>
Do you feel like you’re drowning? These haunting words, in a social media post struck a chord with Paula Rastrick.
The advert, from a private clinic specialising in menopause treatment, seemed to list all her problems: anxiety, insomnia, fatigue and lack of sex drive, to name a few. They were symptoms that, till then, Paula had put down to stress. After all, she’d recently been though a redundancy, an aborted house move and launched a new business.
But the psychotherapist and mother-of-one, then 45, had begun to feel like she was slipping under. Could her hormones also be to blame? If that post was anything to go by, then the answer was yes. What’s more, there was a treatment that could help. ‘You can feel like you again,’ claimed another post.
Searching for something that would ease the pressure, Paula booked an appointment with the clinic.
The 30-minute consultation a few weeks later was short and to the point: the doctor said Paula was perimenopausal, the stage before the menopause when a woman is still fertile and having periods but levels of the female hormone oestrogen become erratic, triggering symptoms.
She should start on HRT patches and tablets immediately.
RECOVERING: Paula Rastrick was on double the maximum HRT dose – which her NHS GP then slashed
Paula asked few questions. ‘This was a specialist menopause clinic, and the doctor was highly regarded,’ she says.
‘I didn’t know much about hormones – I barely knew what oestrogen was. But I wasn’t feeling well. I just did what was recommended.’
The medication would, Paula was assured, help her feel better.
In reality, that appointment in February 2017 marked the start of a year-long ordeal that Paula is still struggling to come to terms with – one that saw her symptoms worsen, her mental health deteriorate to the point of breakdown and her marriage almost collapse.
Despite her fragile state, when she returned to the clinic the specialist – who The Mail on Sunday is not naming for legal reasons – simply upped her dose of HRT.
Following this, at her lowest ebb, she admits she considered ‘driving off a cliff and ending it all’.
And, alarmingly, she began to suffer heavy menstrual bleeding without warning. It was only at this point, after six months of worsening health, that Paula visited her own GP.
He immediately told her the ‘alarmingly high’ dose of HRT she was taking was the cause.
Although she didn’t know it at the time, Paula had initially been put on the maximum allowed dose patch. And when her medication was adjusted, the private menopause doctor had doubled it.
Paula was given HRT at a specialist menopause clinic where she says the doctor was ‘highly regarded’
Both these actions break with standard guidelines produced by health watchdogs and the drug makers themselves.
Paula’s GP and the doctors who later treated her – and gynaecologists spoken to by this newspaper – have said that her bleeding was a direct side effect of the medication.
Her psychiatric symptoms – tearfulness, panic, uncontrollable, irrational rage and suicidal thoughts – could have been, at the very least, exacerbated by the hormone drugs.
Today, thankfully, Paula is well again. Now 50, she is still on HRT, but a moderate dose.
Antidepressants helped ease the worst of her distress, and she says: ‘I feel good. It was hard work to get here, but the worst is behind me.’
Yet reliving her darkest moments while speaking to The Mail on Sunday’s Medical Minefield podcast, the emotions are still clearly raw.
Paula has decided to speak publicly to warn other women, because, worryingly, she is far from alone. Numerous reputable experts we spoke to said they have seen increasing numbers of women being prescribed these doses of HRT by private doctors.
The majority of medics in the field work within limits set by health watchdog the National Institute For Health And Care Excellence (NICE). Yet there is a growing minority who are working outside the guidelines, they warn.
HRT is astonishingly effective in reducing many symptoms of the menopause, but it is not without risks, particularly if too much is given.
Indeed, there can be disastrous consequences, as Paula discovered almost too late.
Recalling her state of mind before she booked that first private consultation, which cost roughly £300, Paula says: ‘Life had been extremely stressful for a long time. I just wanted to feel better. Those social media posts really spoke to me – I just thought, they know what I’m going through.
‘Although I wasn’t having hot flushes, I was feeling anxious, tense and irritable. I was struggling to sleep, or concentrate, and had lost interest in sex, and in life generally. I felt exhausted, and often found myself crying at nothing.
‘Before my appointment, I filled out a questionnaire detailing this, although we didn’t discuss this. During the consultation, the doctor just told me my symptoms were related to the change in my hormones.’
Paula was prescribed Evorel – one 100 microgram patch, twice a week – and Utrogestan, a drug containing progesterone, another female hormone, to be taken daily for two weeks each month.
A follow-up appointment in two to three months with the same doctor was recommended.
‘At that point, I felt relieved,’ Paula continues. ‘I had an explanation for why I’d been feeling so bad and I was getting something to help me get better.’
But that’s not what happened. Paula was taking her medication as directed but says: ‘My life was still stressful. I was on the rollercoaster of trying to launch a new business – something I’d never done before. I’d just been through eight months of difficult redundancy negotiations. But I didn’t feel like I could take a break and I was just frantically trying to stay afloat.’
Over the next few months, Paula’s mental health worsened.
‘I started to become extremely angry and aggressive,’ she says. ‘At home, I’d snap at the slightest thing, and yell at my husband.
‘A friend suggested I didn’t seem myself, and I flew into a rage at her. I hate to think about it now, but at the time I couldn’t think rationally.
‘I also started drinking to try to get to sleep – two or three glasses of wine every night, and more at weekends.’
Paula’s next appointment at the menopause clinic was in May that year. She says: ‘I explained I’d not improved, and in fact felt worse.
‘Looking back, I think I was depressed. I’d been prescribed antidepressants after having my son, so it wouldn’t have been the first time.
‘I also mentioned that I’d started bleeding in between periods.’
In a follow-up letter to Paula, the doctor wrote: ‘Understandably some of your stresses are related to starting up a new business… however I feel that some of your symptoms are related to your hormones. I do not feel that you are clinically depressed and need antidepressants at this time.’
Paula was told to double her dose of Evorel, to two 100 microgram patches twice a week and prescribed testosterone gel, a hormone medication. She says: ‘I believed it would help me feel better.’ Yet at this point, she ‘started to unravel’.
Paula continues: ‘I became highly paranoid and my anxiety was through the roof. My husband and I were arguing constantly.
‘One Sunday morning, after a screaming row, I was sitting in the car, parked outside the church in my village. I could hear the bells chiming and decided that was it. I would just drive off a cliff.
‘I wanted to end it, that’s how bad it was.’
Paula was told by her GP that the amount of HRT she had been taking was far too high and this was causing her bleeding
Thankfully, Paula didn’t follow through. ‘After that, I moved out temporarily – I stayed in a hotel, and then with a friend.’
And there was worse to come.
‘I was in the pub one evening when I felt the most horrible sensation, almost like my insides were falling out of me. I stood up and looked down at the seat.
‘It was covered in blood. I ran out and called my husband, who came and picked me up. I don’t remember much else about it – I was distraught.’
Realising something was wrong, Paula arranged to see her GP. ‘It sounds stupid, but I didn’t connect the HRT to what was going on. In fact, I asked my GP if he’d write me another prescription.
‘He took one look at what I was taking and said, “What are you doing with this amount of HRT? There is no way we’re giving it to you.”
‘He explained that the bleeding, and possibly also the way I was feeling, had been due to the medication. He said they’d have to get my dose down. At first I refused – I was convinced that without the HRT I’d disintegrate.’
Worse, Paula was told she would need to be investigated for womb cancer. High doses of oestrogen can increase the risk of developing the disease, and heavy bleeding can be a symptom.
She adds: ‘He asked me whether I wanted to make a complaint to [doctors’ regulatory body] the General Medical Council about the specialist. But I was too shocked to even think about it.’
The following week, Paula saw a gynaecologist and underwent scans.
‘At this point, I just fell to pieces, crying. I was put on antidepressants and medication to stop the bleeding.’ Fortunately, the cancer tests came back all clear.
‘Slowly, the GP reduced my dose of HRT. And I began to feel more like myself again, but it’s been a slow process. In 2020, Covid happened and we had to close the business for a while. I took it as an opportunity to focus on my health and repair my marriage. It’s been hard, but I feel I’ve finally recovered.’
Guidelines produced by NICE and the Primary Care Women’s Health Forum suggest menopausal or perimenopausal women should be started on a low dose of oestrogen HRT.
If symptoms are still present after a month, an increase within licensed dose recommendations should be considered.
More modest amounts, the guidelines say, can cause ‘fewer side effects such as breast tenderness and vaginal bleeding, and keeps risks [including womb cancer] minimised. Most women find a standard dose of a 50 microgram patch adequate for symptom relief.’
Evorel patches are available in four strengths: 25, 50, 75 and 100 micrograms. According to the drug manufacturer: ‘For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose… should be used. A dose of 100 micrograms… should not be exceeded.’
Additional guidance from the British Menopause Society states that should a high dose of oestrogen be given, higher doses of progesterone medication should be offered too.
Progesterone has a protective effect, reducing the risk of heavy bleeding and womb cancer. In Paula’s case, this additional adjustment did not happen.
Gynaecologists warn that some private doctors are regularly prescribing far outside the guidelines. One senior medical source told The Mail on Sunday: ‘We are all aware of what’s going on and it’s a huge concern. There have been high-level meetings about it.
‘Many of us have tried to explain to these doctors what they’re doing is not best practice, but it seems to be falling on deaf ears.’
Dr Paula Briggs, a sexual and reproductive health expert and chair of the British Menopause Society, says: ‘Guidelines are important – they’re what keep patients safe.
‘Giving high doses of oestrogen, and not using enough progesterone puts women at risk.’
Dr Annice Mukherjee, a consultant endocrinologist and women’s health expert, says Paula’s is not the only such story she has heard, and adds: ‘Best practice is to start patients on a low or standard dose of HRT and build up from there. If we are giving drugs in higher-than-recommended doses – we call this off-licence – it’s really important the patient is given evidence for why it is being done, and is fully aware of the potential risks.
‘It’s also important to mention that not every problem a woman has in midlife is due to the menopause. Just offering HRT, and giving more hormones when a patient doesn’t respond, is an oversimplistic way of looking at a woman’s health.’
Paula has been left shaken by her experience. She called the clinic last year and attempted to initiate a complaint.
She says: ‘But as I spoke to the person on the phone, I realised I couldn’t go through with it. It was just too difficult to relive.
‘I’m 50 now and I’m still on HRT, but a low dose. I wonder whether I could stop completely, because I feel good these days.
‘I don’t want anyone to be scared of taking this medication, or to think HRT is dangerous. But I was given too much. I can’t say the drugs caused all my problems, but I think they screwed me up even more.
‘What scares me most is that’s happening to other women.’