A practice in the Leeds area

6. Ms J complains about the care she received from the Practice. Ms J says the Practice:

• did not appropriately treat her perimenopause symptoms and disregarded her concerns she was perimenopausal based on normal blood test results • did not prescribe her HRT • did not advise the Practice policy of only prescribing HRT to over 45s.

7. Ms J says she suffered with perimenopause symptoms for four to five years without treatment, which had a significant impact on her mental health. She has since moved surgeries and been immediately prescribed HRT, which has significantly improved her quality of life. She says she felt dismissed and abandoned and her menopause experience was made needlessly difficult.

8. Ms J is seeking an apology, acknowledgement of failings and service improvements.

9. Ms J is a 45 year old woman. She had a womb ablation in May 2019. She says her mother went through an early menopause and was prescribed hormone replacement therapy (HRT) from the age of 44. She says she presented to her GP numerous times between 2021 and 2025 with perimenopause symptoms, but the Practice did not prescribe her with HRT. She was prescribed HRT when she moved to difference practice in March 2025.

10. On 24 September 2019, Ms J expressed concerns to her gynaecologist, saying she was experiencing symptoms of the menopause. The gynaecologist ordered blood tests, which came back as normal on 2 October 2019.

11. On 21 October 2019, she attended a GP appointment with continued perimenopausal symptoms. The Practice ordered repeat blood tests. These came back as normal on 7 November.

12. On 27 September 2021, Ms J attended a GP appointment presenting with perimenopause symptoms. The Practice requested further blood tests and results came back as normal on 14 and 26 October.

13. Ms J had a further GP appointment on 26 April 2024 and the Practice ordered a blood test. On 30 April, her bloods were normal. The Practice ordered repeat blood tests at a further appointment on 21 October and were normal.

14. On 19 November and 13 December, Ms J had further GP appointments and the GP requested additional blood tests. These results came back as normal on 31 December.

15. On 17 January 2025, Ms J had another GP appointment, when she described similar symptoms. The Practice GP referred her to a private endocrinologist.

16. On 11 March, Ms J changed GP practices and had an appointment with the nurse on 15 March. The nurse at the new Practice recorded Ms J was likely perimenopausal and HRT was offered and accepted. Ms J reported the HRT improved her symptoms significantly over the following months.

The Practice did not appropriately treat Ms J’s perimenopause symptoms and disregarded her concerns based on normal blood test results

20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

21. Ms J complains the Practice did not appropriately treat her perimenopause symptoms following her appointments between 2021 and 2025. She says it disregarded her concerns she was perimenopausal based solely on her blood test results.

22. In its response to Ms J’s complaint, the Practice said it had followed NICE guidance NG23, ‘Menopause: identification and management’ when it treated Ms J.

23. It must have been difficult for Ms J to experience challenging symptoms over an extended period of time. We recognise she is concerned that the Practice should have given her HRT earlier, after she had good results with the treatment when she changed practices in March 2025. We are very sorry to hear of the distress this has caused her.

24. NICE NG23 section 1.3 covers identifying menopause and perimenopause. Section 1.3.1 says menopause can be identified in people aged 45 or over with menopause-associated symptoms. Section 1.3.6 says clinicians should consider using a FSH blood test to confirm menopause only in people aged 40-45 with menopause-associated symptoms. These sections of the guidance have not changed in the period of care Ms J complains about.

25. The records show Ms J presented to her gynaecologist in September 2019 with perimenopause symptoms. The clinician ordered an FSH blood test, the results of which did not indicate menopause or perimenopause.

26. Ms J presented to the Practice for the first time in September 2021 with similar menopause-associated symptoms. The Practice GP ordered an FSH blood test, the results of which did not indicate menopause or perimenopause.

27. In April, October, and December 2024, Ms J presented to the Practice with similar symptoms. The Practice GP ordered an FSH blood test each time, which returned normal results each time.

28. We consider the Practice’s approach of requesting an FSH blood test to confirm menopause, when Ms J presented with menopause-associated symptoms, was in line with the relevant NICE guidance. This is because NICE NG23 1.3.6 says clinicians should consider using a FSH blood test to confirm menopause only in people aged 40-45 with menopause-associated symptoms and Ms J fitted this profile at the time of her appointments at the Practice.

29. Our adviser said that an FSH blood test is not very reliable, because a person’s FSH level can vary from day to day. However, we understand that because Ms J had five FSH blood tests over a period of several years, all of which returned normal results, it is less likely that the results were incorrect in this instance.

30. Our adviser also said the management of Ms J’s symptoms was complicated by her clinical history of depression. They explained there is an overlap of symptoms between depression and menopause. Symptoms such as low mood, low energy levels and poor sleep are common to both, which may have informed the Practice’s decision to confirm a menopause diagnosis via an FSH blood test.

31. Further to this, our adviser said this case represented an example of variation in approach between different GP surgeries. They said the Practice had taken a very rigid approach to the guidelines in Ms J’s treatment, whereas NICE guidance is nuanced and allows clinical discretion in diagnosis. Our adviser confirmed that in some cases, menopause can be diagnosed in people aged under 45 without an FSH test and an FSH test is not obligatory to confirm the diagnosis.

32. In summary, we consider the Practice’s treatment of Ms J’s symptoms was in line with guidance, although based on the advice we received, we understand it represented quite a rigid approach.

33. We recognise how distressing it would have been for Ms J to experience a significant improvement in her symptoms after changing practices and receiving HRT. We acknowledge her distress and concern that she could have been productively treated for these symptoms at an earlier point. Having reviewed all the evidence, we are satisfied the Practice acted in line with NICE guidance NG23 on menopause and perimenopause identification. We will therefore not be looking at this part of the complaint further.

The Practice did not prescribe Ms J HRT

34. Ms J complains the Practice did not prescribe her HRT to treat her symptoms. In its response to Ms J’s complaint, the Practice said it had followed NICE guidance in its treatment of Ms J.

35. NICE NG23 sections 1.4.2 and 1.4.3 discuss HRT but do not specify when it should be prescribed.

36. Our adviser said there is no guidance which suggests HRT should be offered to people aged under 45 with menopause-associated symptoms who have normal FSH blood test results. They explained the decision on whether to prescribe HRT in this scenario is up to each individual clinician. We understand that practice around the prescription of HRT for menopause-associated symptoms has been through a process of gradual change since 2019 when Ms J first raised her concerns that she might be perimenopausal to a clinician.

37. Our adviser explained that growing societal awareness of menopause symptoms and HRT in the period since 2019 has made clinicians more likely to use their discretion to offer an HRT trial. We acknowledge that in line with this, some clinicians may have used their discretion to offer a patient in Ms J’s position a trial of HRT, irrespective of FSH blood test results.

38. In summary, our adviser said that with the guidance in its current form, the decision on whether to prescribe HRT to people with menopause-associated symptoms and normal FSH blood test results was a matter of clinical discretion. Taking this into account, we consider the Practice decision not to offer HRT to Ms J was in line with guidance.

39. We recognise that Ms J feels she should have been offered an HRT trial at an earlier point. We understand her position and are sorry that she feels her menopause experience was harder than it could have been. Having reviewed all the evidence, we are satisfied the Practice acted in line with NICE guidance NG23 when it did not prescribe HRT to Ms J. We will therefore not be looking at this part of the complaint further.

The Practice did not inform Ms J of its policy of only prescribing HRT to people aged over 45

40. Ms J complains the Practice did not inform her of its policy of only prescribing HRT to people aged 45 and over. She says if this had been explained to her, she may have considered switching practices sooner.

41. In its response to Ms J’s complaint, the Practice said it had followed NICE guidance in its treatment of Ms J and apologised if this had not been explained to her earlier.

42. The records do not show whether clinicians explained the NICE guidance to Ms J. Our adviser said it would not be standard practice to explain to patients which guidance was being followed, unless that information was requested.

43. The Practice summarised the NICE guidance in its response to Ms J’s complaint. We consider the summary the Practice provided was not accurate. The Practice said the guidance stated a diagnosis of menopause and perimenopause: ‘should ONLY be considered without blood tests in women over 45, 40-45 we should carry out a blood test and only diagnose on that, therefore [the Practice] are following NICE guidance.’

44. Our adviser explained that the NICE guidance allows clinical discretion and leaves the diagnosis of menopause and prescription of HRT as options, irrespective of the FSH blood test results. The guidance says clinicians should ‘consider’ a confirmatory blood test in people aged 40-45, not that a blood test was essential to confirm a diagnosis. We understand this allows for multiple different approaches and for clinical discretion in diagnosis.

45. We appreciate that Ms J feels she should have been told of the Practice’s approach to the guidance sooner. We understand her position and are sorry to hear of the distress this has caused her. Having reviewed all the evidence, we are satisfied the Practice followed standard procedure in not advising Ms J of the guidance it based its treatment on, given she did not ask them for clarification.

In summary, in our view, the Practice cared for Ms J in line with the guidance but incorrectly summarised its contents when it responded to Ms J’s complaint. The Practice should have explained the guidance accurately in its response to Ms J’s complaint, and we recognise not doing so may have caused Ms J confusion.

46. We emailed the Practice to clarify its position on the NICE guidance. In its response, the Practice confirmed that it followed NICE guidance NG23 when diagnosing menopause and perimenopause. It acknowledged the wording in the original complaint response did not fully reflect the nuance of the NICE guidance and recognised it may have given the impression that a blood test was mandatory in all cases for patients aged 40-45. It said this was not the intended meaning and apologised for any confusion caused. We will be providing a copy of this email to Ms J.

47. We consider this is a proportionate response to the impact this had on Ms J and is in line with the NHS complaint standards with regards to taking accountability for mistakes identified and providing an apology. We will therefore not be looking at this part of the complaint further.

48. We thank Ms J for taking the time and effort to bring her complaint to our attention. We recognise how distressing and frustrating her experience has been for her, particularly given the positive results she has experienced since she began her HRT. We hope these results continue and that our explanation provides some reassurance about the care and treatment she received. We wish Ms J the best for the future.

1. We have carefully considered Ms J’s complaint about the care she received from the Practice between 2019 and 2025.

2. We were very sorry to hear Ms J’s negative experience with the Practice made her feel abandoned.

3. Ms J told us the Practice did not appropriately treat her perimenopause symptoms. She says the Practice disregarded her concerns that she was perimenopausal based on normal blood test results, did not prescribe her hormone replacement therapy (HRT) and did not advise her of the Practice policy of only prescribing HRT to people aged 45 and over.

4. We have looked at Ms J’s treatment from the Practice over this period and the Practice’s response to her complaint. We have seen no indication anything went seriously wrong in the Practice’s treatment of Ms J’s symptoms, the Practice decision not to prescribe HRT or the Practice’s communication of its policy around HRT prescription. The Practice incorrectly summarised the NICE guidance it followed in its response to Ms J’s complaint, but clarified its position and apologised for any confusion caused. We consider this to be a proportionate action, in line with the NHS Complaint Standards.

5. We hope our explanation below reassures Ms J the Practice treated her symptoms appropriately.