Introducing a new treatment or service into clinic can be an exhilarating and exciting experience. As practitioners we are highly motivated to help and support our patients with new offerings and enthusiastic to share our new-found knowledge.
But what happens when we don't know what we don't know? (Kruger and Dunning, 1999). What happens when clinics are offering a percentage of a service that, if full provision were available, would be a CQC regulated activity, but with that missing percentage becomes an unregulated service vulnerable to the kind of lack of regulation we have long been campaigning against in the world of medical aesthetics. What happens to our credibility, ethics and most importantly, what happens to our patients?
The menopausal transition is a profound and intricate phase in a woman's life, marked by biological, psychological and hormonal changes. The growing aging population and societal recognition of menopause has led to an increased demand for menopause care services (Lambrinoudaki et al, 2022) both within the public healthcare system and the expanding private sector.
» The menopausal transition is a profound and intricate phase in a woman's life, marked by biological, psychological and hormonal changes «
This exploration aims to dissect the benefits and pitfalls of the surging provision of menopause care, especially in private settings, with a keen focus on the alarming lack of regulation.
The vulnerability of women during the peri-menopause and menopause stages, particularly when seeking private care, necessitates an examination of safeguarding issues. This paper delves into the imperative for comprehensive wrap-around care, including referra mechanisms to urogynaecology, specialist menopause clinicians, therapists and clinical psychologists, and assesses the role of the Care Quality Commission (CQC) regulation. It also discusses how unqualified providers, working outside established parameters, can inadvertently harm women, especially those with traumatic histories. We will venture into the nuanced realm of menopause yoga and other therapeutic options as a holistic approach to symptom management.
Finally, the article concludes by emphasising the critical need for a highly qualified cohesive multi-disciplinary team with mechanisms to effectively medically manage and support this specific patient group, drawing insights from guidance provided by the National Institute for Health and Clinical Excellence (NICE) and the British Menopause Society (BMS).
Benefits of increased menopause care provision
The heightened attention on menopause care brings forth several benefits. Increased public awareness fosters a destigmatised environment, encouraging open conversations about menopause (O'Connor et al, 2009). Women now have a broader spectrum of care options, allowing for personalised approaches that cater to their unique needs and preferences (NAMS, 2020). The positive impact of this heightened awareness extends beyond physical symptoms, positively influencing mental wellbeing and empowering women to navigate the menopausal transition with greater agency (Hunter, 2016).
Pitfalls of unregulated menopause care
However, the surge in menopause care provision, especially within private settings, has its pitfalls. The lack of regulatory oversight exposes women to potential harm. Unqualified providers may offer ill-informed or damaging interventions, posing risks to the wellbeing of menopausal individuals (Avis et al, 1997). The absence of standardised protocols and qualifications creates an environment where manipulative practices can thrive, adversely affecting the physical and mental health of vulnerable patients.
The menopause consultation is a very personal situation for the patient. With a good therapeutic relationship, the patient may disclose extremely personal information, which may appear unrelated to their symptoms. This can be a very emotional conversation and practitioners need to be absolutely certain that they have the infrastructure, processes and professionals in place to offer appropriate management. Practitioners may need to witness a patient's history of trauma, rape, domestic violence and childhood sexual abuse resurface.
It would be negligent and harmful to ignore what these patients are trying to tell us. Equally, a doctor or registered nurse alone is not usually equipped to manage the emotional impact of uncovering these issues/needs, or potentially hear that a crime has been committed. It is therefore imperative to know what to report and who to report and refer to for advice in order to keep this patient group safe.
This does not necessarily mean patients need to be treated in a large clinic with a plethora of different professionals on hand ‘just in case’, but it does mean that appropriate referral mechanisms need to be well established and integrated into clinic practice.
CQC regulated practices are bound by the guidance which states ‘safeguarding mechanisms are imperative, ensuring that menopause care providers are qualified and possess the necessary insight and skills to support these vulnerable populations’ (CQC, 2022). Clinical psychology plays a crucial role in providing specialised management and support to cope with the intersection of menopausal changes and traumatic experiences (Utian et al, 2008). This is all well and good for the regulated medical providers, but what about the unregulated services; how do they link in with regulated services to safeguard their clients? As is often the case, these wider issues are rarely considered when menopause services are being offered and established and it is all too often the vulnerable patient who is expected to safeguard themselves and their own care. This is a worrying trend observed within the largely unregulated aesthetic sector.
» The vulnerability of women during the peri-menopause and menopause stages, particularly when seeking private care, necessitates an examination of safeguarding issues «
Comprehensive wrap-around care
The complexity of the menopausal experience necessitates a comprehensive and cohesive approach to care. A multi-disciplinary team, including expert medical professionals, therapists and clinical psychologists, is crucial. Referral mechanisms should be in place to ensure women receive holistic support, addressing both physical and psychological aspects of their wellbeing. This approach recognises that menopause is not solely a medical event but a life stage that requires nuanced and integrated care (RCOG, 2015).
Equally, there is a much bigger picture, and where appropriate, hormone replacement therapy (HRT) can be transformative, but it is by no means a silver bullet. There are many highly individualised lifestyle interventions which can be really effective. Therefore, the medical practice, caring for patients to the fullest potential, needs to have appropriate referral mechanisms with a built-in pathway that enables access to a multi-disciplinary team.
The multi-disciplinary team may consist of:
Nutritionist
A nutritionist is essential to have on the team as menopause is catalytic to the function of our metabolism and digestion.
Counsellor
Counselling and cognitive behavioural therapy may also be appropriate and helpful to the patient.
The holistic approach to menopause
Exercise, menopause and yoga
We know that high levels of cortisol play a massive part in exacerbating symptoms of the menopause and therefore a variety of relaxation therapy options can be very beneficial.
Various complementary therapies, including yoga, are considered beneficial for managing menopause symptoms.
Menopause yoga, focusing on restorative exercises to calm the central nervous system, stands out as a tailored approach for symptom management (Hunter, 2016).
However, not all forms of yoga are equally effective. Incorporating mind-body techniques addresses both the physical and psychological aspects of menopause, promoting overall wellbeing.
Menopause yoga involves specific poses, breathing exercises, and meditation tailored to address menopausal symptoms. A study by Innes and Vincent (2015) found that yoga interventions were associated with improvements in sleep quality and reductions in menopausal symptoms.
Clinical aromatherapy, involving the use of essential oils, has also shown promise in managing menopausal symptoms. A randomised controlled trial by Kim et al. (2018) demonstrated that inhaling a blend of essential oils significantly reduced hot flushes and improved the overall quality of life in menopausal women.
Additionally, relaxation techniques, including mindfulness and progressive muscle relaxation, have been explored as effective strategies for managing menopausal symptoms. A meta-analysis by Dodin et al (2013) indicated that relaxation therapies were associated with reductions in hot flushes and psychological distress among menopausal women. However, even with the evidence we have, further research is needed to establish the long-term efficacy and generalisability across diverse populations for these interventions. Therefore, we need to be careful with our recommendations to support the best interests of our patients.
There is a vast amount of marketing around menopause specifically aimed at the body conscious woman who is struggling with additional menopausal weight. This is such a complex subject which needs a deep understanding and very careful balancing of oestrogen, progesterone, testosterone, cortisol and adenosine (as a starter) alongside consideration of activity levels and more specifically, what activity and when it is performed during the day, nutritional requirements and sleep quality. Again, unless the provider is cognisant of these complexities (and many are not) women are left vulnerable to overzealous marketing strategies which play on their insecurities and often finances in a very detrimental way.
Role of guidance and CQC regulation
Regulatory bodies like the CQC play a pivotal role in upholding standards in menopause care provision, within the healthcare sector. However, certain providers operate outside of healthcare and outside the CQC remit, posing risks to patient safety. Stricter enforcement of regulations and increased vigilance are necessary to protect women from potential harm and manipulation in the private menopause care sector (CQC, 2022).
NICE guidelines provide evidence-based recommendations on the diagnosis and management of menopause-related symptoms (NICE, 2015). The British Menopause Society offers additional guidance, ensuring a standardised and evidence-informed approach to menopause care (BMS, 2022). However, the boundaries of CQC regulation and adherence to such guidance documents remain a challenge, allowing unqualified providers to operate outside the established parameters.
Any and all menopause care providers who are responsible for the prescribing of HRT are within the CQC scope for ‘Treatment of Disease, Disorder or Injury’ and therefore are required to be CQC registered and regulated. It is encouraging that the CQC acknowledge the pitfalls around the non-regulated providers but we have a long way to go, and with the emergence of more and more ‘specialists’ the future doesn't look at all clear.
Conclusion
The benefits of increased menopause care provision are substantial, fostering a destigmatised and personalised approach to this important life stage. However, the associated lack of regulation in the private care sector poses significant risks, particularly for vulnerable individuals. The imperative for comprehensive wrap-around care, including highly qualified multi-disciplinary teams and specialised support for survivors of trauma, is evident. The role of regulatory bodies like the CQC is crucial in mitigating potential harm and ensuring the delivery of safe and effective menopause care. Recognising the intersectionality of menopause with mental health and trauma experiences underscores the need for a holistic approach. Moving forward, prioritising the wellbeing of menopausal individuals requires a united effort from healthcare providers, regulatory bodies, and society at large.