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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.

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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 


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