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NICE urges GPs to overcome 'reluctance' to offer HRT in menopausal women

GPs are ‘unduly worried’ about prescribing hormone replacement therapy and should offer more women suffering from symptoms of the menopause the option, NICE has said today.

New guidelines say that GPs should be more proactive both in spotting when women are experiencing problematic symptoms of the menopause and telling them about HRT as well as other treatment options.

And they say GPs are ‘overestimating’ the risks of HRT and contraindications for short-term symptom relief.

However, GP experts stressed that while the guidelines provided ‘helpful clarification’ on treatments, GPs were not ‘afraid’ to prescribe HRT and were already offering it women to help control menopausal symptoms.

The new guidelines are the first NICE has produced on menopause and recommend GPs offer HRT as the first-line treatment option –for both vasomotor symptoms and for psychological symptoms – in women under the age of 60, after discussing the benefits and risks with the individual.

They also say:

  • GPs can reassure women that HRT does not increase the risk of cardiovascular disease in women of that age.
  • That while oral treatments are associated with an increased risk of VTE, patches are not – so women who may be particularly at risk, such as those who smoke or have a BMI over 30, can be offered a patch.
  • GPs should explain that oestrogen-only HRT brings little or no increase in the incidence of breast cancer, while HRT including oestrogen and progesterone ‘can be associated with an increase in the incidence of breast cancer’, but that this risk relates to how long the treatment is taken for, and reduces after stopping treatment.

NICE experts said they hoped the guidelines would provide clarity on the balance of benefits and risks of HRT.

They said that GPs and other clinicians had been put off prescribing it following the publication of the Women’s Health Initiative (WHI) in 2002, which found increases in both heart disease and breast cancer risks with HRT, and the Million Women Study in 2003, which found an increased risk of breast cancer.

They said these studies focused on the use of HRT for disease prevention and potential long-term risks in women starting treatment after the menopause, rather than the benefits of short-term symptom relief from around the time of menopause onset.

The NICE guidance states: ‘One of the aims of this guideline is to help GPs and other healthcare professionals to be more confident in prescribing HRT and women more confident in taking it.

‘A knowledge gap among some GPs and other healthcare professionals could mean that they are reluctant to prescribe HRT because they over-estimate the risks and contraindications, and underestimate the impact of menopausal symptoms of a woman’s quality of life.’

Among other treatment options, the recommendations says SSRIs should not be offered routinely as a first-line treatment for vasomotor symptoms alone – and GPs should avoid using them for low mood in menopausal women who have not been diagnosed with depression.

Dr Anne Connolly, a GPSI in gynaecology in Bradford and chair of the Primary Care Women’s Health Forum, said many women ‘have been denied the option of using HRT to help control their menopausal symptoms because of the negative publicity caused by the WHI study’.

She added that studies since then have since ‘confirmed the benefits of HRT’ and that the NICE guideline ‘provides clear evidence about the benefits and risks of HRT to enable women and their healthcare practitioners to make informed choices about her care’.

However, Dr Martin Brunet, a member of the RCGP standing group on overdiagnosis and overtreatment, speaking in a personal capacity, said that while guidelines provided ‘useful clarification’ on treatments for menopausal symptoms, GPs were already happy to prescribe HRT to help control symptoms.

Dr Brunet said: ‘I don’t think GPs are afraid to give HRT when women have menopausal symptoms. We don’t give it to women any more just because “it’s good for you” but we do give it to control your symptoms.’

Dr Brunet added he was ‘concerned people may imply GPs have been denying women treatment – which just isn’t the case – it’s certainly not my experience’.

NICE menopause guidelines - key recommendations for GPs

NICE Guidance - NG23 Menopause: diagnosis and management 

Readers' comments (21)

  • Sadly, it is my experience that patients were denied HRT by my partners. I had a constant trickle of women who came to me in tears because they had either been denied it or had it immediately stopped because they had reached a certain age or seen a different doctor.
    Interestingly the two doctors concerned were extremely well informed, excellent doctors who quoted the risks verbatim and both had a particular interest in women's health.

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  • What about those women who are 75+, have been HRT since age 45 and refuse to come of it. Some guidance on these and the removal of any liability for the doctor if they were develop VTE or cancer? No? Thought not. As usual general guidelines with no protection for GP's. Lots of implications that they are practicing poorly and all need to learn more as they are "best placed to..."

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  • Nice guidance becomes ever more bound up in caveats and technicalities as to make it inaccessible and near useless. We have seen it with diabetes, lipid protocols, hypertension, now this no doubt. What use is guidance that is too nuanced to remember and too complex to look up within the limits of a 10 minute consultation.

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  • Many women become addicted to HRT and refuse to come off even after decades of taking. NICE, take a long walk on a short peir.

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  • This comment has been moderated

  • many of my most heated consultations have been with women on the stuff 20 years who refuse point blank to come off it, even when their risk profile changes hugely, and on the one occasion I dug my heels in and said I, as the prescriber, was no longer prepared to take the risk of harm, I had a complaint which went all the way to the GMC and NHS ombudsman before being rejected. Forgive me if these issues might steer my prescribing habits, but I am human. Fed up of being told how awful, stupid and uncaring we all are. Academics need every other month in the trenches before they produce more clubs for the media to beat us with. 20th December 2017 remains ringed in red in my diary. Stuff this.

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  • I would echo what Anonymous @ 10:48AM says.

    The reason I am reluctant to start an HRT script is due to a lack of clarity over how and when to stop.

    This creates a recipe for conflict, with unclear medicolegal liability should a patient suffer complications after refusing my advice that it is time to stop taking it.

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  • @|Anonymous | Salaried GP|12 Nov 2015 11:20am

    "This creates a recipe for conflict, with unclear medicolegal liability should a patient suffer complications after refusing my advice that it is time to stop taking it."

    It is not unclear at all. If the patient refuses to follow your advice, and you clearly documented it, on their head be it. Simples.

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  • i never refused hrt to women . i always told them if 2002 study and as far as they understand what expert have said, they can have it. there is small risk in every thing in life.

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  • A doctor's theoretical ( but not real) medico legal risk does not trump a patient's autonomy.
    Patients choose to smoke, drink, sky-dive and drive cars. They are entitled to look at the risk and benefits to themselves of taking HRT and, as long as they understand them clearly, may choose their own course of action.
    In nearly 30 years of prescribing I have never had a patient die as a direct result of HRT, or blame me in any way for prescribing it.
    Get over yourselves and remember who we are there for.

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  • Vinci Ho

    (1) Nothing recommended by NICE on HRT is really new. The balance of benefit against risk is always there to be discussed with individual patient . Individualised medicine as an art of science . Treatment is all about quality of life . Forget about prevention of osteoporosis .
    (2) The risk on breast cancer is translated as 7-8 more new cases per year for every 10,000 HRT users. Unfortunately , this statistical meaning may be that easy to be put in lay man terms . Risk is still small .
    (3) The risk becomes significant after 3-5 years of continuos usage if it was commenced after 50 years old . Yes, the argument about some women refusing to come off after ten years is probably valid .
    (4) Premature Menopause is a different entity and a horrible disease and should be treated promptly and adequately. All these scares about HRT with cancers really apply only to commencement from 50 years old onwards as per previous studies ,
    (5) In term of risk of breast cancer , continuous combined preparation cyclical sequential oestrogen only .
    Hence , hysterectomised women are in better deal . But the combination of oestrogen only patches and MIRENA is a very good compromise to those with an uterus .

    Nothing is easy when you have a medical dilemma

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