Here you see a GP successfully summarising the multiple factors that could be influencing the patient's libido, skilfully doing this without attributing blame on the the way things are, with her roles as a daughter, a parent, a busy Nurse and maintaining a relationship with a husband who is away, and the implications this has for her mindset, which is so crucial for what she wants in terms of libido. 

She proceeds to introduce the patient's expressed idea about Testosterone in a tentative way, "I wonder whether..." as a means of testing out how fixed the idea of Testosterone Replacement is for the patient, or whether other important issues could be considered as part of the long-term management. 

The GP shares her uncertainty, making suggestions rather than recommendations, and this facilitates a discussion about the current UK licensing of Testosterone, the challenges this brings and potential solutions in ensuring safety, reviews and monitoring of Testosterone levels.

Having explored relationship and opportunities for intimacy and connection within the marriage, then exploring the possibilities with Oestrogen dose, the GP can continue to engage the Testosterone request having highlighted the bigger picture.

Adopting this approach in the tone the GP expresses here allows the patient to feel comfortable enough to make the challenging statement and ask if the GP is reluctant to prescribe Testosterone- this clarification as to the GPs thinking is a common strategy of sharing our thoughts with the patient- sometimes called 'thinking out loud' and helps build trust and clarify any misunderstandings. 

It's after this trust-building moment, that the GP broaches the topic of genitourinary symptoms and the impact of atrophic vulvovaginitis as a relevant factor. The patient knowingly smiles and acknowledges this as significant for her, and perhaps this line of enquiry would have been less successfully engaged had it been explored earlier in the consultation whehn the patient's concerns had not yet been addressed satisfactorily. 

What other strategies do you use for managing Genito-Urinary Symptoms of the Menopause (GUSM)?