Experience and Severity of Menopause

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Huang et al.

BMC Women’s Health (2023) 23:373 BMC Women’s Health


https://doi.org/10.1186/s12905-023-02506-w

RESEARCH Open Access

Experience and severity of menopause


symptoms and effects on health‑seeking
behaviours: a cross‑sectional online survey
of community dwelling adults in the United
Kingdom
David Roy Huang1* , Abigail Goodship1 , Iman Webber1 , Aos Alaa1 , Eva Riboli Sasco1 ,
Benedict Hayhoe1   and Austen El‑Osta1   

Abstract
Background Almost all women will experience menopause, and the symptoms can have a severely detrimental
impact on their quality of life. However, there is limited research exploring health-seeking behaviours and alternative
service design or consultation formats. Group consultations have been successfully deployed in perinatal and diabetic
care, improving accessibility and outcomes. This cross-sectional online survey was conducted to explore women’s
personal experiences of menopause, including perspectives on group consultations.
Methods An online survey investigated the experiences of individuals at all stages of menopause and their receptiveness
towards group consultations for menopause. Respondents were categorised by menopause stage according to the
STRAW + 10 staging system. Associations between menopause stage, acceptability of group consultations and participant
demographics were assessed using logistic regression.
Results Respondents experienced an average of 10.7 menopausal symptoms, but only 47% of respondents felt
they had the knowledge and tools to manage their symptoms. Advice on menopause was sought from a healthcare
professional (HCP) by 61% of respondents, the largest trigger for this being severity of symptoms and the main barrier
for this was the perception that menopause wasn’t a valid enough reason to seek help. Of the respondents seeking
advice from HCPs, 32% were prescribed transdermal HRT, 29% received oral HRT, 19% were offered antidepressants,
18% received local oestrogen and 6% were prescribed testosterone. Over three quarters (77%) of respondents indi‑
cated that they would join a group consultation for menopause and would be comfortable sharing their experiences
with others (75%). Logistic regression indicated premenopausal respondents were 2.84 times more likely than
postmenopausal women to be interested in a group consultation where they can meet or learn from others’ experiences.
Conclusions This study highlighted a strong willingness of women aged 35–70 to participate in group consulta‑
tions for menopause, with motivation being strongest amongst premenopausal women. Low awareness of self-
management and lifestyle interventions to manage the symptoms of menopause highlight the need for greater

*Correspondence:
David Roy Huang
davidroy.huang@nhs.net
Full list of author information is available at the end of the article

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Huang et al. BMC Women’s Health (2023) 23:373 Page 2 of 10

outreach, research and interventions to build knowledge and confidence in the general population at scale. Future
studies should focus on investigating the effectiveness and economic impact of menopause group consultations
and the lived experience of individuals participating in group consultations.
Keywords Menopause, Patient acceptance of health care, Delivery of health care, Group consultation, Shared
medical appointment, Self-care

Introduction are unable to access menopause services locally, sug-


Menopause is defined as the permanent cessation of gesting there is an urgent need to increase access [11].
menstruation, resulting from a decline in ovarian folli- Primary care providers are responsible for managing
cular activity [1]. It is preceded by the menopausal tran- the majority of the NHS’ caseload, yet only half of GPs
sition, a period of menstrual cycle irregularity, which receive menopause training [12]. Secondary care referrals
usually begins in the mid 40s, and is followed by the associated with short-term symptom management and
postmenopausal period [2]. By 2025, the number of post- long-term conditions are expected to increase, includ-
menopausal women worldwide is expected to exceed 1 ing uptake of HRT, with considerable pressure on scarce
billion [3]. Despite the ubiquity of menopause, women NHS resources [13]. One approach to help address these
in the menopausal transition report considerably lower problems may be the use of group consultations [14], also
levels of health-related quality of life and higher levels of known as shared medical appointments [15].
work impairment [4]. Vasomotor menopausal symptoms The use of group consultations has seen increasing
are often considered the cardinal symptoms of meno- popularity in the UK, USA, Australia and India, and espe-
pause, and over three quarters of women describe their cially since the advent of the COVID-19 pandemic where
menopause symptoms as moderately or extremely prob- healthcare resources have become increasingly strained.
lematic at work, while 44% have taken undisclosed sick- Group consultations have been successfully used to man-
ness absence due to their symptoms [5]. An American age an increasing variety of conditions, including dia-
study found that $27.6 m was lost in work productivity in betes [16] and post-op orthopaedic care [17], leading to
women with untreated vasomotor symptoms [6]. A study improved patient outcomes and satisfaction rates in that
by the UK Department for Work and Pensions estimated same order [18]. Various models of group consultations
that if 600,000 more post-menopausal women continued have been developed that improve access and continuity
to work full or part-time, this would add £20bn and £9bn of care including antenatal group care [19]. Perinatal care
to GDP respectively [7]. offers the most compelling evidence for group healthcare
The Women’s Health Strategy survey conducted by the as demonstrated by the popularity of National Child-
Department of Health and Social care found that only 9% birth Trust courses in the UK, and the American College
of respondents felt that they had enough information on of Obstetricians and Gynaecologists’ joint opinion that
menopause, and considered menopause to be one of top patients have better prenatal knowledge, initiate breast-
health conditions causing them the highest concern [8]. feeding more often and are more satisfied with their care
Hormone replacement therapy (HRT) is the most effec- [20]. Group consultations can improve patient outcomes
tive treatment option for menopausal symptoms, yet relative to individualised patient care and are not usually
it is widely under-prescribed by healthcare profession- associated with adverse outcomes [21]. They also offer a
als (HCP). Menopause should also ideally be managed special opportunity to deliver more effective care at lower
holistically, using positive health behaviours in combina- cost. Realising group consultations can bring 300–400%
tion with hormonal or non-hormonal treatments. How- efficiency gains over traditional care models, and the
ever, approximately two thirds of menopausal women NHS is actively investigating how best to embed group
are unable to access adequate care for their symptoms consultations into routine practice [22]. This may be
highlighting the demand for more accessible, up-to-date especially beneficial during menopause when timely
information around menopause [9]. Awareness of meno- access to knowledgeable HCPs and quality assured health
pause and positive attitudes can influence the severity literacy information is difficult to find and remains inac-
of symptoms and quality of life. Psychological aspects cessible to many.
such as perceived control and self-compassion are more Only 54% of women seek medical input for menopausal
strongly linked to wellbeing than physiological symptoms symptoms, despite > 80% experiencing some combina-
such as the frequency of hot flushes experienced [10]. tion of symptoms associated with oestrogenic deficiency
Surveys from the Royal College of Obstetricians and [23]. European surveys have explored the perceptions
Gynaecologists demonstrate 58% percent of women and experiences of menopausal women illustrating high
Huang et al. BMC Women’s Health (2023) 23:373 Page 3 of 10

levels of understanding and awareness [24, 25], accompa- The survey adopted adaptive questioning and com-
nied by a significant negative impact on the psychological prised a total of 28 questions. It was accessible using a
and sexual well-being of the individual [26, 27]. However, personal computer or smartphone. Participants could
few studies have investigated the influencing factors that review their answers before submitting them. Ques-
trigger women to seek medical care. The aim of this study tions regarding demographic characteristics of the users
was to investigate the prevailing needs and motivations included information on assigned sex at birth, gender,
of women when seeking health information around men- age, ethnicity, educational level, marital status, the name
opause, and to establish their willingness to participate in of town or city they lived in and employment status. If
group-based healthcare, education, and support. participants did not select ‘female’ as their assigned sex
at birth, they were automatically excluded. Rather than
using the general term of "woman", the assigned sex at
Methods birth allows a greater inclusivity since trans men, non-
Study design binary and other gender nonconforming individuals can
We conducted a cross-sectional online survey of Eng- experience menopause. All data collected through the
lish-speaking respondents between the ages of 35 and survey were anonymised and not personally identifiable.
70 living in the United Kingdom. A structured search The online survey was piloted with a small group of indi-
was carried out in Pubmed prior to deployment of our viduals to ensure technical functionality and usability
survey. Search terms included: “menopause experience”, before being published.
“perceptions of care,” “patient acceptance”, “delivery of Menopausal phase was assessed through questions
menopause care”, “group consultation”, “shared medi- regarding menopausal symptoms and frequency of or
cal appointment”, and “self-care.” There were multiple date of last menstrual period. Respondents were catego-
references. rised into premenopause, perimenopause and postmeno-
The link to the electronic survey was published and pause according to the STRAW + 10 Staging System [28,
made available on the Imperial College Qualtrics plat- 29]. The STRAW system categorises women into meno-
form between 18 November 2020 and 19 March 2021 pausal stages based on when they had their last period
(4 months). The survey was open and could be accessed and the variability of their menstrual cycle, as menopause
by anyone with a link. Survey participants were recruited is clinically defined as having occurred 12 months after
through affiliates mailing lists, such as partnering organi- the final menstrual period. Respondents who indicated
sations and community groups, menopause specialist they had surgically induced menopause were categorised
clinics, and gyms, and online media channels, such as as surgical menopause.
Facebook and Instagram. Potentially eligible participants To investigate menopausal symptoms experienced and
received an invitation email from the study team. The the symptoms that acted as triggers for seeking help, the
researchers’ personal and professional networks were Menopause-Specific Quality Of Life (MENQOL) ques-
also mobilized to respond and further disseminate the tionnaire was adapted into a list of 18 symptoms [30, 31].
eSurvey among potentially eligible participants. The final Self-care behaviours were investigated using a series of
sample is a convenience sample. questions regarding the respondent’s preferred sources of
The Participant Information Sheet (PIS) included infor- menopause information and advice, personal triggers and
mation regarding the study’s aims, the protection of par- barriers for seeking advice and experiences with HCPs.
ticipants’ personal data, their right to withdraw from the The demand for group consultations was evaluated using
study at any time, which data were stored, where and for a number of statements where participants were asked to
how long, who the investigator was, the purpose of the indicate level of agreement. The Checklist for Reporting
study and survey length. Participants were informed that Results of Internet E-Surveys (CHERRIES) [32] was used
this was a voluntary survey without any monetary incen- to guide the development and reporting of the eSurvey.
tives but offering the possibility to access the findings at a
later stage whilst underlining the potential collective ben- Statistical analysis
efits of taking part in terms of shaping our understanding Respondent characteristics were described using fre-
of what the general population thinks about menopause quencies and percentages. Survey responses to the state-
care and how we can design better services in future. Par- ment: “I would join a group consultation if that meant I
ticipants were also given the opportunity to provide their could get personal medical advice from a menopause
contact details on the occasion that they were interested specialist” were used in statistical analysis and logis-
to be interviewed. The data collected were stored on the tic regression models. Associations between meno-
Imperial College London secure database and only mem- pause stage, acceptability of group consultations and
bers of the study team could access the eSurvey results. participant demographics were assessed using logistic
Huang et al. BMC Women’s Health (2023) 23:373 Page 4 of 10

regression models. All analyses were performed using (59.7%). 68.3% reported a lower sex drive, whereas 42%
Stata 15 statistical software (StataCorp). A p value 0.05 of all respondents experienced dry vagina or painful sex.
was considered statistically significant. Dry skin, broken hair and nails affected 54.7% of the
respondents. Migraines, dizziness, and dry mouth or
Ethics eyes were the most common ‘Other’ symptoms, experi-
The study received a favourable opinion from Imperial enced by 7% of respondents.
College Research Ethics Committee (ICREC #20IC6389).
Participants consented to take part in the survey. Sources of menopause advice
Nearly half (46.9%) of respondents felt that they had the
Patient and public involvement tools and understanding to manage their symptoms.
No patients were involved as research participants. The Around two thirds (61%) sought help from HCP or doc-
study protocol and online survey were developed in col- tor. Of those, the vast majority (93.3%) saw an NHS GP or
laboration with Bia Health Ltd, which included input gynaecologist, with very few seeing a psychologist (5.2%),
from PPI group and lay members. Preliminary surveys women’s health physiotherapist (4.1%), nutritionist (3.8%)
were conducted with approximately 200 women to gauge or dietician (1.4%). The largest trigger for seeking advice
their attitudes towards group healthcare and experiences was severity of symptoms (78.7%). The most common
of menopause care. The Survey was reviewed by eight symptom to prompt respondents to seek help from HCP
menopausal women as part of beta testing on usability was hot flushes or night sweats (31.3%). Whilst inconti-
and wording of questions. nence was experienced by three quarters of participants,
incontinence symptoms were amongst the least likely to
Results prompt respondents to seek help (8.1%) (Table S1).
Demographic profile of respondents Forty four percent of respondents who saw HCPs were
The electronic survey captured data from 1547 respond- prompted to do this to understand whether HRT was a
ents. We recorded a total of 594 excluded due to dupli- suitable option. For 71.1% of women, the support pro-
cate entries (n = 7), missing ethnicity (n = 498) or missing vided by their HCP was prescription medication. Trans-
age (n = 235), leaving a sample size of 953. dermal HRT was prescribed to 31.8%, oral HRT to 29.3%
The majority (68.0%) of respondents were aged between and local oestrogen to 18.1%. Only 6.2% of respondents
46 and 55 years (27.7% were 46–50 years and 40.3% were who saw a doctor were prescribed testosterone. Notably,
51–55 years; Table 1). All respondents confirmed their 19.3% of respondents were prescribed SSRIs or SNRIs
assigned sex at birth was female and 99% identified their despite over 14% of this cohort not reporting any vaso-
gender as female. The remaining 1% identified as "other" motor or psychological symptoms. Lifestyle changes
including non-binary and agender. In view of this, and for were proposed to 22.9% of those who saw HCPs, either
reasons of pragmatism, we opted for the use of the term as standalone (7.6%) or in combination with prescribed
"women" in this article but remain aware that meno- medication (15.3%).
pause does not solely concern cisgender women. 88.5% Excluding HCPs, the most popular sources of advice
of respondents identified as white ethnic background, or information about menopause were health websites
and 5.7% identified as Black, Asian, British Black or Brit- (55.4%) and friends (45.1%). However, of those respond-
ish Asian. Whereas 66.0% were educated to university ents who visited HCP, only 11.5% were prompted to do so
degree level or higher, 20.8% were educated to A-Levels, by online research or articles and 7.2% by friends. Only
81.0% were employed, 6.5% were retired and 81.6% were 5.2% of women sought advice from pharmacists. The
married or in a domestic relationship (Table 1). remaining 43.5% of participants who did not seek advice
from HCP reported that their symptoms were not severe,
Symptoms experienced by respondents or they could manage or cope on their own. One hundred
The mean number of menopausal symptoms experienced and ninety-five respondents (52.4%) of those who did
by respondents was 10.7. The most common menopau- not seek advice from HCP felt that menopause was not
sal symptom (81.8%) was sleep disturbances (including a valid enough reason to be seeking support (i.e. they did
difficulty falling asleep, staying asleep or early waking). not think it menopause was an appropriate reason to get
This was closely followed by hot flushes or night sweats medical advice and/or they did not think HCP could help
(80.7%) and forgetfulness or memory problems (75.6%). them and/or that the symptoms they were experiencing
Seventy three percent of respondents experienced symp- warranted HCP time and support). Eighteen respondents
toms of incontinence, Psychological symptoms were (1.8%) described reasons that would fit into the category
prevalent (72.4%) with low or depressed mood (66.6%) of not trusting HCP to help them—either due to a fear
being most common, followed by anxiety or panic attacks of misdiagnosis, not being taken seriously by HCPs, or
Huang et al. BMC Women’s Health (2023) 23:373 Page 5 of 10

Table 1 Participant characteristics


Pre- Peri- Menopausal Post- Surgical P-value
menopausal menopausal (n = 410) menopausal menopause
(n = 27) (n = 390) (n = 102) (n = 35)

Age, mean (SD) 44.3 (5.6) 49.5 (4.0) 54.5 (4.2) 55.6 (5.6) 52.7 (5.4) < 0.001
  < 39 3 (37.5) 4 (50.0) 0 (0.0) 1 (12.5) 0 (0.0)
40–45 9 13.9) 46 (70.8) 6 (9.2) 2 (3.1) 2 (3.1)
46–50 12 (4.6) 173 (65.5) 58 (22.0) 10 (3.8) 11 (4.2)
51–55 2 (0.4) 163 (28.4) 320 (55.8) 71 (12.4) 18 (3.1)
56–60 0 (0.0) 1 (2.1) 26 (54.2) 17 (35.4) 4 (8.3)
Ethnicity, n (%) 0.01
White 21 (2.5) 345 (40.9) 360 (42.7) 87 (10.3) 31 (3.7)
Mixed multiple 2 (8.7) 12 (52.2) 6 (26.1) 2 (8.7) 1 (4.4)
White & black Caribbean 0 (0.0) 9 (33.3) 12 (44.4) 5 (18.5) 1 (3.7)
Asia/ Asian-British 3 (15) 7 (35.0) 8 (40.0) 2 (10.0) 0 (0.0)
British Black / African 0 (0.0) 1 (14.3) 4 (57.1) 0 (0.0) 2 (28.6)
Other 1 (2.3) 16 (37.2) 20 (46.5) 6 (14.0) 0 (0.0)
Education, n (%) 0.49
Secondary school 2 (2.4) 25 (29.8) 42 (50.0) 10 (11.9) 5 (6.0)
A-Levels / College 4 (2.0) 72 (36.4) 93 (47.0) 22 (11.1) 7 (3.5)
University Degree or higher 20 (3.2) 274 (43.4) 250 (39.6) 67 (10.6) 20 (3.2)
Other 1 (2.2) 18 (40.0) 21 (46.7) 3 (6.7) 2 (4.4)
Employment, n (%) 0.05
Employed full time 11 (3.0) 163 (44.4) 144 (39.2) 39 (10.6) 10 (2.7)
Employed part-time 4 (1.7) 100 (42.6) 101 (43.0) 22 (9.4) 8 (3.4)
Self-employed 10 (5.6) 70 (39.3) 74 (41.6) 20 (11.2) 4 (2.2)
Furloughed 1 (4.8) 8 (38.1) 9 (42.9) 1 (4.8) 2 (9.5)
Retired 0 (0.0) 16 (25.4) 34 (52.0) 9 (14.3) 4 (6.3)
Unemployed 1 (1.8) 22 (38.6) 30 (52.6) 2 (3.5) 2 (3.5)
Unable to work 0 (0.0) 11 (28.9) 17 (44.7) 6 (15.8) 4 (10.5)
Marital status 0.07
Married 17 (2.6) 257 (39.8) 290 (44.9) 60 (9.3) 22 (3.4)
In a domestic relationship 6 (4.3) 58 (41.1) 56 (39.7) 16 (11.3) 5 (3.5)
Never married 1 (1.5) 32 (48.5) 20 (30.3) 10 (15.2) 3 (4.5)
Divorced 2 (2.6) 32 (41.0) 33 (42.3) 10 (12.8) 1 (1.3)
Widowed 0 (0.0) 3 (37.5) 2 (25.0) 3 (37.5) 0 (0.0)
Other 1 (4.3) 7 (30.4) 8 (34.8) 3 (13.0) 4 (17.4)
What triggered you to seek professional advice for your menopause?
Severity of symptoms 3 (0.7) 181 (39.3) 214 (46.4) 41 (8.9) 22 (4.8) < 0.001
Concerns over no longer being able to conceive 1 (25.0) 2 (50.0) 0 (0.0) 1 (25.0) 0 (0.0) 0.04
To understand whether HRT is suitable 0 (0.0) 87 (34.1) 128 (50.2) 29 (11.4) 11 (4.3) 0.001
Concerns over long term health 1 (0.6) 57 (34.5) 76 (46.1) 16 (9.7) 15 (9.1) < 0.001
Recommendation from a friend 1 (2.3) 20 (46.5) 14 (32.6) 6 (14.0) 2 (4.7) 0.72
Recommendation from a sibling 0 (0.0) 6 (54.5) 5 (45.5) 0 (0.0) 0 (0.0) 0.65
Recommendation from your children 0 (0.0) 2 (50.0) 2 (50.0) 0 (0.0) 0 (0.0) 0.94
Recommendation from partner/spouse 0 (0.0) 15 (44.1) 16 (47.1) 2 (5.9) 1 (2.9) 0.73
Online research or articles 2 (2.9) 27 (38.6) 29 (41.4) 7 (10.0) 5 (7.1) 0.61
Social media 0 (0.0) 11 (45.8) 10 (41.7) 1 (4.2) 2 (8.3) 0.51
Other 0 (0.0) 15 (24.6) 31 (50.8) 10 (16.4) 5 (8.2) 0.01
Huang et al. BMC Women’s Health (2023) 23:373 Page 6 of 10

the perception that HCPs lacked specialist menopause Univariable and multivariable association of menopause
knowledge and training. status with acceptability of group consultations
Univariable logistic regression showed that premenopau-
sal women were 2.84 times more likely than postmeno-
Lifestyle management of symptoms pausal women to be interested in participating in group
Seventy percent of respondents indicated that they had consultation (Table 2). The association remained signifi-
implemented lifestyle changes to help them self-care for cant in the multivariable model after adjusting for ethnic-
their menopause symptoms; 37.8% reduced their alco- ity, education, marital status and employment (Table 2).
hol intake, 35.6% started a new exercise regime, 27.4%
reduced caffeine intake, 6.7% started cognitive behav- Discussion
ioural therapy and 4.2% stopped smoking. Of those Summary of key findings
respondents, 82% indicated that these lifestyle changes To our knowledge, this is the first study to investigate the
were moderately effective for symptom relief. Less than feasibility and acceptability of group consultations for
half (40.5%) of respondents identified taking supplements menopause. We analysed data collected over a 4-month
such as black cohosh, evening primrose oil or magne- period from 953 respondents assigned female at birth,
sium to help them manage, with 75% of those respond- living in the UK aged 35–70 years, across all stages of
ents indicating they had some effectiveness for symptom menopause. Our findings suggest that group consul-
relief. tations would be widely accepted among menopausal
Two hundred and eighty four respondents (29.8%) populations as the majority (76%) of participants indi-
made no behavioural or lifestyle changes. 9.9% of cated that they would join a group consultation for this
respondents reported making ‘Other’ lifestyle changes. purpose.
The most common changes were reducing work stress or Compared to other women, pre-menopausal women
changing jobs (39.1%) and specific dietary changes, such specifically were most likely to be interested in a meno-
as removing dairy or wheat from their diet. Of those that pause group consultation where they could meet and
made lifestyle changes, 82% report the changes having learn about other women’s experiences. The proportion
some effect, with the majority (71.6%) only reporting a of women interested in menopause group consultations
slight or moderate effect. reported in this study exceeded the proportion of preg-
nant women who were interested in participating in group
antenatal care in a similar quantitative survey in 2015
Acceptability of group consultations [33]. The prevalence of menopause symptoms among
Overall, 77% of participants agreed that they would join women aged 35–70 reported in our study is broadly con-
a group consultation if it meant that they could get per- sistent with previous literature [34]. As reported here and
sonal medical advice from a menopause specialist. Three elsewhere, approximately 8 out of 10 women reported hot
quarters (75%) of study participants agreed that they flushes and night sweats, which are considered the hall-
would be comfortable sharing their menopause experi- mark indicators of menopause [35]. A similar proportion
ences in a confidential group setting with others. The of respondents suffered from sleep disturbances, although
majority (80%) of premenopausal individuals agreed they previous studies have indicated lower levels of sleep dis-
would join a group consultation or sessions where they turbances in midlife women, ranging between 40 and 56%
could meet or hear from others’ lived experiences, com- [36, 37]. The reason for this disparity is difficult to deter-
pared to 63%, 59% and 70% of perimenopausal, postmen- mine because the cause of each woman’s sleep distur-
opausal and women experiencing surgical menopause, bance may be multifactorial, and sleep issues were likely
respectively (Table S1).

Table 2 Association of menopause status with acceptability of group consultations


Univariable Multivariablea
Stage OR 95% CI P-value aOR 95% CI P-value

Post-menopause Ref Ref


Pre-menopause 2.84 (1.05, 7.69) 0.04 2.79 (1.02, 7.67) 0.05
Peri-menopause 1.21 (0.92, 1.59) 0.17 1.16 (0.88, 1.53) 0.3
Surgical menopause 1.63 (0.76, 3.50) 0.21 1.54 (0.70, 3.42) 0.29
a
Model adjusted for ethnicity, education, marital status & employment
Huang et al. BMC Women’s Health (2023) 23:373 Page 7 of 10

exacerbated by changes in lifestyle and routines during in their menopausal journey were more receptive and
the COVID-19 pandemic [38]. whether this pertains to their relative lack of experience
The percentage of women who were prescribed HRT is with menopause or better knowledge of the benefits of
consistent with the limited literature available [39, 40]; it group consultations.
is interesting to note that our study found that the same
proportion of women were prescribed oral HRT and
transdermal HRT. This is despite data indicating that the Implications for policy and practice
overall risk–benefit profile of transdermal HRT makes Further implications for menopause healthcare policy
it a more attractive option for the majority of menopau- and practice can be identified from our findings around
sal individuals and suggests that more work needs to be patient experiences and health-seeking behaviours.
done in promoting the use of transdermal HRT [41]. The mean number of symptoms reported by respond-
Testosterone can demonstrably improve sexual func- ents was 10.7, indicating the diversity of symptoms
tion and is recommended by the National Institute experienced by menopausal women. This suggests that
for Health and Care Excellence (NICE) guidelines for clinicians need to be more aware of the broad range
menopausal women with low libido where HRT alone is of self-care strategies available to support individuals.
ineffective [42, 43]. However, our data suggests that tes- For example, for menopausal patients suffering from
tosterone is largely underutilised since prescriptions were insomnia, CBT-i could be recommended as it is largely
only given to 6% of those who saw a healthcare profes- considered to be the first line of treatment for insomnia
sional, despite 68.3% of participants in our study admit- [45]. Another key point regarding symptoms is despite
ting experiencing symptoms of low libido. There are the high percentage of women experiencing urogeni-
currently no available licensed testosterone preparations tal symptoms, only a small percentage of those are
for women in the UK, which could explain the low levels prompted to seek help as a result of their symptoms.
of prescription. This suggests that women are either unaware that these
One of the top sources of advice reported here is the are treatable menopause symptoms or don’t feel com-
use of health websites, suggesting that over the past dec- fortable seeking help. A longer dwell time with clinicians
ade, the popularity of the internet as an advice source for within a group consultation setting could not only help
menopause has skyrocketed. destigmatise but would also allow for an exploration of
front-line therapy options, including vaginal oestrogen
Need for greater awareness or non-hormonal management strategies such as life-
Group consultations in other areas including diabetes style changes, vaginal moisturiser or lubricants [46].
and antenatal care have been largely successful [19, 44]. In the UK, there are 449 million visits to commu-
The findings of our study highlight that the demand for nity pharmacies annually, and evidence suggests that
menopause group consultations seems equally as high, if integrating pharmacists into primary care could help
not higher, than in these other healthcare areas. reduce GP workload. Our data also indicated that phar-
Over three-quarters of participants indicated that macists are an underutilised resource and would be ide-
they would join a group consultation if it meant they ally placed to offer quality assured menopause advice
could meet others or hear others’ experiences of meno- [47]. However, as over half of participants did not seek
pause. This suggests that although menopause involves advice because they did not think menopause was a
many intimate areas of health, women would enjoy valid enough reason to schedule an appointment with a
the integrated community aspect of group consulta- HCP, this indicates that as a society we need to change
tions, although around half of participants had doubts the narrative to let women know that their experiences
whether group consultations would be as good as a are valid, and that it is important to seek help for any
one-to-one consultation. Growing evidence suggests symptom that adversely affects their lived experience
that outcomes from group consultations are the same, or quality of life. HCPs also need to change attitudes
or sometimes better than one-to-one consultations, and perceptions towards menopause and be proactive
and some even preferred groups given the relation- in providing help to those that need it. Worryingly, a
ship-building aspect in addition to extended time with number of participants demonstrated a lack of trust in
the specialist [22]. Here there was a clear mismatch their clinicians to be able to provide them with the sup-
between the perceptions of group consultations and ini- port they needed, which could relate to the widespread
tial preferences, which indicated the need for improved lack of menopause training for doctors. Group consul-
education surrounding the benefits of group consulta- tations are an opportunity to educate patients and better
tions. It is interesting to consider why women earlier on utilise HCPs that have been trained.
Huang et al. BMC Women’s Health (2023) 23:373 Page 8 of 10

Study strengths and limitations of breast cancer who otherwise have limited options and
To our knowledge, this is the first study to investigate the have shown benefit from group and peer support [52].
feasibility and acceptability of group consultations for
menopause in the UK. Conclusion
The principal limitation of this study was that we col- Our study highlights a strong willingness of women
lected data between November 2020 and March 2021. aged 35–70 to participate in group consultations for
This time horizon included national lockdowns and so menopause and demonstrates that this motivation is
we need to take into consideration that the COVID-19 strongest amongst premenopausal women. Our survey
pandemic may have influenced personal experiences also indicated that only a small percentage of women
of menopause and that general accessibility to meno- felt that they had the tools and understanding to man-
pause care also is reported to have declined [48]. We also age menopause necessitating further research and
acknowledge that because the survey was conducted and interventions to build knowledge and confidence in the
distributed electronically, we may have excluded individ- general population at scale. Using group consultations
uals with limited digital access. Additionally, the demo- for first-line menopause healthcare provision should be
graphic profile of study participants largely consisted of strongly considered to improve accessibility and meet
university-educated cisgender women, implying that this growing global demand for care.
cross-section may not be representative of the wider UK Future studies should focus on investigating the effec-
population experiencing menopause. tiveness and economic impact of menopause group
consultations and the experiences of individuals in
those consultations. Within these studies, the effect
Further research of group size and composition should be evaluated.
This study sheds some important light on women’s pref- Additionally, remote group consultations should be
erences on what information they would like to receive compared to in-person group consultations, as remote
about menopause and the value of group consulta- consultations would decrease the resources needed and
tions with input from a prescribing clinician who could increase accessibility.
streamline access to HRT as needed. Whilst there is lim-
ited evidence available on the clinical efficacy of meno- Supplementary Information
pause group consultations specifically, the substantial The online version contains supplementary material available at https://​doi.​
need for further support for women in accessing health- org/​10.​1186/​s12905-​023-​02506-w.

care advice and treatment relating to the menopause


Additional file 1: TableS1. Demographics, health-seekingbehaviours
identified in this study, and the evident interest of women and healthcare experiences.
in group consultations for this purpose, indicates that
group consultations for menopause should now be tri- Acknowledgements
alled to determine the extent they are able to improve Benedict Hayhoe, Immy Webber, Aos Alaa and Austen El-Osta are supported
clinical outcomes in the context of the NHS and real- by the National Institute for Health Research and Care (NIHR) Applied Health
Research (ARC) programme for Northwest London. The views expressed in
world healthcare settings. We can use the data collected this publication are those of the authors and not necessarily those of the
here to target women who are more likely to be open to National Health Service (NHS), the NIHR or the department of Health. Research
group consultations, consequently increasing the poten- was completed in association with Bia Health Ltd. David Roy Huang is the
guarantor.
tial for self-care and improvements in patient activation
measures. Authors’ contributions
Further studies might also investigate the evolving David Huang and Abigail Goodship wrote and edited the main manuscript
text. Abigail Goodship conducted the data analysis and preparation of the
landscape in the medical management of menopause, tables. Iman Webber, Aos Alaa and Eva Sasco contributed to the survey
including the role of groups in accelerating the dissemi- design, data collection and critical revisions. Benedict Hayhoe & Austen El-
nation of information and the uptake of novel therapeu- Osta contributed critical revisions and final approval. All authors reviewed the
manuscript.
tic options. Examples include the changing prescribing
patterns of hormonal therapies, such as testosterone for Funding
libido and fatigue symptoms, or the use of selective oes- This research received no specific grant from any funding agency in the pub‑
lic, commercial or not-for-profit sectors.
trogen receptor modulators (SERMs) for vulvovaginal
atrophy or overactive bladder symptoms [49, 50]. In addi- Availability of data and materials
tion, SERMs and emerging non-hormonal therapeutics, The datasets used and/or analysed during the current study available from the
corresponding author on reasonable request.
including neurokinin 3 receptor antagonists [51], have
additional utility when managing patients with a history
Huang et al. BMC Women’s Health (2023) 23:373 Page 9 of 10

Declarations 14. Gibson H, Huang D, Hayhoe BWJ, El-Osta A. A Virtual Group Consultation
Model of Care for Menopause Treatment. NEJM Catal [Internet]. 2022 May 18
Ethics approval and consent to participate [cited 2023 Feb 17];3(6). Available from:https://​doi.​org/​10.​1056/​CAT.​22.​0041
The study was approved by the ethics committee of Imperial College. Imperial 15. Hayhoe B, Verma A, Kumar S. Shared medical appointments. BMJ.
College Research Ethics Committee (ICREC) reference #20IC6389. 2017;30: j4034.
The study was approved by the Research Governance and Integrity Team 16. Sadikot SM, Das AK, Wilding J, Siyan A, Zargar AH, Saboo B, et al. Consen‑
(RGIT) and no significant ethical issues have been identified in the protocol sus recommendations on exploring effective solutions for the rising cost
or ethics application. All experiments were performed in accordance with of diabetes. Diabetes Metab Syndr Clin Res Rev. 2017;11(2):141–7.
relevant guidelines, regulations and data governance rules. Informed consent 17. Powell RL, Biernacki PJ. Shared Medical Appointments in Preoperative
was gained from all participants to take part in the online study. Joint Replacement: Assessing Patient and Healthcare Member Satisfac‑
tion. J Healthc Qual. 2019;41(5):329–36.
Consent for publication 18. Edelman D, Gierisch JM, McDuffie JR, Oddone E, Williams JW. Shared
Not Applicable. medical appointments for patients with diabetes mellitus: a systematic
review. J Gen Intern Med. 2015;30(1):99–106.
Competing interests 19. Cunningham SD, Lewis JB, Thomas JL, Grilo SA, Ickovics JR. Expect With
Benedict Hayhoe is Clinical Lead for Research and Development, eConsult Me: development and evaluation design for an innovative model of
Health Ltd (a provider of an online consultation platform for NHS primary, group prenatal care to improve perinatal outcomes. BMC Pregnancy
secondary and urgent and emergency care) and all other authors declare that Childbirth. 2017;17(1):147.
they do not have competing interest. 20. ACOG Committee Opinion No. 731 Summary: Group Prenatal Care.
Obstet Gynecol. 2018;131(3):616–8.
Author details 21. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group
1
Self‑Care Academic Research Unit (SCARU), Department of Primary Care & versus conventional antenatal care for women. Cochrane Pregnancy and
Public Health, Imperial College, London W6 8RF, UK. Childbirth Group, editor. Cochrane Database Syst Rev [Internet]. 2015 Feb
4 [cited 2023 Feb 12];2017(1). Available from: https://​doi.​org/​10.​1002/​
Received: 17 February 2023 Accepted: 24 June 2023 14651​858.​CD007​622.​pub3
22. Jones T, Darzi A, Egger G, Ickovics J, Noffsinger E, Ramdas K, et al. Process
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23. Constantine GD, Graham S, Clerinx C, Bernick BA, Krassan M, Mirkin
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