The Quiet Harm of Clinical Dismissal 

Every so often a patient story lands with a thud, not because it is shocking, but because it is so tediously familiar. I want to be clear at the outset: most GPs are conscientious, thoughtful, and doing their best in a strained system. But the minority who default to dismissal rather than curiosity can cause disproportionate harm. They erode trust, delay diagnosis, and leave patients questioning their own bodily experience. 

A patient I’ve mentioned before, the same woman whose inflammatory arthritis was confidently labelled ‘just osteoarthritis’ and treated with a breezy suggestion to take paracetamol, recently told me another story. It is a case study in how women’s symptoms are still too often reframed as emotional states rather than physiological events. 

She had been prescribed SSRIs and Evorel 25 patches. On paper, this is a reasonable combination. In practice, her body had other ideas. Within hours of applying the patch she developed an extremely rapid pulse, profuse sweating, a pounding heart that felt as if it were trying to exit her chest, and difficulty breathing. She genuinely thought she was having a heart attack. On the brink of calling an ambulance, she tore the patch off –  and the symptoms subsided. 

This wasn’t a one off. It happened again the next time she applied the patch, pushing her to the edge of a panic attack. She needed the SSRI. She also wanted the HRT. So, she did what many women end up doing when the system doesn’t help them: she experimented. She cut the patches in half. That [it seems] her body could tolerate. 

Now, the physiology here is interesting, and importantly, not far-fetched; oestradiol is not a passive hormone. It has direct effects on central autonomic regulation, serotonergic signalling, and noradrenergic responsiveness. Transdermal delivery is often described as ‘steady’, but in reality there can be a relatively rapid rise in circulating oestradiol after application, particularly in sensitive individuals or those who absorb efficiently. 

Oestradiol also modulates serotonin pathways [the same pathways targeted by SSRIs such as sertraline]. This creates a biologically plausible interaction: not dangerous in the sense of toxicity, but capable of temporarily altering autonomic balance. In practical terms, that can mean a short-lived increase in sympathetic output: tachycardia, sweating, heightened interoceptive awareness, which the brain then interprets as threat. 

In other words, the sequence she described [rapid onset after application, resolution on removal, recurrence on re-exposure, and tolerance at a lower dose] is not the pattern of imagination. It is the pattern of a dose-dependent physiological response with a clear threshold effect. 

A clinician with even a passing interest in mechanism could have explored this. They could have asked whether she might be particularly sensitive to hormonal shifts, whether the site of application affected absorption, whether her SSRI dose or timing played a role … 

None of this requires specialist training, even I could do it. It just requires curiosity, and a willingness to take the patient’s timeline seriously. 

Instead, when she recounted the episodes, her GP waved a hand and told her she must be imagining it. 

When she explained that it had happened twice, he doubled down: she had ‘got herself into a state last time’, so naturally she was ‘expecting it again’. The implication was clear. Her body was not the problem. Her mind was. 

This is the part that made me angry. Not because it is rare, but because it is routine. Women are still told, implicitly or explicitly, that their symptoms are exaggerations, misinterpretations, or emotional artefacts. The diagnostic label becomes anxiety not because the physiology points that way, but because the clinician has reached the limits of their interest. 

The irony, of course, is that she was not anxious until the symptoms began.  

The symptoms created the fear, not the other way around. Acute autonomic activation feels like danger because, physiologically, it is indistinguishable from it. But once a clinician has decided a woman is anxious, every subsequent symptom is funnelled through that lens. It is a self-reinforcing loop that absolves the clinician of further investigation. 

What she needed was not a miracle of endocrinology. She needed a GP who could ask a few sensible questions. She needed someone who recognised that plausible mechanisms exist even when guidelines are silent. She needed a clinician who understood that adverse reactions are not moral failings, and that reproducible symptom patterns deserve attention. 

Cutting the patches in half should not have been her responsibility. It should have been a collaborative adjustment, not an act of self-preservation. 

This is why we need a more ‘pattern-aware’ approach to women’s health. Not because herbalists or integrative practitioners are inherently better, but because we are trained to listen for patterns rather than dismiss them.  

We are taught that when a patient says, ‘This happened twice, and here is the sequence,’ the correct response is not, ‘You imagined it,’ but,  

‘Interesting, let’s figure out what is going on…’. 

Patients do not need perfection. They need clinicians who are willing to think.