Dr Deirdre Lundy is a specialist in women’s health and menopause. She is a member of the urology team at St Michael's Hospital, Dun Laoghaire and a Surgeon Prosector in the anatomy department of the RCSI. Dr Lundy assesses the current situation around hormone replacement therapy and the prescribing guidelines.
Lately the more positive media coverage of menopausal experiences and the benefits of hormone replacement therapies (HRT) has created a surge of interest from our patients. An overstretched primary care service working through a pandemic is perhaps not the ideal setting for every patient who feels they are suffering menopause related issues – but that is where we are in 2022.
As far as controlling perimenopausal symptoms is concerned there is only one remedy that will improve most if not all the symptoms of the perimenopause with any proven efficacy and that’s HRT. Recently, some patients seem to be seeking a trial of HRT in the absence of typical perimenopausal symptoms. Is this FOMO? Are they hoping HRT will keep them permanently youthful and well? Maybe. But maybe this is more a reflection of the thousands of unheard voices from the dark times of menopause care over the previous 20 years.
The resurgence in HRT requests has thrown up an additional hurdle in that stock shortages have become normal over the last 2-3 years. The good news is that things are on the mend.
How to prescribe?
Our guidelines for prescribing are fairly clear. Women under 60 without comorbidities CAN almost always try HRT if they like. If it doesn’t help, they stop. If it does, they can choose to carry on. We strive to tweak those modifiable risk factors too. Prescribers should give balanced information and signpost evidence-based information. As with any medication, there are benefits and risks.
Should everyone be using HRT? The current recommendations say no. We do not have enough data to say all women should keep their estrogen levels high – there are many unknowns or “not too sures” surrounding risks of ongoing HRT use in people who do not need HRT for symptom relief.
HRT is not for everyone and is certainly not to be used as a salve for people who know they ought to move more, eat better, drink less and stop smoking! But if a patient is struggling, if they are not well and if they are likely to get more benefits from using HRT than risks, then we offer HRT.
So, if someone is experiencing classic symptoms of ovarian hormone fluctuation/decline, who is also generally healthy and in the typical perimenopause/menopause age group and who – most importantly – would like to try a menopause hormone therapy of some kind, then why not?
And the most important thing to remember is that while individual doctors and attitudes may vary and are worthy of discussion, we have the benefit of UK, European and international guidelines on menopause care. And they all sing from the same hymn sheet – the title of which is individualisation.
We are all agreed that HRT is not a magic wand and is not necessarily going to fix everything that ails you. HRT is just hormones and they are not without risk. Over prescribing of any medication is not wise and every consult needs to be taken as it comes. If it feels like every woman over 40 has now decided she is having menopause symptoms and wants HRT, well, we have excellent prescribing guidelines and these encounters are also an ideal opportunity to highlight screening and modifiable risks. Additional support on HRT prescribing rules is available for doctors in Ireland via the ‘HRT prescribers’ chat group on Telegram.
Dr Haitham Hamoda, past chair of the British Menopause Society (BMS) and Sara Moger, current BMS CEO, published an editorial in BMJ on 15 June 2022.1 Some of their bullets remind us:
• Over 25% of women in the menopause describe their symptoms as severe and loss of estrogen can have a detrimental effect on bone and heart health.
• For most women with problematic symptoms the benefits of HRT are likely to outweigh the risks.
• NICE and other guidance agencies recommend an individualised and comprehensive approach. Information & advice about exercise, healthy weight, smoking, and alcohol, as well as all the various menopause therapies should be open to discussion; including HRT.
• HRT is mainly offered for problematic menopausal symptoms and improving quality of life. Evidence from randomised trials shows clear benefits in this context, and no arbitrary limits should be placed on duration of use.
• Current evidence suggests that oestrogen-only HRT is associated with little or no change in the risk of breast cancer, while oestrogen plus a progestogen HRT can be associated with an increased risk. The risk is low (absolute excess risk over 10 years = 3-7/1000 women taking combined HRT for up to 5 years) and compares well to breast cancer risk associated with other modifiable factors such as obesity and alcohol.
• Breast cancer related HRT risk appears to be duration dependent and may vary with the type of progestogen used.
• HRT significantly protects against Osteoporosis related fragility fractures and helps prevent osteoporosis in both spine and hip.
• HRT (+/- progestogen) started before the age of 60 or within 10 years of the menopause may protect against cardiovascular disease. Timing of when the HRT is started is critical to this effect.
Medical Protection advice
Prescribing issues are something of a hot topic at the moment, with renewed attention given to HRT shortages and what your obligations are in prescribing this treatment, says Dr Rachel Birch, Medicolegal Consultant at Medical Protection.
• Whilst the Medical Council expects doctors to recognise and work within the limits of their competence, there is also an expectation that doctors improve their knowledge and skills and address areas within their scope of practice where they lack competence to provide safe care.
• The Medical Council advises doctors to ensure that “any treatment, medication or therapy prescribed for a patient is safe, evidence-based and in the patient’s best interests”.
• GPs should ensure that they are familiar with current guidance on the menopause and prescribing guidelines for HRT.
• Doctors have a responsibility to look after their own health and wellbeing. If, as a doctor, you are experiencing menopausal symptoms that may be impacting on your work, ensure that you do not make an assessment of your own health or prescribe for yourself – instead you should consult with your own GP.
1BMJ 2022;377:o1425