Unnecessary referral to hospital
13. Ms M says she arranged an appointment with a GP to discuss symptoms of perimenopause. The Practice referred Ms M to gynaecology.
14. The Practice says when Ms M first reported perimenopausal symptoms, it requested a blood test which was normal. She was referred to the HRT team at a hospital given Ms M’s family history of breast cancer and the associated risks with HRT. It says the referral was done to obtain advice from a specialist, so that the correct treatment was prescribed.
15. NICE guidance on the assessment and diagnosis of menopausal symptoms says:
‘Consider using serum follicular stimulating hormone (FSH) level to confirm menopause in a person not taking combined hormonal contraception (or hormone replacement therapy), if they are:
• Aged between 40–45 years with menopause associated symptoms, including a change in menstrual cycle.’
16. The guidance also says:
‘Take a detailed clinical history about medical history that may affect the choice and safety of treatment options, including:
• Family history including premature menopause or premature ovarian insufficiency, venous thromboembolism, or hormone-dependent cancer, including breast cancer.’
17. GMC guidance on good medical practice says: ‘In providing clinical care you must:
• adequately assess a patient’s condition(s), taking account of their history, including • symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs • consult colleagues or seek advice from your supervising clinician, where appropriate • refer a patient to another suitably qualified practitioner when this serves their needs.’
18. Ms M saw a GP on 19 March 2024. The GP took a detailed clinical history of her symptoms, which included lighter periods, a low mood and libido, memory issues, and hot flashes. This is in line with GMC guidance.
19. The Practice requested a blood test to rule out any other causes for Ms M’s symptoms. Menopausal symptoms can be due to other conditions including thyroid issues, anaemia, low B12, folic acid, and vitamin D levels. The blood test also included a serum FSH test in line with NICE guidance.
20. Ms M saw a GP on 16 April. Her blood tests were normal, and the GP referred her to the HRT clinic for advice given her family history of breast cancer.
21. Ms M saw the HRT team on 25 September. A hospital consultant referred Ms M to clinical genetics for further discussion about HRT due to her family history of breast cancer and the risks associated with taking HRT when patients are at risk of breast cancer.
22. The GP’s decision to refer Ms M to gynaecology was appropriate given Ms M’s family history of breast cancer and to seek additional advice from a specialist to ensure the correct treatment could be given. This is in line with guidance from the GMC. We have seen no indication of failings in the Practice’s referral of Ms M to hospital.
Being asked to speak to a different GP
23. Ms M says she eventually asked a GP for a prescription of HRT on 23 December. She says a male GP told her she should book in with a female GP, who knew more about menopause. She says she had no idea that a GP in a Practice would have areas of specialism, or that GPs can be split along gender lines.
24. The Practice says it recommended Ms M book a follow-up appointment with a GP who was more confident with treating menopause and perimenopause. The Practice says it is common for GPs to feel more confident in certain specialties over others and it recommended another GP with more confidence and experience in this area as they thought this would be beneficial to Ms M.
25. GMC guidance on good medical practice says: ‘In providing clinical care you must:
• refer a patient to another suitably qualified practitioner when this serves their needs.
26. A GP advised Ms M to speak with a female GP although the reason for this was not documented at the time. The Practice’s response to Ms M’s complaint acknowledges it asked her to speak to a female GP, but the reason was not because the GP was female.
27. Our adviser says it is in the best interest of a patient for them to discuss symptoms with a GP with the relevant expertise. GPs in a general practice develop expertise in different clinical areas. It was appropriate for the GP to ask Ms M to speak to a GP with expertise in menopause. This was in line with guidance from the GMC.
Wrong HRT
28. Ms M says when she registered with another GP Practice, she was told she had been given the wrong HRT, which was for women who were no longer menstruating and/or menopausal rather than perimenopausal.
29. NICE HRT guidance in place at the time (the 2022 version) said:
‘A continuous combined regimen is not suitable for use in the perimenopause or within 12 months of the last menstrual period’.
30. Continuous combined HRT is where oestrogen and progesterone are taken together. Sequential combined HRT is where oestrogen is taken every day, and progesterone is taken for half the month.
31. On 23 December, the GP prescribed HRT patches following advice from gynaecology. The letter from the gynaecology consultant said they had discussed ‘you would need sequential HRT’, a regime for women that have a regular cycle.
32. However, the letter went on to say, ‘we discussed the use of transdermal HRT […] in the form of Evorel Conti’. This is a continuous form of HRT. There is a clear contradiction in the letter about which type of HRT Ms M should be given.
33. Given the contradiction noted in the letter, the Practice should have checked this with gynaecology. Instead, it gave Ms M a prescription for the continuous form of HRT (Evorel Conti) against NICE guidance that did contraindicate the use of continuous HRT. The patches prescribed were therefore not in line with the NICE HRT guidance in place at the time.
34. NICE reviewed the HRT guidance between January and April 2025 and published a new version in July 2025 based on the most up-to-date evidence. The new version does not say that a continuous form of HRT should not be given to perimenopausal women with menstrual cycles. The July 2025 version says:
‘Combined HRT can be prescribed as a monthly sequential/cyclical regimen or a continuous combined regimen. Continuous combined HRT is associated with less unscheduled bleeding than sequential HRT in postmenopausal women but if given to perimenopausal women who still have menstrual cycles, endogenous follicular activity can lead to irregular bleeding.’
35. Although irregular bleeding can occur in perimenopausal women who still have menstrual cycles with a continuous form of HRT, Ms M did not report this as a symptom at her next appointment for an HRT review with a GP. The updated guidance does not otherwise say continuous HRT has any adverse effects for perimenopausal women or is less effective as a treatment than sequential HRT.
36. That said, we think it probably was distressing for Ms M to find out from her new GP Practice that the type of HRT she was taking was not in line with what the NICE guidance recommended. We discussed this with the Practice. The Practice recognises the distress the events had on Ms M. It has agreed to apologise to Ms M and to implement several service improvements to prevent a recurrence.
37. The Practice will ensure a greater scrutiny of secondary care correspondence, especially where recommendations appear contradictory. The Practice will implement clearer processes for seeking clarification from specialist teams before prescribing.
38. The Practice says there is ongoing menopause and perimenopause training within the Practice, including enhanced involvement of its Practice pharmacist and it will reinforce the current NICE guidance on HRT prescribing for all clinicians.
39. We consider this is enough to remedy the impact the events had on Ms M and prevent a recurrence.
Antidepressants
40. Ms M booked an appointment with a female GP, three weeks into taking HRT. She said her symptoms had not yet eased but she was told she should go on anti-depressants. Ms M refused the anti-depressants believing this was an incorrect response to her early experience of HRT.
41. The Practice says Ms M had not had much change in her symptoms despite using HRT. The GP advised she could consider anti-depressants to treat some of her symptoms which Ms M declined. Ms M was told to continue using the HRT prescribed and book for another follow-up appointment in three to four weeks.
42. NICE guidance says:
‘Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms (hot flashes) alone.’
43. Information on prescribable non-HRT from Menopause Matters says:
‘SSRI DRUGS (Selective Serotonin Reuptake Inhibitors). A class of anti-depressant drugs that has been studied and widely used effectively for reducing hot flushes in women.’
44. Ms M was seen on 21 January 2025 for an HRT review. Ms M’s history and advice from gynaecology was noted.
45. It is noted Ms M reports little difference in symptoms since starting HRT four weeks earlier, and she was still having symptoms of insomnia, agitation and hot flushes and her periods were closer to each other.
46. The GP did a clinical examination, and Ms M’s blood pressure, heart rate and cardiovascular exam were all normal. As Ms M’s symptoms were not under control, she was offered antidepressants, but Ms M wanted to continue to take HRT only. A follow up after three weeks was advised if the current HRT regime did not help alleviate Ms M’s symptoms.
47. Our adviser says it can be too early to expect any real difference in symptom control in a short timeframe and the GP therefore gave Ms M the option of taking an anti-depressant alongside HRT to help alleviate some of her symptoms.
48. Our adviser says patients can take HRT and antidepressants together to control menopausal symptoms and the GP’s offer of antidepressants was appropriate to help manage symptoms including the hot flushes Ms M was continuing to experience. The offer of antidepressants was not a first line treatment, as Ms M was already taking HRT. The GP’s decision to offer antidepressants was therefore, in line with guidance from NICE.
49. We recognise the frustration Ms M experienced in the clinical care and treatment she received for perimenopause. We acknowledge the distress this caused her. We are grateful to Ms M for bringing her concerns to our attention.