The controversial history of HRT: Menopause campaigners warn against new guidance

Middle-aged woman using hormone gel on her skin, hormone replacement therapy
Hormone replacement therapy (HRT) can relieve almost all symptoms of menopause. (Getty Images)

Menopause awareness campaigners have warned that new guidelines from the National Institute for Health and Care Excellence (Nice) around care for women going through menopause will harm women’s health rather than help them.

It comes after the new draft guidelines for GPs were published last month. Nice has said that doctors should offer cognitive behavioural therapy (CBT) “alongside or as an alternative to” hormone replacement therapy (HRT) in women struggling with symptoms of menopause.

HRT can alleviate symptoms of menopause - like hot flashes, night sweats, vaginal dryness, sleep issues and mood swings - as it replaces oestrogen, progesterone or both. These hormone levels drop naturally as a woman ages, usually between the age of 45 and 55.

Nice’s new guidelines “lays out clearly the risks and benefits of taking HRT”, and states that CBT “was found to reduce the frequency and severity of hot flushes and night sweats”.

It adds: “While it is important that people know about the risks associated with HRT, it is also important they are made aware it is unlikely to increase or decrease their overall life expectancy.”

‘This guidance will worsen the struggle’

Portrait of a woman sitting at the notebook, red cup of tea on the table. Reflection of a face in the monitor screen, chin on hands. Architect, interior designer, real estate sales, consultant, psychologist
Many women who go through the menopause struggle with symptoms that can be disruptive to everyday life. (Getty Images)

In recent years, awareness around menopause has increased dramatically, thanks to campaigners and celebrities like Davina McCall who are speaking up about it.

But the organisation’s new guidance has not been welcomed by campaign groups and experts, who warned that it uses “misogynistic language” and would result in doctors becoming “more reluctant to prescribe HRT and women more fearful about asking for or accepting it”.

In a statement to the Guardian, Justine Roberts, founder and chief executive of Mumsnet, highlighted that women currently struggle to access HRT, adding: “By emphasising the negative over the positive, failing to include information about the safest forms of HRT and placing CBT on par with hormone replacement therapy, this guidance will worsen the struggle.”

Dr Louise Newson, a GP and menopause specialist who also campaigns loudly for better menopause care, told Sky News that the guidelines were “a disappointing draft update”. “We must address the long-term health risks of low hormones,” she continued. “There is good quality, established evidence about the protective effects of HRT in relation to osteoporosis, heart disease, clinical depression, and colon cancer, and there is emerging evidence around dementia risk also being reduced.

“These are ignored in this document and the perceived risks of breast cancer stated in these draft recommendations are not based on good quality evidence.”

Dr Newson is referring to a part of the guidelines that reads: “While there is some evidence around taking HRT and breast cancer risk in early menopause (ages 40 to 44), there is a lack of evidence about the effects of taking or not taking HRT on overall health outcomes in this age group.” Nice called for more research into this area.

Why is there a taboo around HRT?

To understand the backlash against Nice’s draft guidelines, we must look back to the start of the 20th century. HRT first became available in the 1940s in the form of an oestrogen pill under the brand name Premarin. It grew in popularity and hit its peak in the 1960s, considered to be revolutionary for women managing their menopause symptoms.

But in the 1990s, HRT’s status plummeted after a clinical randomised trial in the US, called Women’s Health Initiative (WHI), raised concerns about HRT and suggested that extended use of the drug could increase the risk of breast cancer and heart disease.

According to the British Menopause Society, the UK’s regulatory authorities issued an urgent safety restriction on HRT following the publication of the WHI study. This resulted in “widespread confusion and uncertainty amongst both doctors and HRT users”.

“Many doctors stopped prescribing HRT and many women abandoned HRT immediately, with a return of their menopausal symptoms. The number of women taking HRT fell by 66%, which has not changed so that now after more than 10 years, there has been almost a generation of women who have mostly been denied the opportunity of improved quality of life during their menopausal years,” the society said in its 2022 factsheet about HRT.

The WHI study, which was published in 2002, tested the cardiovascular effect of hormone therapy in older women (50 to 79 years). The test focused on a form of progesterone and oestrogen that is no longer used by doctors today due to the development of more effective and safer HRT, and did not include a large number of women who recently started menopause.

Close up of a Latin woman using medicine pills. She is sitting on bed and reading patient information leaflet.
The benefits of taking HRT may outweigh the risks, menopause campaigners have argued. (Getty Images)

The study reported a 26% increase in the risk of breast cancer among these older women on this specific type of HRT - but it did not make a distinction between the participants who used HRT and their age. The results received a huge amount of negative media attention.

Dr Ginni Mansberg, author of The M Word, wrote in the Guardian: “As a postscript, late analysis of WHI data shows that if you look only at women between the ages of 50 and 59, when most women use it and need it, there are clear benefits of HRT. These women had fewer cancers, fractures and deaths from any cause compared with the women taking placebo.”

But the legacy of the WIH study has continued to persist, with many women declining HRT out of the belief that it puts them at a much higher risk of developing breast cancer.

Is HRT safe now?

The risks associated with HRT vary depending on what type of HRT is used, your existing risk of developing breast cancer (ie. family history of breast cancer), and lifestyle factors that may increase the risk such as smoking and obesity.

The British Menopause Society said that, while the WHI long-term randomised clinical trials published in 2020 found that women on combined oestrogen and progestogen HRT had an increased risk of breast cancer diagnosis, there was no significant increase in mortality.

It adds that other data has suggested that other forms of HRT are “likely to be associated with a lower risk of breast cancer compared to that seen with other progestogens”.

Studies have also suggested that HRT can help reduce the risk of cardiovascular disease, and is unlikely to increase the risk of dementia or have a negative effect on cognitive function in women starting HRT under the age of 60.

Attitudes towards HRT have begun shifting, with the number of patients being prescribed it in England rising by almost a third in just one year, from 1.8 million in 2022-23 to 2.3 million in 2021-23. In April this year, HRT pre-payment certificates were introduced to make it more affordable and accessible.

But the damage done by the WHI study continues to make women fearful of HRT, with only 14% of menopausal women in the UK taking HRT. According to Balance, Dr Newson’s menopause support website, uptake of HRT is as low as 2% in some areas of the UK, and there are concerns that women in the most deprived areas do not have equal access to HRT.

Dr Newson wrote: “The fact that more women are accessing the treatment they need to manage their menopause symptoms is fantastic, and illustrates that awareness of menopause is increasing and women are more confident in seeking help. But we want to ensure that all women have equal access, whatever their income or circumstances, and that no woman experiences supply issues with the medication they rely on.”

Watch: NHS should offer women therapy for the menopause, new guidance says

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