Statement
There has been a surge in media coverage of both menopause and HRT prescribing over recent weeks. Whilst we welcome an increase in awareness of menopause and how it can be safely identified and treated, we are aware that there has also been controversy. Much of this comes from well-meaning discussion and debate and there will be an inevitable spectrum of opinion amongst medical professionals. This statement is to reassure you of the prescribing practice at Menopause Care Limited and what you can expect as one of our patients.
The doctors and clinicians at Menopause Care Limited have been trained to British Menopause Society gold standards. The vast majority of the doctors hold the British Menopause Society Advanced Certificate in the Principles and Practice of Menopause Care. This is currently the highest accreditation possible and has been designed to equip clinicians with the skills to provide specialist menopause care, manage complex cases and lead menopause services. As far as we are aware, this high level of training across the clinicians is unique to a clinic the size of Menopause Care Limited.
As a team we encourage ongoing open discussion, undertake clinical and non-clinical audits, and regularly review our prescribing policies and clinical practice as new guidance emerges.
The vast majority of our patients are prescribed HRT or non-hormonal medication within the manufacturers’ licence, as this is what they require for symptom control. Our prescribing is in-line with our training and level of expertise. On occasion we do prescribe off-licence. This may take the
form of a higher oestrogen dose, a lower progesterone dose regime, or an off-licence route of administration. There will always be a clinical indication, often in a complex clinical setting, for example, a patient with surgical menopause, POI, PMS, PMDD, and/or progesterone sensitivity.
The decision to do so is made after discussing both risks and benefits with the patient and often after an anonymised discussion in a team clinical meeting. For a patient on a reduced progesterone regime, we always recommend additional endometrial surveillance. This is in line with current British Menopause Society guidance. We do not take any off-licence decision lightly and we communicate every clinical encounter with the patient’s GP if consent has been given by the patient to do so.
In the past year the British Menopause Society guidelines have changed with regards to the consideration of an increased dose of progesterone for patients on higher oestrogen dose HRT regimes, and with regards to testosterone replacement. We have carefully considered, as an experienced specialist team these recommendations for change and have updated our practice and audited accordingly.
The above policy and practice, in combination with the strict safe prescribing guidance by both CQC and the GMC, is the rationale behind why clinical reviews of women after starting or changing regimes, and annual reviews are compulsory. This is the only way we can safely prescribe.
Aim
To ensure that all patients are prescribed medication appropriately and safely following a relevant consultation.
Note: to be read in conjunction with C07d Repeat Prescribing.
Policy
Only doctors may prescribe medication. Doctors must use published guidance (BNF, MIMMS) in decision making. This practice does not usually prescribe controlled drugs. Where a doctor wishes to prescribe unlicensed medications they must first consult the GMC Good Practice in
Prescribing.
Procedure
Doctors use published guidance (BNF, MIMMS BMS guidance) about how to prescribe medicines safely. The choice of medicines are patient centred, taking into account their:
- Age
- Choices
- Lifestyle
- Cultural and religious beliefs
- Allergies and intolerances
- Existing medical conditions and prescriptions
- Adverse drug reactions
- Recommended prescribing regimes
An up-to-date list of current medications, drug history and allergies is recorded in the notes at the first consultation and also periodically.
Wherever possible, appropriate information about the medicines and the risks involved is made available to them, either verbally or written or both.
Doctors will regularly review their patient’s medications to ensure that it is appropriate, up-to-date and responsive to any changes in their condition. Doctors will monitor the effect of the medicine and take the necessary actions if a side effect or adverse reaction is observed, using the yellow card system if appropriate. If a patient has difficulties with taking their medications, the doctors will support them with their needs, for example dossette boxes, formulation changes.
Staff have access to current BNFs and MIMMS books. Doctors receive written notifications from the MHRA on drug safety updates via email. Patient safety alerts, rapid response reports and patient safety recommendations disseminated by the National Patient Safety Agency are acted upon in a timely fashion.
Prescriptions are only shared electronically with pharmacies directly and not emailed to patients to avoid the risk of patients printing the script multiple times.
Notification of patients usual GP
The prescribing doctor must share prescribing actions with the usual GP. If the patient does not wish this to happen then the prescribing doctor must consider whether to prescribe or limit the prescription. A record is made in the patient notes to highlight this as potential risk.
If the patient requests a repeat prescription, the practice may decide not to re-issue without sharing with the usual GP.
Repeat prescription policy
Please see this policy as it forms part of the practice overall medicine management policy.
Guidelines
Doctors prescribe medication from our usually prescribed drug formulary and use described by the BMS.
We occasionally use some medications such as male testosterone, Utrogestan and other progestins and higher doses of oestrogen off licence as per these guidelines. Please also see our prescribing statement.
We have not had the need to prescribe CDs. The only medication possibly to be prescribed is gabapentin or pregabalin. If this were to be the case the patient would be discussed in an MDT joint decision and a prescription plan be made which can then be relayed to the GP for prescribing.
Testosterone prescribing
We prescribe testosterone in accordance with BMS guidelines and adhere to recommendations on monitoring via blood levels.
Ordinarily, we discuss prescribing testosterone with a patient after they have had oestrogen replacement. We do blood levels for FAI and total testosterone and if they are low and the patient is symptomatic we discuss replacement. We explain the difference between the male (off licence) products and the female product only available privately and the financial implications.
If the decision is made to initiate testosterone levels are monitored after 3, 6 and 12 months and annually thereafter. We do not offer repeat prescriptions without monitoring and review.
Progesterone prescribing
We have updated our progesterone prescribing based on new BMS recommendations. If we prescribe off licence, we inform patients we are doing so. Patients on low progesterone regimes are labelled in the notes and have additional monitoring for safety.
Oestrogen Prescribing
We occasionally have the need to prescribe oestrogen at doses higher than licenced. This is the exception rather than the norm. It is normally required in patients with POI, surgical menopause, PMS or occasionally poor absorbers. We discuss each case on an individual basis, explain risks and benefits and document accordingly. We always have patient son the lowest dose required for symptom control.