WA News News & Reports HT Resurgence?
HT Resurgence?
Written by Peter McClelland
Thursday, 27 April 2017

 

Over recent years, three doctors have written in Medical Forum that HRT, on the available evidence and risk-benefit analysis, was underused. What do they think today?

Dr Alison Creagh (ex-FPWA medical educator, pictured above) thinks GPs not prescribing HT is part of the problem. “This is unfortunate, because the risks of hormone therapy for perimenopausal women are low, and there are significant benefits. It’s time we took a balanced approach,” she said adding that taking a good history was key as contraindications to hormone therapy were mainly “past breast cancer, stroke, ischaemic heart disease and VTE”.

For significant hot flushes she recommends hormone therapy and gabapentin; and consideration of SSRIs and SNRIs (although less effective). The risks and benefits of hormone therapy should be discussed with the patient – “for combined hormone therapy, the benefits are effective treatment of symptoms, small decreased risks of colon cancer and osteoporotic fracture, and a decreased risk of death. The small increased risks are for breast cancer, VTE, heart disease and stroke.”27042017-smith-margaret-dr-feb06Dr Margaret Smith

Dr Margaret Smith (retired gynaecologist) is tired of the profession’s post-2002 response to the Women’s Health Initiative data and recommends the Jean Hailes website as a great resource, saying HRT is “safe and effective”. Like others she points to flaws in the WHI study – different hormones studied to those used today, women studied were older and had a different risk profile, etc.

“The major deficiency symptoms that [may] need oestrogen are hot flushes, sleep disturbance and vaginal dryness. HRT can also relieve depressed mood” she said. On the main issue of breast cancer scare she said “oestrogen does not cause breast cancer but can encourage its growth when it already exists” and “heart attack and stroke risks are usually due to other factors but may be enhanced by HRT.” She re-emphasised the same risks and benefits as Dr Creagh, adding that “all women should have a mammogram before HRT is started.”

27042017-welborn-tim-dr-jul15Prof Tim WelbornProf Tim Welborn (endocrinologist) clarified his stance. “Doctors and patients continue to show extreme caution about the use of HRT since the critically flawed Women’s Health Initiative report. Recent evidence-based guidelines indicate that women with moderate to severe menopausal symptoms will get substantial relief from early supervised therapy. Oestrogen treatment also gives vascular protection and improves bone density.”

“There is further data that the added risk of breast cancer is negligible for 20 years. Clear contra-indications to HRT include long duration menopause lasting beyond 5-10 years and/or a family history of hormone dependent cancers. Those at risk of thrombo-embolic disease should be offered trans-dermal oestrogens. Women with an intact womb can be prescribed an oestrogen-progesterone combination, to protect against endometrial hyperplasia or cancer, or be given cyclical oestrogen (with withdrawal bleeds) or oestrogen plus a Mirena coil.”

By Peter McClelland

While communication is one thing, investigation of notifications is another. We believe good doctors want the bad ones weeded out but they don’t want to be part of a witch hunt or get buried in lawyers, politics or paperwork.

The national Medical Board can respond to a complaint or act on the advice of the WA Medical Board to establish an assessment panel to either examine the health or performance and professional standards of a doctor. Health consumers are represented on panels along with medical practitioners.

The Medical Board and AHPRA have undisclosed lists of doctors who are approved by them as panellists and probably as expert witnesses. Many of these people, we believe, were ‘grandfathered’ across when National Law first came in (2010). Their impartiality is as unknown as they are. Then we have expected biases of the legal assessors, chosen by AHPRA, possibly thrown into the mix.

Is there a problem, Houston?

It is important this is sorted to everyone’s satisfaction as 42% of doctors in our survey thought panellists could lack impartiality to a serious extent.

In fact, only one quarter of doctors we surveyed (n=195) were happy with the impartiality shown by AHPRA or the Medical Board in processing a complaint (with 36% unhappy and 39% undecided). Nearly all of those who were unhappy said they were concerned that unfairness will be seriously damaging to someone. Investigation is a very confronting experience.

If someone is being investigated by a panel, either the panel or the person being investigated can opt for a more out-in-the-open State Administrative Tribunal (SAT) judicial hearing – the panel usually refers because it feels the evidence before it constitutes more serious professional misconduct.

What Fair Doctors Want

Talking to doctors, they appear to want an apolitical system of investigation that is fair and timely. They want to be treated reasonably. Unlike the legal profession, their work is mostly built around trust and honesty. They do not want a return to the ‘good old days’ where those with a political bent in the medical profession could influence what the Medical Board did.

While this is a very difficult area for us to investigate, with arguments and counter-arguments at every step, we cannot understand why the Medical Board would turn to arguably the most political organisation, the AMA, for its counsel (the national Board Chair met earlier this year with “senior leaders from AHPRA and representatives of the AMA” to workshop doctor complaints).

Why? Our e-Poll responses raise a question mark over the AMA’s involvement (and we don’t think AMA members have been polled on this issue.)

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