Delay in prescribing testosterone
11. Ms A tells us she started on HRT in October 2021 and went back and forth trying hormone treatments, including different oestrogen gels and patches, that gave her no relief. She tells us she asked the Practice for a prescription of testosterone but the GP refused to prescribe this until November 2022. Ms A says she went through more pain, discomfort and disruption to her life than she would have if she had been given the testosterone earlier.
12. The Practice says it sympathises with Ms A’s experience of seeing little improvement of her symptoms while she was on HRT, but testosterone is not commonly prescribed to treat menopause. It explains it followed the current NICE guideline which says testosterone gel is not licensed for use in women but can be prescribed after the menopause by a specialist doctor.
13. Our adviser pointed us to the NICE guidance on the diagnosis and management of menopause. This tells clinicians to adapt treatment as needed based on the woman’s changing symptoms and to consider testosterone supplementation for women with low sexual desire if HRT alone is not effective.
14. Other clinical resources such as the NHS article on ‘Types of hormone replacement therapy (HRT)’ and the BMS guidance are clear that testosterone treatment is not the first treatment offered for menopause. Testosterone treatment should only be considered when a woman reports ongoing low sexual desire and other options have been exhausted.
15. We can see from the records that while Ms A reported ongoing menopause symptoms, low sex drive (decreased libido) was first reported in August 2022. She had filled in electronic questionnaires before attending consultations and at least two times, in October 2021 and then in May 2022, she was asked if she had experienced decreased libido and her answer was ‘no’.
16. Once Ms A reported lowered sex drive on 24 August 2022, the Practice arranged a referral to a gynaecology clinic. A consultant gynaecologist reviewed her in September 2022 and recommended the GP first try changing Ms A’s HRT from oestrogen pump packs to tablets or patches, and if this did not help, to give lifestyle advice to help with the decreased libido. The gynaecologist did not suggest prescribing testosterone at this point. In November 2022, after other treatments continued to be ineffective, the Practice prescribed testosterone as recommended by the gynaecologist.
17. We think the Practice acted in line with guidance by considering testosterone only when Ms A reported a decreased libido, and by following the gynaecologist’s advice to see if changing HRT might help. Even in patients who are experiencing low sex drive, the correct clinical approach according to NICE and BMS guidance would have been to try lifestyle changes and other medication first to see if there is improvement. While we accept it took a long time for Ms A to get relief from her symptoms, unfortunately, this was unavoidable as other treatment had to be tried first.
Delay in blood test to support testosterone prescription
18. Ms A says the Practice did not quickly arrange for her to have a blood test, which would have supported her prescription of testosterone. The Practice said that her testosterone levels when tested were within ‘normal’ levels and it followed NICE guidance on testosterone prescription.
19. BMS guidance on testosterone prescription says blood tests are used to make sure a woman is not getting too much testosterone on top of her own natural levels, not to see if she needs testosterone. This can be checked by taking blood tests before starting testosterone treatment and then again after a few months.
20. Ms A first reported low sex drive in August 2022, which would have been an indication to consider testosterone treatment. A GP arranged a blood test for Ms A on 25 July, but said this was for the purpose of finding what was causing her constant fatigue, rather than to explore the possibility of prescribing testosterone. This blood test found that her testosterone levels were normal but her vitamin D level was ‘slightly low’, which could have caused her tiredness.
21. The GP later referred Ms A to the gynaecology clinic with a note about her testosterone levels and decreased libido. The gynaecologist wrote back to say the Practice could first try varying her HRT medication and to check her free androgen index levels (FAI is a measure of biologically active testosterone in blood). They said if her FAI level was less than 1% this would mean they could potentially prescribe testosterone safely and they could recheck in three months, to make sure it was not too high (over 5%).
22. We do not think there was a delay in arranging blood tests, as the Practice did not have to arrange a blood test even after Ms A reported decreased libido in August 2022. Having done a blood test already in July, the Practice were able to gather the information necessary (checking that her testosterone level was not so high that she should not have supplements) which was useful for the later prescription of testosterone.
Delay in referral to gynaecologist
23. Ms A complains a GP at the Practice agreed to refer her to a gynaecologist in April 2022, but that did not happen until August.
24. The Practice was unable to give any comments on this issue.
25. The records show that on 5 April Ms A spoke to a GP (Dr A) on the phone, who prescribed new oestrogen patches as her ongoing HRT. Dr A also agreed to refer her to a gynaecologist if those new patches did not improve her symptoms over the next two months.
26. On 10 June, Ms A spoke to another GP (Dr B) on the phone who said she should try a different HRT first (oestrogel) for at least a month before referral to secondary care. We can see Ms A was not happy about this but agreed to try the new medication. Dr B also offered to book her in for a phone call with Dr A, which Ms A accepted. Dr A messaged Ms A on 30 June to arrange a call, but it seems she did not respond.
27. Ms A had another phone consultation with Dr A on 25 July and they discussed her ongoing treatment. Ms A reported improvement in sleep and her joint aches had eased for two weeks before returning. She continued to experience tiredness. Dr A agreed to a blood test to look at this, but there was no discussion of a gynaecology referral. It was only after Ms A reported lowered sex drive in August that the Practice arranged a referral.
28. NICE guidance on management of menopause says clinicians should:
‘1.4.20 Refer women to a healthcare professional with expertise in menopause if treatments do not improve their menopausal symptoms or they have ongoing troublesome side effects.
1.4.21 Consider referring women to a healthcare professional with expertise in menopause if: • they have menopausal symptoms and contraindications to HRT or • there is uncertainty about the most suitable treatment options for their menopausal symptoms.’
29. In line with this guidance, if there had been no improvement in her symptoms after starting the new oestrogel in April 2022, it would have been appropriate for the Practice to refer Ms A to a gynaecologist for review. The records show there was at least some temporary improvement by July. There was no sign of negative side effects from HRT.
30. We think the Practice acted in line with the guidance by referring Ms A to a specialist in August when she experienced no relief from symptoms and reported decreased libido. We do not think the Practice should have referred Ms A in April because she was trying a new HRT and it was appropriate to wait to see if that improved her symptoms.
31. We appreciate trying different hormone treatments for months at a time with no long-lasting relief and not feeling supported was stressful for Ms A. We hope we have given her some reassurance that this was because of the features of menopause and HRT and not because the Practice had failed her.