128

Journal of the Royal Society of Medicine Volume 84 March 1991

Patterns of referral to

a menopause

clinic

T Garnett MBBS A Mitchell sRN J Studd MD FRCOG Dulwich Hospital, East Dulwich Grove, London SE22 8PT

The Menopause Clinic,

Keywords: menopause clinic; hormone replacement therapy; self-referral

Summary One hundred and fifty new patients attending the Menopause Clinic at Dulwich Hospital were questioned on their attitudes and fears about hormone replacement therapy and the perceived attitudes of their general practitioner. The majority of patients attending the clinic had initiated referral themselves and many had travelled from outside- the health authority area in order to be seen. The waiting list for an appointment was often unacceptable. We conclude that specialist menopause clinics in teaching hospitals are unable to cope with the demand for information about the menopause and hormone replacement from post-menopausal women and suggest alternative means for providing this service. Introduction The demand for hormone replacement therapy by women in the United Kingdom increases but many patients continue to report difficulty in obtaining treatment from their general practitioners and seek advice elsewhere by self-referrall'2. Others, concerned about the adequacy of monitoring that their GPs are able to offer request referral to a specialist clinic3. Consequently the few menopause clinics which exist are vastly oversubscribed with a potential deterioration in the level of care offered. We examined a series of 150 patients referred to our Menopause Clinic to determine how and why they came to be referred, and the perceived attitudes of their GPs towards referral and hormone replacement therapy. From this we draw some conclusions about the future of hormone replacement therapy prescribing in the United Kingdom. Patients and methods One hundred and fifty new patients attending one of our Menopause Clinics were asked to fill in a short questionnaire on arrival. They were questioned concerning source of referral, duration of symptoms, their own attitudes to treatment and their GP's feelings about hormone replacement therapy (Table 1). The questionnaires were collected by the doctor seeing them in the clinic prior to the consultation.

Results Of the 150 questionnaires received 149 were suitable for analysis, one having been completed incorrectly. Not all patients answered all questions, and results are therefore expressed as a percentage of those answering each question (Table 1). Only 34% of the patients lived within 5 miles of the hospital, 38% had travelled between 5 and 20 miles and 27% had travelled more than 20 miles. General practitioners had referred 52% of our patients with

47% being self-referrals. Of those patients who were referred by their GPs, 52% claimed that it was at their own suggestion rather than that of their doctors. Thirty-eight per cent of the patients had been suffering with symptoms for more than 5 years, yet over 50% of these had only sought medical advice within the last 3 years. Fifty-one per cent of these patients explained that they thought their symptoms would pass spontaneously, and 25% claimed that they did not know that help was available. Only 13% had fears about side effects of hormone replacement therapy which had caused delay in seeking medical advice. Generally the patients' perception of the attitude of their general practitioners towards hormone replacement was favourable, with 59% of patients finding their GPs supportive and helpful. However, 33% claimed that their GPs were disinterested or

unhelpful. The self-referred patients had learned of the clinic from a friend or relative (28%) or via the media (25%). Twenty-three per cent of patients had to wait 4 months or more for an appointment. Discussion At Dulwich Hospital there are two NHS menopause clinics each week, one seeing 50 old patients and 12 new patients, the other 30 old patients and eight new patients. There are also two pre-menstrual syndrome clinics which patients with climacteric depression may also attend. These data show that our clinics see patients from a very wide catchment area, with 27% travelling more than 20 miles. Despite this our clinic receives no extra NHS funding. The premises and nursing staff are supplied by the hospital, but the five medical staff are salaried entirely by research grants. Although over 100 patients are seen each week in these extra clinics the waiting time for a consultation is unacceptable with nearly a quarter having to wait four months or more. The majority of our patients had initiated referral to the clinic themselves, 47% of patients had been self-referrals and 26% claimed that referral by their general practitioners was at their suggestion. The frequency with which hormone replacement is featured in magazines and newspapers is partially responsible for this, with 25% learning of the clinic through the media, but it may also reflect a reluctance amongst general practitioners to discuss hormone replacement with menopausal women. Ofthose who had consulted their GPs, half found them to be helpful and supportive but one third were dissatisfied with the reception they received. It is interesting to note that there was no correlation between the GPs attitude to hormone

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Journal of the Royal Society of Medicine Volume 84 March 1991 Table 1. Referral questionnaire with responses expressed as a percentage of those answering each question Question

Answers

1 How far away do you live?

(34%) (38.5%) (24%) (3.5%)

2

(52.5%) (47%) (0.5%)

3

4

5

6

7

8

9

10

11

Less than 5 miles 5-20 miles 20-100 miles More than 100 miles Not answered Were you referred to this clinic GP Self by your GP or did you refer Other yourself? Not answered Less than one year ago When did you first experience 1-3 years ago menopausal symptoms? 4-5 years ago >5 years ago Not answered When did you first seek advice Less than one year ago about these symptoms? 1-3 years ago 4-5 years ago More than five years ago Never Not answered If there was a delay in seeking Thought symptoms would pass spontaneously Did not know help was available treatment, why was this? Had fears about the treatments Did not have a good relationship with GP Embarrassed to consult GP Not answered If you consulted your GP, what Helpful and understanding was his attitude? Fairly supportive Not interested Totally unhelpful Not answered How old do you think your 25-40 GP is? 40-55 Over 55 Not answered Is your GP male or female? Male Female Not answered If you were referred by your GP, GP's was it as his suggestion or Self Not answered yours? How did you learn of this clinic? GP or other doctor Friend or relative Newspaper or magazine TV or radio Not answered How long did you wait for an 0-2 months 3-4 months appointment? 5-6 months >6 months Not answered

replacement and their age or gender refuting the popular belief that it is older male GPs who are the most unhelpful. With current patterns of referral the few specialist clinics which exist will soon be unable to cope with the huge number of new and return attendances. There are three possible solutions.

(1) Establish more specialist clinics in hospitals There are currently 24 free NHS menopause clinics in the United Kingdom of which no less than 17 are based in teaching hospitals and involved in clinical

(14%) (40%) (8%) (38%)

(23%) (30%) (7%) (20%) (20%) (52%) (22%) (13%) (12%) (1%)

(43.5%) (20.5%) (26.5%) (9.5%) (33%) (49%) (18%) (58.5%) (41.5%) (48%)

(52%) (39%) (30%) (25%) (6%)

(30%) (46%) (23%)

(1%)

49 55 34 5 3 75 68 2 1 18 54 11 51 12 32 43 10 28 28 4 57 24 15 13 1

36 51 24 31 11 29 45 67 24

82 58 6 36 39 75 54 41 35 8 8 40 61 31 4 10

research (information supplied by the National Osteoporosis Society). Such clinics are centred in the larger cities with one third in London. The capacity for expansion on such a basis is limited as it is unlikely that funding for further NHS clinics will be forthcoming. As hormone replacement therapy is a simple and uncomplicated treatment requiring few extra baseline investigations and little continuous monitoring above that which all post-menopausal women should receive (ie regular pelvic examination, smears, breast examinations and mammography) the provision of more expensive clinics in teaching

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Journal of the Royal Society of Medicine Volume 84 March 1991

hospitals cannot be justified. Such clinics will always be needed for problems and to allow further research to continue, but are not an answer to the general problem.

(2) Encourage GPs to prescribe hormone replacement without referring to hospital-based menopause clinics In our clinic we see a biased population of patients with a greater proportion dissatisfied with their GP consultation and having consequently self-referred. There is no evidence that GPs in general are reluctant to prescribe hormone replacement therapy, yet many of our patients could be treated more easily at their local surgery4. All women should be able to discuss hormone replacement therapy with their doctor as they approach the menopause, even if only a small proportion will take up the offer. It is now established as an important form of preventive medicine for osteoporosis, heart disease and strokes, quite apart from the relief from menopausal symptoms and improved quality of life it can offer5. There is perhaps a tendency for GPs to dwell on alleged contra-indications, for example, past history of thrombosis, deep vein thrombosis, hypertension or benign breast disease, often drawing parallels with the oral contraceptive pill. Recent moves to monitor the prescribing of general practitioners and limit their prescription budgets will not encourage them to give hormone replacement therapy as a preventive measure since it will greatly increase their pharmacy bill. (3) Establish menopause clinics within the community on the same basis as family planning clinics and well-woman clinics It would appear, however, that the option of creating menopause clinics along the lines of, and running in parallel with, family planning and well-woman clinics, would be a realistic alternative. The recent amalgamation of well-woman and family planning services in many areas, usually staffed by women

with a particular interest in women's health care and preventive medicine, would seem to be an ideal location for the HRT clinic. Indeed in some areas such as Staines and Brighton menopause clinics have already been established on this basis with great success. Not only are the clinics run by staff with an interest in the field, they also satisfy the patients' desire to be seen in a specialist clinic rather than by their GP. Women attending these clinics will be able to avail themselves of the other preventive health care measures available at any well-woman clinic. Most specialist menopause clinics in teaching hospitals see so many patients that they are fast approaching saturation point, seeing women who need hormone replacement therapy but no special investigations or follow-up. The existence of a network of family planning and well-woman clinics would seem to be an ideal niche for transferring some of this work to doctors and nurses well versed in preventive health care who have access to all the screening procedures required by patients on hormone replacement therapy. Our experience is that such clinics are more than willing to take on the extra responsibility, provided a network of tertiary referral clinics remain intact.

References 1 Barlow DH, Grosset KA, Hart M, Hart DM. A study of the experience of Glasgow women in the climacteric years. Br J Obstet Gynaecol 1989;96:1192-7 2 Draper J, Roland M. Peri-menopausal women's views on taking hormone replacement therapy to prevent osteoporosis. BMJ 1990;300:786-8 3 Hunt K. Perceived value of treatment among a group of long-term users ofhormone replacement therapy. JR Coll Gen Pract 1988;38:398-401 4 Shears MR. Brighton practitioners' attitudes to hormone replacement therapy. Practitioner 1989;233:146-9 5 Studd JWW, Whitehead MA, eds. The menopause. Oxford: Blackwell Scientific Publications, 1988

(Accepted 14 August 1990)

Patterns of referral to a menopause clinic.

One hundred and fifty new patients attending the Menopause Clinic at Dulwich Hospital were questioned on their attitudes and fears about hormone repla...
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