A blanket-solution provided by GPs is overlooking the real issues behind women's complaints
- Joanne Murphy
- Nov 15, 2023
- 9 min read
Date: March, 2023
Photo by National Cancer Institute on Unsplash
If your doctor told you that oral contraceptives would regulate your periods, banish your acne and release you from the burden of your menstrual cramps, what would you do? For almost 40 years, general practitioners (GPs) have been prescribing female patients the same treatment – oral contraceptives. This seemingly one-fits-all approach simply masks the signs of underlying health conditions, delaying diagnosis and leading to potentially detrimental outcomes.
Struggling to get valuable information and treatment is a problem faced by many women across the UK. In the last two years, there have been 38 petitions demanding that the government provide more research, education, and support for women’s health issues. One, titled ‘Increase funding for research into Endometriosis and PCOS’, received 101,910 signatures. This led to a parliamentary debate in November 2021 and, subsequently, the creation of the Women’s Health Strategy.
Lottie Saunders began experiencing irregular periods, bloating and skin problems aged 14. She was finally diagnosed with Polycystic Ovary Syndrome (PCOS) and suspected Endometriosis last year, at 21 years old, after her condition worsened with severe cramping and thinning hair.
Reader in Reproductive Physiology at St George’s University, Dr Suman Rice, has extensively researched PCOS and explained that the diagnostic criteria for the condition, which affects around one in ten women, have been historically flawed.
“There was no defined consensus for diagnosis so, in the early two thousands, they created the Rotterdam criteria. You had to have two out of the three symptoms: irregular cycles or no menstrual periods, high androgens coming from the ovaries, and arrested follicles,” she said.
High levels of androgens - “male” hormones - cause the ovaries to enlarge and the fluid-filled follicles that contain the eggs to stop growing, known as polycystic ovaries, which prevents ovulation.
Saunders’ suspected diagnosis, Endometriosis, is a condition where tissue grows outside of the uterus, often spreading to the fallopian tubes or ovaries, which causes pain and can prevent normal pregnancy. A laparoscopy - “keyhole” - surgery is the only definitive diagnostic method, used to detect abnormal tissue and, if necessary, to remove it.
Photo by Melany @ tuinfosalud.com on Unsplash
It was only through comparing her experiences with other women that Saunders realised she may have these conditions. Her GP, at Wallace House Surgery in Hertford, never mentioned the possibility, instead, only prescribing the contraceptive pill. “It did help regulate my periods but didn’t help with anything else, and my pain has still worsened years later.”
She asked her GP for a referral to a private gynaecologist, which led to her eventual diagnoses.
While it took Saunders six years to receive a suspected diagnosis of Endometriosis and be scheduled for a diagnostic laparoscopy in March this year, the average time of diagnosis from the onset of symptoms is eight years for the one in ten women suffering with the condition.
All the women we spoke to, who were eventually diagnosed with PCOS or Endometriosis, were given combined oral contraceptives (COCs) as the first line of treatment, with minimal advice and no tests or referrals given.
This is consistent with National Institute of Excellence’s (NICE) guidelines, which is reviewed every five years and advises GPs against gynaecologist referrals and ultrasound scans until patients have been menstruating for eight years.
COCs contain synthetic forms of hormones progesterone and oestrogen. Among more minor side effects of nausea and headaches, they also include increased risks of breast and cervical cancer, and blood clots, leading to complications such as strokes and heart attacks.
Charlotte Kemble, a 23-year-old with PCOS, was prescribed the pill after suffering with extremely irregular periods, pain, cystic acne and excessive sweating. She expressed a lack of advice about symptom management from GPs at her surgery in Essex and said that the pill made her mental health worse. She has researched her own PCOS-friendly diet and regularly exercises, which has helped her mentally and physically.
NICE guidelines state that GPs should “inform women diagnosed with PCOS about the possible long-term complications, including type 2 diabetes and cardiovascular disease”, for which they should be screened.
None of the women we spoke to were offered these tests.
By treating women with COCs without exploring underlying issues, Dr Rice worries that women face dangerous consequences. This can be particularly true when trying to conceive, if a woman’s treatment has not been tailored to the current stage of her reproductive life and what her goals might be.
The increased risk of weight gain and insulin resistance presents new dangers for pregnant women with PCOS, who “are more at risk of getting gestational diabetes, hypertension and preeclampsia.”
The guidelines recommend COCs as a first line of treatment for women’s reproductive issues, with no mention of sleep, stress or exercise, and only non-specific dietary advice for “overweight” individuals to reduce the risk of diabetes.
Numerous studies have proven the benefits of alternative treatments, including Chinese acupuncture for reducing pain, studied by Yang Xu and Wenli Zhao at the Tianjin Academy of Integrative Medicine in 2017, and gluten-free diets, in a study by Megan Marziali and Talia Capozzolo in The Journal of Minimally Invasive Gynaecology in 2015. The guidelines do “not support the use of traditional Chinese medicine”.
In her two decades working as a GP, Dr Semiya Aziz at Chase Lodge Hospital in London said doctors “must look at [NICE guidelines] for basic advice regarding treatment”.
Consultant dietician Ursula Philpot noted that legal consequences will be faced by GPs who don’t follow NICE guidelines. She uses international guidelines when working with PCOS patients. “Where there are gaps in the knowledge, we look at primary research and independently critique that evidence to discuss with patients.
“There isn’t a great deal of evidence around diet and hormonal imbalance. There haven’t been many high-quality trials, and it is under-resourced,” she said.
The UK Clinical Research Collaboration (2015) showed that less than 2.5% of publicly funded research in the UK was dedicated to reproductive health.
GP Dr Aziz said: “I do believe alternative therapies are beneficial, but we can't really advocate them as doctors since there has not been enough scientific research done to validate the benefits”.
From dietician Philpot’s point of view, “without lifestyle interventions in national guidance, it’s far too easy to say it’s a hormone issue and the pill will help.”
Her advice for PCOS patients – who require an average 400 fewer calories - is generally to “reduce sugar and large or carbohydrate-based meals”. This helps to combat hunger, fatigue and cravings, that result from difficulties in controlling blood sugar.
Rarely seeing NHS patients, Philpot explained, “we often see people whose GP recommended a low calorie, low carbohydrate diet and they end up bingeing. Although the intention is there with GPs, they are going at it far too hard and fast in 10-minute appointments. It's much better to take the time to explore their relationship with food”.
With guidelines recommending against referring patients, Lottie Saunders had to request her own referral to a private gynaecologist at Rivers Hospital in Sawbridgeworth, which cost £200 per appointment. Only then was she diagnosed with PCOS. She felt her gynaecologist "actually cared” and improved her fatigue symptoms by reducing stress-levels and focusing on sleep.
A GP at Saunders’ surgery for almost 30 years, Dr David Mclees said: “It’s important for clinicians to work within the scope of their training and to refer onwards to those who are more specialised.”
But NHS waiting lists for appointments are growing, with a Royal College of Obstetricians and Gynaecologists report from March 2022 showing that 610,000 women were on gynaecology waiting lists - a 69% increase since pre-pandemic.
People are seeking private healthcare to receive fast diagnoses and treatment, but YouGov polling for the IPPR in 2022 showed that 59% of UK patients would wait longer than 18 weeks because they could not afford it.
Sophie Burrows, 23, was able to speed up her diagnostic laparoscopy surgery for Endometriosis when she accessed private health insurance through her job.
After visiting her GP about period pain eight years prior, she was given the contraceptive pill and not sent for any tests until three years later, when her symptoms became unbearable and affected her work. With blood tests and scans coming back normal (as they do with endometriosis), she was prescribed painkillers for another two years before being put on a waiting list for the surgery.
“The consultant said that she'd give me a laparoscopy,” she explained, turning down an NHS appointment for the surgery and cancelling her referral. “Then my private consultant decided she [wanted me] to try the Mirena coil as a hormonal management method instead.”
Burrows was made to wait a minimum of three months, by which time she was still experiencing pain and no longer had access to private health insurance. She restarted her NHS referral, which was pushed back three times due to the pandemic, but she finally received a diagnosis of “deeply infiltrating” endometriosis in January this year.
Of the top ten-ranked universities in London for qualifying GPs, only St George’s University MBBS courses contain relevant compulsory modules, such as obstetrics and gynaecology, with a 5-week mandatory placement at a clinic covering those areas.
Another, King’s College, has no related modules on key courses for qualifying GPs.
University College London has only one module dedicated to “Women’s Health and Men’s Health” in their five-year MBBS degree.
After completing a four-year medical student program, a two-year foundation program is required to practice as a doctor in the UK, before choosing training in a specialised field.
GP David McLees qualified in Medicine in 1988 from the University of London, where he spent two months focused on Obstetrics and Gynaecology. While he is well-educated in the field, he said, “it is up the individual to keep up to date with changes in medical practice.”
Qualified GPs must partake in continuing professional development (CPD) - earning 50 hours of CPD points per year – with events that allow professionals to share, learn new skills and stay up to date with the latest developments. There are no CPD topics specific to reproductive health issues, with the closest being menopause and fertility problems.
Dr Aziz said: “In all the courses I've been to regarding menopause and hormones, I very rarely see male doctors there. It's always females”.
Dr McLees argued: “We need to appreciate the time constraints of fitting in CPD to the work schedule when there are other mandatory topics that need to be covered yearly, such as Resuscitation Training.”
An analysis of complaints from the General Medical Council (GMC) in 2019 found that women were more than twice as likely to complain about male doctors not listening to them than men about female doctors.
Lottie Saunders initially saw a male GP but after one consultation, she asked for a referral as she felt “dismissed” and that a woman would “better understand her condition”.
In August 2022, the then Secretary of State for Health and Social Care, Steve Barclay, presented to parliament a 10-year Women's Health Strategy for England, sparked by a debate that followed the petition titled “Increase funding for research into Endometriosis and PCOS”. This was shaped by a survey with 100,000 responses from women and 400 experts, with aims to “improve the way the health and care system listens to women's voices” and “boost health outcomes for women and girls”.
The new government strategy led to the appointment of a Professor Dame Lesley Regan as the country’s first Women’s Health Ambassador in June 2022, to support its implementation and raise awareness for an initial 18-month period.
She has been recognised for her work as Honorary Consultant in Gynaecology at St Mary’s Hospital and Professor of Obstetrics and Gynaecology at Imperial College.
Professor Dame Lesley Regan did not provide a comment for publication.
The strategy outlined the appointment of a deputy and a clinical women’s health lead in the NHS as “immediate commitments”, but there has been no progress on these positions.
Parliamentary Under-Secretary of State for Mental Health and Women's Health Strategy, Maria Caulfield, did not provide any updates on these appointments. She responded to our questions with a letter that was sent to MPs in England on 25th January 2023, about one-year priorities, which only mentioned reproductive health conditions in relation to support in the workplace.
Patient Safety Commissioner Henrietta Hughes, who was appointed in July 2022, said: “Female patients have told me they were called hysterical. All health professionals need to ensure they are listening to patients. Only then can we reduce the incidence of injury and harm from medicines and medical devices.”
Prime Minister Rishi Sunak has failed to comment on the Women’s Health Strategy or reproductive health. In his New Year’s Address, he made the NHS one of his top priorities and set a series of goals, such as reducing wait times and achieving faster care for patients. Previously, he has abstained from votes such as the introduction of ‘buffer zones’ - to prevent anti-choice gatherings outside abortion clinics - and the continuation of a two-year trial of a “pills by post” scheme that allowed abortions pills to be taken at home.
Photo by Alexander Grey on Unsplash
After fourteen years of inadequate support, Sophie Burrows is now scheduled for a laparoscopy to remove her “deep and far-spread" endometrial tissue but, even so, there is no guarantee that new scar tissue will not form.
“I wish that my endometriosis had been diagnosed sooner, as I do wonder whether my surgery would have been less intensive. My negative feeling moving forward is the possibility that my fertility may be affected,” she said.
This investigation was conducted with contributions from fellow journalism students at the University of Roehampton, Vivienne Muehlhaus and Natalie Cox.
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