Q What first inspired you to become a GP with a special interest in women’s health?
From the age of about 11 or 12, I wanted to be a gynaecologist and deliver babies. However, as a medical student on a GP placement in a rural area, I realised that the sort of women’s health work I most wanted to do could be done in general practice.
Q What does your role as a GP with a special interest in women’s health involve?
From early in GP training, much of my work was to provide women’s health services. I completed family planning and IUD training while still a registrar.
I became an instructing doctor in family planning in 1995. This involved practical aspects of IUD and implant fitting, and the problem-oriented approach that is necessary in a primary care setting.
I have been a GP with a special interest since 2001.
As the women’s health lead for Cornwall, my role now includes training and monitoring the quality of services provided.
I have also been involved in the work of NICE, the British Menopause Society and the Primary Care Women’s Health Forum. A key part of my work is battling the many myths and misconceptions that still surround women’s health problems and their treatment.
Q Would you recommend other GPs to take on a similar role?
Absolutely. A lot of problems can be effectively managed in general practice with just a little bit of education. With more GP focus on women’s health, teenage pregnancy rates in Cornwall have come down to below the national average, and we have a lower than expected hysterectomy rate.
There is also the element of satisfaction, in being able to make a difference to people’s lives.
Enabling a woman to manage the problem of heavy periods or menopausal symptoms can have a substantial impact on her quality of life.
Q In your view, how will the forthcoming NICE guideline on the menopause affect GP practice?
The guideline will be revelatory for some, and should allow women to be offered more choices. It will provide practical advice regarding risks and benefits.
It should also spread awareness that women prescribed HRT for premature ovarian loss do not need to stop it before the age at which they would be likely to have reached menopause – the average age of the menopause is 52.
Q Should GPs advise against oral contraception in women aged over 40 years?
A risk assessment is vital. A healthy, slim, active 44-year-old can be offered combined hormonal contraception as an option, and there might be advantages that they would gain.
The UK Medical Eligibility Criteria for Contraceptive Use, which are available from the Faculty of Sexual and Reproductive Healthcare, are a very useful resource in these cases.
The criteria support women’s use of combined hormonal contraceptives up to the age of 50 years if there are no medical contraindications to their use.
Q How should GPs advise women who are worried about the risk of breast cancer if they take HRT?
The evidence shows that HRT does not initiate breast cancer. It may promote the growth of breast cancer if you have it already, so surveillance is important.
However, there is no evidence that you are more likely to die of breast cancer if you take HRT.
Q What do you tell women who have a family history of breast cancer and are considering HRT?
I explain to these patients that research has not shown combined hormonal contraception to increase risk and this is an option they can consider.
After the menopause, use of hormone therapy needs to be evaluated on an individual basis, but a family history does not always exclude the option of taking HRT.
Q What approach would you recommend to heavy menstrual bleeding?
The key is to listen to the woman, understand the impact her periods are having on her life, evaluate the possibility of there being a pathological explanation and offer her something to help, whether to mitigate during investigation or to provide definitive treatment.
Very few women will need a hysterectomy. Some might be satisfied with a fairly modest reduction in bleeding.
We need to help women to make the decision that suits them, without being paternalistic.
The NICE clinical guideline on heavy menstrual bleeding, CG44, and the subsequent quality standard outline what to do.
Q Are there any simple measures that GPs can take to help women with endometriosis?
For women who have endometriosis, consider continuous use of combined hormonal contraception to provide better suppression of cyclical activity and the endometriosis itself.
Women can use their method until they experience a bleed, stop for a few days, then resume. This is outside of licence, but can be very helpful.
GPs should also be aware that a component of the pain women experience in endometriosis can be neuropathic in origin.
The Primary Care Women’s Health Forum ebulletin for May 2015 offers useful resources about endometriosis.
Dr Sarah Gray