'It's time to remove the negativity around HRT,' says expert leading Mid-West menopause clinic
Casey, Nenagh Consultant Group, In Picture: Hospital Brian Ul With Dr Cathy Arthur Hospital
“You sit with the patient and listen above anything else. The one thing women want is that you listen to them.”
So says the consultant leading the first menopause clinic to open outside of Dublin at Nenagh Hospital in Tipperary. Among those attending are women in their 60s who are getting help with their menopause symptoms for the first time.
Dr Cathy Casey, consultant obstetrician and gynaecologist with a special interest in menopause with UL Hospital Group, said she is “thrilled” it is open.
“I think it’s great because the Mid-West is often forgotten about,” she said.
“I’m getting women right into their 60s, who had no help before and who still have symptoms. Without the specialist centres many of our patients would be left without intervention.”
Having worked in menopausal health for over 35 years, she welcomes the recent investment of dedicated funding supporting menopause care around the country.
This service opened in June, and for now runs twice a month — offering care to women referred from across North Tipperary, Clare and Limerick.
It is part of an effort to shake up menopause care in Ireland and offers help, especially to women facing the biggest challenges.
“Every woman is going to go through the menopause, and some will sail through and they will be fine, but about 75% will get significant symptoms,” she said.
“About 30% of those are really severe. It can last up to seven years and symptoms have a really negative impact on quality of life, relationships, family life, and a huge impact on the workplace.”
Under this new system GPs can now refer women with complex conditions and share their treatment. New guidelines and training are being developed for GPs around all levels of menopause care.
A ‘complex medical issue” could be women who have survived cancer, with heart or autoimmune conditions or women who have had a clot in their leg or lungs.
Dr Casey can take GP referrals for women who have been getting menopause care from their family doctor but are not seeing improvements from that.
“Also (women with) premature ovarian insufficiencies, who are women whose ovaries stop functioning or lose significant function under the age of 40,” she added.
“If they’re left without proper management they can have significant long chronic illness between bone and heart going forward. They’re a specific group that we really watch out for here as well.”
The medical clinic itself is bright and welcoming, with walls painted with dandelions — a flower often associated with hope and endurance.
“Initially women would go to their GP, the GP would do an assessment. It is vitally important that this is very much an individualised approach, whether it is in primary care or hospital care,” Dr Casey said.
“There has to be a benefit-risk profile done, so you sit with the patient and listen above anything else.” She said it is at this stage that decisions are taken around whether lifestyle changes alone can help or is HRT (hormone replacement therapy) also needed.
“You start really with lifestyle modification. It’s a holistic approach, it's not just all about HRT,” she said.
“It’s very much a holistic approach. You look at lifestyle, diet, exercise, smoking, weight, and alcohol so all of those have a role to play. Modifying those (factors) will manage their symptoms also.” Increasing exercise levels to include three 30-minute walks every week and light weight-training is also crucial, she said.
She shares research with women about the benefits of endorphins from exercise which, she said, can “significantly improve mood, emotional ability and vasomotor symptoms like your flushes and sweats.”
As part of this discussion, other aspects of daily life are analysed.
“Alcohol will aggravate flushes and sweats, caffeine will aggravate flushes and sweats. Obesity will aggravate flushes and sweats and poor sleep and mood,” she said.
“So we go through all of that, we go through the lifestyle and then we see do they need medication. The next step then is to see are they suitable for HRT or do they have any contraindications?”
Until relatively recently women were reluctant to take HRT for menopausal symptoms, due to the fallout from some high-profile studies which are now seen as having been misapplied.
“We were dealing with HRT and menopause for years,” she said.
“Then the two studies in the early 2000s came, good studies but they were looking at a much older age-group with a higher dose of HRT. They extrapolated all that information to cover every menopausal or peri-menopausal woman, and then HRT just became really a negative treatment.”
She urged: “It’s time to remove that negative narrative, remove the negativity around HRT.”
There has been push-back, especially in the last two years against the findings of those studies, with a resultant surge in awareness of HRT for menopause symptoms.
In fact, the surge has been so swift, many countries including Ireland have seen shortages of particular types of this medication, especially transdermal skin patches.
“Everybody was talking about how unsafe HRT was theoretically, and nothing was said about the impact that menopause was having on women, both the quality of life at the time and the risks for cardiovascular disease and osteoporosis as they became older,” Dr Casey said.
“There is a cohort of women out there who are suffering significantly because of no access at that time.”
However, she stressed not all women need HRT as other changes can help, and in some cases there are medical reasons why a woman cannot take HRT.
Typically women would attend this clinic once and then return to their GP with a treatment plan. They can be referred back if this new plan does not help, but she expects the system to work well this way.
Each appointment takes around 30 minutes, and she said on a typical day they would see about six patients.
The clinic, part of a €1.4m extension to the outpatient department in Nenagh, is supported by the Women’s Health Taskforce and the HSE National Women’s and Infants Health Programme.
This women’s health hub also contains an ambulatory gynaecology unit (opened in March) and a fertility service.
By this time next year, Dr Casey hopes to offer two weekly menopause sessions, with help from a local GP who is due to join shortly.
“(Ideally) we would have a clinical nurse specialist who is there as a support for the patients, education and training,” she said.
“We have a specialist physiotherapist coming. I would love to see a nutritionist here. I’d like to see a clinical psychologist, I think that’s highly unlikely because they are so hard to get, but I’d like to access to them in UHL.”
Under the national plans, Cork University Hospital will also host a regional women’s health hub and this will cater for women in Cork and across the south-east
The menopause clinic in Nenagh is part of what will be a national network of supports for women at primary care and hospital level.
“I’m delighted with how it’s going,” said Dr Deirdre Lundy, the GP specialist in women's health who leads the menopause clinic at the National Maternity Hospital.
This was the first of what will be six publicly-funded clinics to open under a new state policy.
“I think the waiting lists for our clinic are at a zenith now, because up until recently there was no other option,” she said, welcoming the opening of other Dublin services as well as that in Nenagh.
“Until five years ago a GP could do their whole career and never hear the word menopause,” she said.
“The last 20-odd years from 2002 to 2016 I’d say, the general consensus among the untrained was that if you use HRT it would give you breast cancer. That was never true but that was the perception. So even women who were extremely unwell didn’t want to talk about menopause or HRT.”
She previously offered women’s health services at a practice in Bray, Co Wicklow, and has seen attitudes to HRT and towards menopause change.
“Looking after a lady with menopause symptoms, who is generally fit and healthy, that’s a GP’s job,” she said.
“There has been a huge up-swell of doctors demanding training courses from the GP bodies.”
The specialist clinics have a more limited remit, in order to ensure waiting lists are manageable, she said.
“If someone has had breast cancer, ovary cancer, womb-lining cancer, blood clots which we know have a hormone link, people with HIV, sickle-cell, diseases of the blood or immune system, we see those,” she said. “We’re going to expand.” One challenge, she said, is finding “experienced personnel” to work in the clinics.
Symptoms commonly included temperature regulation, fatigue and insomnia, menstrual changes, reduction in libido, and brain fog, respondents to a Department of Health survey said.
Information on supports available at ‘gov.ie/menopause’ https://www.gov.ie/en/campaigns/menopause