The signs and symptoms of menopause can be challenging to treat. Many men, including myself, often don’t truly appreciate how menopause can negatively affect a woman’s quality of life.
For example, almost one out of five women will experience heavy menstrual bleeding as they approach menopause. To manage this heavy bleeding, there are several non-surgical treatments that can be first tried to avoid or delay a hysterectomy. Although many women begin menopause in their 40’s, some will experience menopause earlier because of surgical removal of the ovaries or other medical conditions.
Women’s health issues may be overlooked in Hong Kong. What follows is a story of a long-time Hong Kong resident and her challenges receiving appropriate care as she started menopause, and faced greater restrictions on physician choice with changes in her employer’s insurance policy. Here is Michelle’s* story in her own words.
Health Care in Hong Kong
Whether I was in need to major surgery for a recurrent cholesteatoma in my ear or the simple treatment at the start of menopause, I required medical and surgical assistance over a 20 year period in Hong Kong.
Twenty years ago my choice of surgeons was fabulous. Clearly the prominent airline staff medical provider has changed its goal posts significantly since then.
I’m lucky to have had the same fabulous surgeon who knows my case and deals with my complications as they arise. Today this doesn’t come without a fight.
Every six months, I am required to obtain a referral from a general practitioner (GP) before I make the appointment to see my surgeon (normal protocol). Nowadays, I am required to see the new panel appointed ear, nose, and throat doctor (ENT) who confesses right away “your case is too complicated for me, you must go back to see your original guy, I will write a letter of referral”. So now me and my insurance company have put more money into another GP referral and another ENT’s pocket to obtain the same result. Waste of time, money and resources.
My ENT also voiced their concerns as they have tried many times to reason with the health fund providers and employment institutions giving their patients the best options/solutions for care. Access to treatment appears to be political, and sadly not in the best interest of the patient.
Now to my perimenopause saga.
By the age of 38, I had 4 young children, and my breeding days were essentially over. Come period time, I started to bleed out. This went on for 3 years. I had many doctor consults, essentially monthly.
My ferritin levels got down to as low as 4, I was continually prescribed Ferrum Hausmann® (chewable iron tablets). I had a Mirena® intrauterine device put in one time under general anaesthetic by a well known lady doctor who had a practice in Central, Hong Kong. After it was inserted, I continually bled out for 6 months. The intrauterine device was eventually removed as it was ineffective. My iron levels essentially remained unmanaged during this time, only ever took the chewable iron tablets.
The gynaecologist I saw recommended a full hysterectomy at this stage, she wanted to book me into the Matilda Hospital and do it ASAP. No options were provided to manage my iron levels. I couldn’t quite come to grips with ripping my insides out at the age of 40, and not given any other option, I declined the hysterectomy.
Three years later at the age of 41, we moved our children to Australia to school them. I am a private pilot, and had completed my pilot medical exam in Australia.
The aviation medicine doctor asked how I was, so I told her of my ordeal in Hong Kong. Her eyes shot wide open. I told the doctor how I had no energy, and gave her a copy of my recent blood results. We then discussed the options for fixing the heavy and persistent menstrual bleeding.
I explained that I was offered a hysterectomy and that I declined. She suggested that I do a 90 second procedure called ablation, explaining that I couldn’t have children after the procedure, but my insides remain intact. A full set of blood tests were also ordered, and I was sent home with a prescription for an intravenous iron infusion.Within 20 minutes I was sorted and I had an appropriate treatment and follow-up plan.
Two days later the phone rang—it was the doctor with the lab results. My iron levels were still 4 (extremely low), after all these years of chewable iron tablets! My teeth are now a shade of yellow as a result of continuously munching on iron tablets for years.
I had a double iron infusion, and the 90 second endometrial ablation procedure. I haven’t had a period since, and my ferritin is at 130 (normal). I can now donate blood regularly and I have never felt better.
All after a basic pilot medical with a bulk billing doctor in Australia (I had to obviously pay for the aviation medical exam). I was gobsmacked at the chalk and cheese service compared to HK.
Moving forward with the menopause, I am now monitored constantly, using both blood and saliva for checking my hormonal levels and blood counts. Post 45 years of age, I now take 100 mg bioidentical progesterone, plus a transdermal patch 25 mcg/day of oestrogen. Unfortunately the oestrogen transdermal patches (Estradot®) are not available in HK. They really need to update their drug rules and laws.
If menopause was a major, common men’s health issue that affected 50% of the population, you can guarantee there would be legislative action in favour of moving with the times to assist 50% of the population with the latest and greatest options. How many women are in LegCo (Legislative Council)? Just saying. Women have a right to life changing simple medicine.
There appeared to be a lack of experience managing iron deficiency anemia because of the heavy bleeding in perimenopause. In my experience, most adults would be treated with solid (non-chewable) oral iron product. Liquid or chewable iron would only be considered in adults who have difficulty swallowing a tablet or capsule. It seems strange that an adult with no swallowing problems would be prescribed a chewable iron product, especially since a common side effect of liquid/chewable iron is tooth staining.
Indeed, transdermal estrogen patches are not registered in Hong Kong. This type of estrogen may have a lower risk of causing a blood clot, and may be preferred by some women. Not being a registered drug limits access for women who could benefit from this important first-line treatment.
Finally, there is a lack of women legislators in Hong Kong. Only 14% (10/70) of LegCo members are women, which may contribute to the lack of emphasis on women’s health issues.
I am happy that Michelle finally received the appropriate care she, and all women deserve. She has graciously shared her story to help raise awareness of the barriers to timely and appropriate treatment, that women can encounter in the Hong Kong health system. I hope her story encourages others to request safer and higher quality care from the government, insurers, and individual health care professionals.
*The patient’s name has been changed to protect her privacy.
Caveat Emptor or “Let The Buyer Be Aware”
No one wants to get ripped-off. Even worse is when you know you are being overcharged and the person doing the billing is a medical doctor.
Last month, my wife shared a Facebook post with me. A mother named Jamie* had asked if it was legal for a doctor to refuse to write a prescription in Hong Kong. Many doctors in Hong Kong also dispense medications, so by not giving Jamie a prescription, she was forced to buy her drugs from the clinic, rather than having the option of purchasing her medication at an outside pharmacy.
Since there is a lot of misinformation about the laws governing private healthcare in Hong Kong, I reached out to Jamie to answer her question.
Requesting Prescriptions in Hong Kong
It began as a regular doctor appointment on Friday June 15, 2018. Jamie saw a medical specialist at a private network medical clinic. After a satisfying consultation, Jamie went to pay the bill and requested a doctor’s prescription for her medications. This is her normal practice since she often obtains prescriptions in Hong Kong from her family doctor, who is located at another clinic within the network. Jamie usually gets a prescription for her chronic medications so that she can have medications dispensed by a registered pharmacist at a reasonable cost. This is very important since her insurance coverage for drugs has an annual limit.
Rather than fulfilling her request, the clinic nurse stated it was against company policy to provide written prescriptions. The nurse sternly told Jamie that she had to purchase drugs directly from the clinic dispensary.
Jamie did her best to explain how her family doctor would normally provide prescriptions, and that they also worked at a clinic within the network. How could this discrepancy be standard company policy? The nurse insisted that Jamie had to buy her drugs from the clinic. This put tremendous pressure on Jamie since she was with her daughter and didn’t want to cause a large scene in front of other patients.
Jamie paid the bill, purchased the medicine and left the clinic feeling confused and upset with her experience.
Jamie brought this conduct to the attention of her insurer, the clinic manager, the Consumer Council, and the Medical Council of Hong Kong. After hearing this story, I also contacted the clinic manager, who explained that this was a misunderstanding by the nurse involved. She said the company has a policy that they will provide a prescription if one is requested by the patient. Apparently nurses were asked to track the number of outside prescriptions to determine if the clinic was maintaining adequate stock of these drugs. The nurse mistakenly interpreted this direction to mean that patients could not request written prescriptions. The manager said the nurse would follow-up with Jamie and apologize.
However, it seems strange that none of the other nurses or doctors attempted to correct their colleague’s misguided understanding of clinic policy. This makes me wonder if the pressure to minimize outside prescriptions is growing within the private health care sector in Hong Kong.
In the end, Jamie was charged $800 HKD ($100 USD) for a one-month supply of 28 tablets of brand name Nexium. She could have easily purchased this product, or a generic equivalent, from a local pharmacy, for about $300 ($38 USD). Not only did the doctor and the clinic overcharge Jamie, they also deprived her of choosing a personal pharmacist to professionally dispense her drugs.
The Wild “East” of Private Health Care
The truth is that the laws governing healthcare and drugs in Hong Kong haven’t fundamentally evolved since British colonial times.
Some laws governing pharmacy and non-Chinese drugs were slightly updated in 2015, but the legal framework is still based on the 1937 Pharmacy and Poisons Ordinance.
What’s more is that the government acknowledges that the laws governing private health care facilities have not had a substantial update since 1966! This creates a healthcare market that is largely lawless and unregulated. Some laws governing private healthcare exist, yet they are minimally enforced by underfunded and ill-equipped regulators.
That’s why I sometimes refer to private healthcare in Hong Kong as the Wild “East”. Doctors in Hong Kong often prescribe a bewildering cocktail of drugs for a minor cold or stomach ache. Drugs are then dispensed by clinic staff with little or no professional training. There is no requirement that drugs must be double checked by a registered pharmacist, since dispensing doctors are the rule, rather than the exception.
Finally, there are no mandatory controls on the prices of health care services. Jamie and many other locals have told me that pricing often depends on if you have health insurance. If you tell the staff at the clinic that you have insurance, you might receive an unexpected 20% fee increase!
Is Refusing to Provide a Prescription Illegal in Hong Kong?
In short, the answer to this question is no. I have thoroughly reviewed the laws that govern medical clinics, physicians, and pharmacy, and there is nothing in the law that states that a doctor must provide patients with a written prescription. Many people would certainly conclude that this practice is wrong and possibly unethical. To be sure, I am not talking about prescriptions that are not clinically warranted. I am referring to legitimate prescriptions for treatments recommended by the doctor.
In fact, Jamie’s situation seems to contravene the Code of Professional Conduct for Registered Medical Practitioners, which states:
9.3 Patients should be given the choice of either receiving medicine directly from the doctor or taking a prescription from him.
However, these guidelines appear to be optional since they use the word “should” rather than “must”. Further, the introduction states that the the code is not a legal document. This contrasts with many other international codes of practice for healthcare professionals which are key components of the legal regulatory framework.
The practice of refusing to write a prescription limits patient choice as to where to obtain medicine. Because it could be considered an anti-competitive practice, I submitted a complaint to the Hong Kong Competition Commission on behalf of Jamie. Unfortunately, they feel that it isn’t anti-competitive because patients have the choice as to where they receive medical services. See the full response from the Competition Commission.
Murky Medical Practices
Now you might question the use of these personal stories rather than objective data. The data does exist although it is frequently obfuscated by the players in the private health care sector.
Bupa, a large insurer and healthcare provider, released a report in January 2018 that looked at the very issue of transparency in the private health care sector in Hong Kong. The report concludes that the lack of transparency in the Hong Kong health system negatively impacts patient safety, costs, quality of care, and the patient experience.
One of the most fascinating insights from the report is the variation in costs for the same medical procedure. Prices can vary substantial depending on the “room class” at private hospitals. Furthermore, the same room class (e.g., semi-private) may not be directly comparable between hospitals.
Lastly, the report raises the point about the lack of a sole regulator for healthcare in Hong Kong. The public system is closely regulated by the Food and Health Bureau whereas the private system is loosely regulated by the Department of Health. This in fact means that the public system is more in line with international norms of data transparency and reporting.
There are many good healthcare professionals and positive aspects of health care in Hong Kong. However, certain practices that harm patients and reduce the value of healthcare provided need to be addressed.
You can try to protect yourself by asking important questions before visiting a doctor. Ask them for their fee schedule and if they have different fees for patients with insurance and without insurance. Does the clinic allow you to request a written prescription that can be taken to an outside pharmacy? This could save money and allow you to get professional advice from a pharmacist of your choice. Finally, you should ask all clinics if they separate the doctor consultation fee and the fees for any required medicines. All these important questions will help you understand how you will be billed for a visit to a private doctor.
Have you had a disappointing healthcare, medication, or pharmacy experience in Hong Kong? Leave your comments below!
In my next post, I’ll share a personal story about a mother who was approaching menopause, and her struggles to find appropriate treatment in Hong Kong.
*The patient’s name has been changed to protect her privacy.