptoms but engage in a meaningful informed discussion around treatment options – especially the use of HRT – and develop a jointly agreed plan about the best way forward.

The days of ‘doctor knows best’ are outdated and no longer reflect the current approach used by GPs when it comes to making decisions about your health. The role of the healthcare professional is to advise their patient and give relevant information in a clear and supportive manner, to enable the patient to decide on their preferred course of action.

If this sounds too good to be true, we hope the following information leads you to have improved shared decision making with your health professional around your menopause and treatment options.

How it should be done…

New guidelines from the General Medical Council (GMC), came into effect in November 2020 around how decisions should be made between a patient and doctor and how informed consent should be gained (read them in full here).

In June 2021, the National Institute for Health and Care Excellence (NICE) published Shared Decision Making guidelines (NG197) to promote ways for healthcare professionals and people using services to work together to make decisions about treatment and care. It includes recommendations on training, communicating risks, benefits and consequences, using decision aids, and how to embed shared decision making in organisational culture and practices.

If you are having difficulty accessing the HRT treatments you would like, the following statements from these guidelines will be of interest to you.

The GMC states that Doctors must…

•             Keep their professional knowledge and skills up to date

•             Recognise and work within the limits of their competence

•             Work in partnership with patients

•             Listen to, and respond to, patients concerns and preferences

•             Give patients the information they want or need in a way they can understand

•             Respect patients’ right to reach decisions about their treatment and care

•             Support patients in caring for themselves to improve and maintain their health

Doctors and nurses have a duty to give patients clear, accurate and up-to-date information, based on the best available evidence.

NICE guidelines state that clinicians should…

• encourage the patient to take an active role in making decisions about their treatment
• take into account what is most important to the patient, their expressed needs and priorities, and explain treatment options in light of these
• have an open discussion about the risks, benefits, and consequences of each treatment option, including doing nothing, with the acceptance that the patient’s views can differ to the professional’s
• allow time to answer questions and time to make decisions, making it clear that the patient can change their mind down the line
• come to a joint decision that is satisfactory to the patient

All patients have the right to be involved in decisions about their treatment and to make informed decisions if they can. For menopausal women, this means the information healthcare professionals give about HRT should be based on the best available evidence when discussing the risks and benefits of HRT. This should include information about the various ways to take HRT, and an explanation about how any risks are particularly relevant for you. They should support you to come to a decision about what treatment you would like and respect your right to make that decision.

Montgomery ruling

In 2015, (as a result of a legal case by a mother called Nadine Montgomery), the law around consent saw a significant shift that positioned the patient in the centre of their own healthcare decisions.

The ruling stated:

“The law on consent has progressed from doctor focused to patient focused. The practice of medicine has moved significantly away from the idea of the paternalistic doctor who tells their patient what to do, even if this was thought to be in the patient’s best interests. A patient is autonomous and should be supported to make decisions about their own health.”

In response to the Montgomery ruling, General Medical Council chief executive Niall Dickson, said:

“We are pleased that the court has endorsed the approach advocated in our guidance on consent. [Doctors] must work in partnership with their patients, listening to their views and giving them the information they want and need to make decisions.”

Both the law and guidelines from medical professional bodies agree that patient choice matters and should be central when making decisions.

It shouldn’t be so hard to get the menopause treatment you want, so what can you do about it?

How to encourage shared decision making with your healthcare professional

Do your own research and be prepared

Use reputable, evidence-based sources of information, such as the NICE menopause guidance and the shared decision making guidelines. 

Keep a record of your symptoms (you could download the balance app to do this) before you start any treatment and also afterwards to gain a good understanding of whether treatment is helping. Read up about your symptoms, and the role hormones play in different areas of your body.

If you are interested in starting HRT, learn about the different components involved, for example, estrogen, progesterone and possibly testosterone. Read about the different ways to take replacement estrogen, such as a patch, gel or spray, and think ahead about which option you prefer. If you still have your womb, learn about the different forms of progesterone/progestogen and decide which one you would like to try.

If you have already started HRT and want to change the way you take it or want the dose to be altered, read up about those specific issues and the risks and benefits to your health.

You may want to use vaginal (local) estrogen in the long term but have been incorrectly told you need to stop using it. You may have read about the benefits of testosterone but have been wrongly told that testosterone is not safe and cannot be prescribed.

The NICE menopause guidelines are a very useful set of guidelines for doctors in diagnosing and managing the menopause. Unfortunately, doctors are not always aware of these recommendations, so you may want to print off particularly relevant sections for you and take it with you to an appointment.

Plan the time you need

If you feel the usual 10 -minute appointment time is not going to be long enough to discuss things adequately, you can ask for a double appointment before you book or spread out the discussion over two separate appointments at different times. Try and be as succinct as you can when explaining things to your doctor and write comments or questions down, if you’re worried you might forget in the moment.

The healthcare professional should answer your questions honestly and accurately, and as fully as they can in the time allowed. They should be clear about the limits of their knowledge and, if they can’t answer a question, they should explain whether it’s something they just don’t know themselves or something that no one knows yet because the research hasn’t been done.

Know your rights as a patient

You have the right to choose what treatment you would like as long as you show you fully understand all the implications of the decision, including any risks there may be. This includes any treatment option that your healthcare professional does not think is the best option. Regarding your decision as ‘unwise’ is not enough of a reason to refuse, if you can show you are informed and have considered the consequences of your choice.

Explain your reasons for making your decision, your understanding of what is involved, and your expectations of how it would improve things for you. The doctor or nurse should take these factors into account before deciding whether or not to prescribe the treatment you want.

If, after discussion, the professional does not consider your treatment choice an appropriate course of action, they do not have to provide it. The doctor or nurse should explain their reasons for refusing it to you and explore what other options might be available, including your right to seek a second opinion.

If your doctor wants to provide a treatment for you that you disagree with, say so. Professionals need to show that you consent (agree) to any decided course of action. For example, many women are prescribed antidepressants when they first go to their GP for HRT. This is not recommended as an appropriate ‘first-line’ treatment for menopausal women and you do not have to agree to this way of managing your symptoms.

Be persistent but polite

If you do not get the desired outcome at the first appointment, try again another time, and in the meantime research the evidence base for the reasons why your preference was denied.

You can ask to see another doctor (or nurse) within your practice. Ask which member of the team has an interest in menopause or women’s health and if there is no one with that interest, consider changing practices to one where there is.

If you are struggling to find a GP with an interest in women’s health, you can search all of your local practices here  and then click through to a surgery’s own website. Under ‘Staff’ or ‘Team’ tabs there is usually a short description of each GP (or nurse) and their special interests.

If you think writing a letter to your doctor would be useful, we have a template here that you could base it on.

Ask if there is an NHS menopause specialist clinic in your area or, if you are able, consider having an appointment with a private menopause specialist.

In general, your best approach when talking to your doctor about your menopause is to clearly state your reasons for what you would like, explain what information has led you to this decision, and that you know what the associated risks might be but that it is still what you choose to do. This information may need repeating on several occasions, to several doctors or nurses, but persistence often pays off when you can give a clear and rational argument that shows careful consideration of the evidence of the risks and benefits to your health.

Useful External Links

NICE menopause guidelines: https://www.nice.org.uk/guidance/ng23

NICE Shared Decision Making guidelines: https://www.nice.org.uk/guidance/ng197

GMC guidelines on decision making: https://www.gmc-uk.org/-/media/documents/updated-decision-making-and-consent-guidance_pdf-84160128.pdf