Hello and welcome to BJGP Interviews.

I'm Nada Khan and I'm one of the Associate editors of the bjgp.

Thanks for taking the time today to listen to this podcast.

In today's episode, we're talking to Claire Mann, a research fellow who's based at the University of Warwick, and Sarah Hillman, who is a GP and Clinical Associate professor based at the University of Birmingham.

We're here to discuss the recent paper published here in the BJGP titled Accessing Equitable Menopause Care in the Contemporary NHS Women's Experiences.

Thanks, Claire and Sarah, for joining me here today to talk about this work.

This study focuses particularly on the women's experience of menopause and accessing general practice and primary care.

But I'll point out just before we begin that you've also published a linked paper looking at the clinician perspective.

So anyone who's interested in that angle should look up your other paper.

But back to this one.

Sarah, I wonder if I could start with you first.

I wonder if you could just talk us through the focus of the paper here and the kind of disparities that different women might face in accessing menopause care in the UK.

Essentially, this work came about because in 2020, we published a piece of work in the BJGP that looked at prescribing a practice level of hrt.

And what we found was that actually, if you were a patient at one of the most deprived practices in England, you were about a third less likely to be prescribed HRT than if you were in the most affluent.

What we didn't have at that point in time was data at an individual level, just at a practice level.

But it was important that work was done because that really pushed that forwards.

But what we didn't understand was what was going on underneath that.

So.

So we asked the nihr, we wrote a grant for something called Research for Patient Benefit and said, look, we want to explore exactly why there is this disparity, because our feeling as researchers was that it wasn't straightforward and that there was a lot going on, both from the woman's perspective and the healthcare professional's perspective.

And we really wanted to know exactly how that was all adding up to this gap in prescribing.

What we did was we spoke to 40 women, but we were incredibly mindful that we wanted to speak to women that were less likely on paper to be prescribed hrt.

So we tried to speak to women that were from more socially economically deprived areas and also black and South Asian women.

So this project really was.

Was underlying that.

That gap.

Yeah.

And I guess, as you said, based on that previous research, you really wanted to get this deeper understanding of what was shaping menopause and HRT management and prescribing patterns.

And I think just to sort of move on to what you found, really, I thought that one of the initial things that really stood out to me was the women that you spoke to talked about the menopause and how menopause care has changed over generations and how that impacts how women seek help.

And I wonder if you could just start by talking us through this and what the women you spoke to told you.

It's a really interesting study because obviously the time is right to be talking about menopause.

It's going through this phenomenal change.

And a lot of the women that we spoke to reflected on how that change had impacted their lives and how different their experiences might have been from the.

The previous generation.

A lot of women talked about when it came to menopause, they wanted to know about their mum and their mum's experiences.

That's often a first port of call.

But actually what a lot, particularly of the black and Asian women were telling us was that they were experiencing a different life to their own mum, that there were different pressures now, particularly in terms of being career driven, juggling intergenerational family and feeling the pressure of modern life, whilst also trying to manage their own experiences.

So the current generation really are quite unique in as far as they've got a whole load of challenges and a whole load of stress that perhaps generations before them haven't had.

So when they're having conversations in the family, it's a little bit mismatched because Mum might be saying, well, that's not what my experience was like.

But the younger generation is perhaps thinking, well, yeah, because mom didn't, perhaps didn't work full time or, you know, didn't exist in the Western world in the same way as we do now.

So it, I think that comes to play for a lot of women, particularly around career development and the fact that so many women in their middle lives now are still working full time and juggling family responsibilities, and that presents an additional stress to then also prioritizing your own health.

And that's something that women found difficult to do amongst all those pressures as well, I think, was something they told us.

Yeah.

And in some communities it seemed as though there's still quite a lot of stigma around discussing the menopause openly.

What did they talk about here?

Yeah, I think obviously menopause is a hot topic and it's being spoken about in lots of ways, but that doesn't mean it's not still taboo for lots of women.

Many of the women that we spoke to still hadn't had those conversations within their families because it was still something that was considered perhaps shameful and that they were expected to just deal with.

Some of the black women spoke about the stoicism and being expected to be brave and have a high pain threshold.

And some of the Asian women spoke about families and fertility and the patriarchy and the way that things are perceived and said that for them, actually having those menopause conversations within their homes was not as easy as it might be perceived.

And so having that peer support from within the family, within the communities hasn't developed as strongly yet.

It is starting to come through so that women are enabling each other with their own experiences.

And where that does happen, it's really powerful.

I think the women told us that, you know, peer support is really valuable, family support is really valuable, but it is still a topic that women feel stigmatized and embarrassed sometimes to talk about, particularly if it's not something that they've been open to discussing as they've been brought up through their, through their families.

Yeah, it's really interesting because when we think about maybe the kind of information sources that women might have, so family or community or peer support would really play into that.

And I wonder if they talked about that tension from how menopause or seeking help for the menopause might be perceived in the community and how that affected their help seeking behavior to their gps at all.

So I think, I think that's exactly right.

Women spoke about how not only how menopause was, as Claire said, talked about or not talked about in their own communities, but actually how any information around menopause in this country, how often they felt they didn't feel represented.

And actually if they didn't feel represented, that might be through what was said or an image of what a woman going through menopause might look like or on an advertisement, actually.

They just didn't feel a connection there.

And therefore they felt, well, this isn't about me.

And that was a barrier really for them not going forward to get help.

But really interestingly, lots of women spoke about the fact that actually when they'd got to a stage when they felt that they did need help, some of them considered how they might be in sometimes racially stereotyped during that consultation.

That was something that for me as a researcher, I thought, crikey, the fact that women had actually had to go away and think, how am I going to approach this consultation?

Because I don't want to be stereotyped as having a higher pain threshold or being angry or all these other things, which meant that actually they thought the whole thing out before they even got through the door.

And women also spoke about the fact that they felt sometimes that healthcare professionals didn't appreciate the fact that by the time they'd got in front of them, they hadn't been experiencing symptoms for a little bit of time.

They'd been experiencing symptoms for a long time.

And so actually, at that point in time, they really needed the GP to pay attention and listen to them.

Yeah.

And I think that really came out in the paper where, as you say, some of the women described how, by the point, they got to see their gp, they were at that stage where things had been difficult.

And you described this almost emotionally charged consultation where they knew what they wanted from the interaction as well.

And could you talk us through a little bit more about how women experienced this and how it impacted how things were managed in the end?

So, interestingly, one of the things that they felt was going to happen was that they were going to have to advocate for what they wanted, particularly hrt.

Now, actually, that didn't always come to pass, and I think that some women were in front of the GP and the consultation didn't go as they thought it would, but it was this.

Whether it's been fueled by things they've seen in the media, women felt that they were going to have to sit there and advocate for their HRT and that it was likely it was going to be refused, but that actually, sometimes that was a problem and sometimes they felt fobbed off and sometimes they felt that they'd been offered alternatives that they didn't want, but actually, sometimes they were given the prescription that they wanted.

But it was just really interesting that women felt before they even walked through the door that they were going to have a fight on their hands.

And I think that was, again, as a clinician, that was a really important learning point for me.

And I think, in general, what you found here is that women's cultural backgrounds had a really big impact on their approaches to accessing care.

And I wonder if you wanted to just unpick this a bit further at all.

So I think one of the things that was interesting was that actually it was around what care they were expecting, actually, when they presented with menopausal symptoms, and that some women wanted hrt, which was incredibly important.

But many women found or felt that actually what they wanted was a much more holistic approach.

They felt like they wanted advice about lifestyle and other aspects of menopause.

They also felt that they wanted often to talk about complementary therapies.

And that's because for some women in the communities that they live in, complementary therapies are incredibly important.

But actually, as gps, we're often not trained in that area.

So that was a slight area in which women felt that their options weren't being addressed because it was a sort of HRT or nothing situation and they felt they needed more than that.

Yeah.

And just following on from that, I wonder what either of you thought really about what you would want to tell gps about how they approach women from different cultural backgrounds around the time of the menopause.

Based on the results of this study.

I think what I would want to say to gps is that there are certain groups of women that are not going to sit in front of you and tell you that they've got perimenopausal, menopausal symptoms.

It's going to take more than one consultation and sometimes there are going to be some stigmas and taboos that you might have to break down a little bit.

And to keep the consultation holistic, make sure you're talking about hrt, but also about other options and to make sure that you keep the door open.

I think that's incredibly important.

I think a lot of women felt that the consultations were one off.

And actually what they were saying was, I want somebody who is going to help me throughout this period of my life.

And as we know, you know, average length of sort of vasomotor symptoms, things could be eight years.

We don't want women to think that this is a one time offer.

And I also think that it's incredibly important to recognise as a gp, that when the person sits in front of you, I know you've done 10, 15 consultations already that morning, but for them, they may well have been experiencing those symptoms for a long time.

And that consultation might have taken a lot of preparation.

And I think it's really identifying that and acknowledging that, and I think that's important.

Sorry, Claire, go ahead.

Do you wanted to add something?

Yeah, no, I was just going to fully support that and say, actually opening the door to the conversation is one thing, and then ending the conversation with that door open.

A woman will come back if you tell her, I want you to come back.

And there was some really great examples of women and GPs that we spoke to where they'd had an initial appointment and been given some time to go away and consider things and read things and learn more and then come back and have another conversation.

Somebody who is reluctant to HRT initially may well change their mind over the course of conversations.

But I think Sarah's absolutely right.

Sometimes it takes a lot for a woman to get through the door on that first occasion and it's unlikely that everything might be resolved.

So they need that door open and that encouragement for that continuity of care.

Because this is a journey, as you say, it's gonna, it's gonna last several years and women need to be encouraged to engage with us throughout that journey whenever they need us.

I think.

Yeah, well, I think you took the words straight out of my mouth, Claire, about continuity of care.

And I think that especially with menopause and discussions around prescribing or not prescribing or alternative options, these kind of conversations can't happen in 10 or 15 minutes.

And it is something that needs to be a much longer term solution and discussion as you, as you both identify.

But I think that's a great place to wrap things up.

But I just wanted to say thank you very much both for your time here and for joining me to talk about this work.

Oh, thank you for asking us.

And Claire, thanks for joining as well.

Thanks for having me.

Yeah, real privilege to be involved.

Really appreciate it.

Thank you.

And thank you all very much for your time here and for listening to this BJGP podcast.

The original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com and again, it's great to see research that's involved so much of women's experiences and patient engagement.

So well done to Claire and Sarah for involving that in this, in this research as well.

Thanks again for listening and bye.