In this Blog, GP and menopause specialist Dr Shalini Khunger reflects on a recent Guardian article by Anna Bawden that highlights a study revealing that white women in England are most likely to receive Hormone Replacement Therapy (HRT) prescriptions, raising concerns about inequality in menopause care.
I read with interest the recent Guardian article by Health and social affairs correspondent Anna Bawden, titled “White women most likely to get Hormone Replacement Therapy (HRT) prescriptions in England, study finds.”
Studies like this are clearly welcome and a step in the right direction towards reducing inequalities in menopause care.
However, it made me reflect on some deeper issues too.
Firstly, I noted that in the study, only the HRT scripts were examined, not other types of NICE recommended alternatives to HRT.
It could be that the non-hormonal medications are being prescribed instead to these groups of women. This may be due to their preference or possibly because their Health Care Professional (HCP) felt this is a more appropriate treatment for them due to pre-existing conditions or other factors.
It would be interesting to know the number of women in these groups who seek help for menopause symptoms or who wish to discuss HRT but have their request for HRT declined by the HCP.
Inequalities in women’s health care are not limited to the perimenopause and menopause. I recall a study which researched pain relief in childbirth and this revealed stark inequalities for Black, Asian, and Minority Ethnic (BAME) mothers. This study revealed that BAME women were less likely than white women to receive epidurals.
Another study in 2018 found Black women in the UK are five times more likely to die than white women as a result of complications with their pregnancies or during childbirth. South Asian women were found to be two times more likely to die.
These are worrying statistics and it seems that women’s health care from younger to older ages need to be reevaluated so the care provided is of a consistent clinical standard but also tailored to the needs of women of all backgrounds.
There can be a reluctance to consider HRT in certain groups of women, reasons could be due to lack of knowledge of HRT or not having access to up to date information about HRT. There can also be concerns about the risks and less awareness of the wide range of benefits of HRT.
Vasomotor symptoms such as hot flushes and night sweats can be a distressing and life-impacting part of menopause and Black women are 5 times more likely to report severe vasomotor symptoms. There is an established link between severity of vasomotor symptoms and Cardiovascular disease (CVS). CVS disease risk is known to be higher in Black women so potentially approaching HRT use as an effective “preventative” treatment for cardiovascular disease in certain women could be beneficial and could encourage use of HRT If there is any initial hesitance.
Similarly, Asian women have a higher risk of osteoporosis than other ethnicities – again HRT can be promoted as a preventative treatment to minimise the often severe and life limiting complications of osteoporosis.
A concept which is not mentioned in this article is conscious and unconscious bias. This can play a large role in treatment decision making and how patients are steered towards making certain decisions.
Bias is recognised as a barrier to effective patient care and medical education establishments are offering training and courses to improve recognition of bias and steps to mitigate its impacts. However this type of attitudinal change depends on the receptiveness of the HCP and their wish to change their mode of practice.
A well informed patient can reduce the impact of HCP bias in a consultation as they will question decisions made and add their opinions.
A less well informed patient may be satisfied with a more ‘paternalistic’ approach to decision making and therefore more vulnerable to the biases of the HCP. They may also not have their own personal or cultural health beliefs considered or discussed if they are not given the opportunity to express them freely.
Hence the need for readily available high quality information about menopause and HRT so that patients can approach consultations with a degree of agency.
This also applies to the “Lay referral network” which can lead to women seeking help for menopausal symptoms. This network will often consist of friends and family members.
If the people advising her are well educated about HRT and menopause then they are more likely to steer her towards recognising her symptoms as being those of menopause and considering HRT.
Therefore education and information about menopause needs to be freely available to all and started even in schools so it is recognised as a part of normal life, like periods and pregnancy.
I will end with a reflection on the concept of “Mrs Bibi”. This is a disparaging label given to often older, South Asian women who exaggerate their health complaints and are all thought to have ‘total body pain’ and many symptoms ‘in their head’.
Clearly this is a sexist and racist stereotype which is unhelpful for patients but also unhelpful for HCPs as it leads to a shutting down of diagnostic curiosity to discover the reason for the patient’s symptoms.
Thankfully improved training and awareness of bias is minimising this approach to patients but I do wonder if many of ‘Mrs Bibi’s symptoms’ could be attributed to menopause and therefore amenable to HRT treatment.
It is sobering to think that such a simple treatment could lead to a significant improvement in these lady’s quality of life and also great health benefits and chronic disease prevention.
I hope that community women’s health hubs mentioned in The Guardian article help to improve access to menopause care and that they reach women of all backgrounds and ethnicities.
High quality evidence based information and education will also be an impactful way to improve patient’s experiences and satisfaction with their menopause care.
About Dr Shalini Khunger
Dr Shalini Khunger is a GP with a specialist interest in Menopause. She graduated from Manchester Medical School and has worked in the Manchester and Cheshire areas since then.
As well as working for the Care Quality Commission (CQC), Manchester University and as a GP in Cheshire, she has an interest in women’s health and has been developing this throughout her career.
She works in a community Gynaecology clinic as a coil fitter and is very experienced in Menopause care and is currently working toward British Menopause Society Certification.
Shalini sees patients in-clinic at our Manchester Clinic, based in the Manchester Private Hospital and can also provide online consultations.
Call 01252 915333 or email info@thefemalehealthclinic.co.uk if you would like to book an appointment to discuss further with one of the Specialist Team.
