NICE stresses HRT as first-line menopause treatment

Health assessment body NICE has stressed to GPs hormone replacement therapy (HRT) should be offered as the first treatment option to ease menopause symptoms.

In its updated guidance, the use of talking therapy is set out as an additional method of help.

After a detailed analysis of data on links between HRT and conditions such as heart disease, stroke, some cancers and dementia, NICE concluded HRT does not affect life expectancy.

The guidance includes a new discussion aid to help GPs give patients the most useful information they can about the HRT drugs and what they do.

HRT replaces the hormones oestrogen or progestogen, or both, when women's periods stop - normally between the ages of 45 and 55.

It is administered using gels, creams, pessaries, tablets, patches or sprays and is sometimes prescribed during perimenopause, as the hormones start to fluctuate but before menstruation stops altogether.

In updated menopause guidelines, NICE (the National Institute of Health and Care Excellence) says healthcare professionals should take into account a woman's personal situation, and provide all the information needed to help her make the best choice on treatment.

The guidance is clear that HRT is the go-to treatment option for hot flushes and night sweats caused by the menopause.

Talking therapy known as CBT (cognitive behavioural therapy) is to be offered to women over 40 alongside HRT or, if the patient's individual circumstances call for it, in place of it.

That is a change from draft guidelines, published in late 2023, which caused controversy by suggesting that talking therapy could replace HRT as a treatment.

The level of feedback received by NICE on that point led to a longer than usual delay in issuing the final guidance.

The document highlights that while there are some increased risks linked to taking HRT, it is unlikely to lengthen or shorten overall life expectancy.

Easy-to-read illustrations of the likelihood of developing certain health conditions are featured. These are intended to help GPs have informed conversations with patients.

Dr Marie Anne Ledingham, consultant clinical adviser to NICE, explained that an independent panel assessed available scientific evidence to come up with the information.

She said the risk of coronary heart disease, stroke and ovarian and endometrial cancer was no higher among women aged 45 and over taking combined HRT, compared to those who had never taken it.

And HRT actually reduced the risk of fractures linked to the bone condition osteoporosis, which is more likely to develop after the menopause.

But the risk of breast cancer for women did rise slightly, affecting:

• 59 in every 1,000 women who never take HRT
• 79 in every 1,000 taking combined HRT for five years from the age of 50
• 92 in every 1,000 taking combined HRT for 10 years

The risk of dementia was also slightly higher if women started taking HRT after the age of 65. In younger patients there was no elevated risk of developing dementia.

"The risks are very low in the population, and HRT can provide huge benefits at a very difficult point in many women's lives," Dr Ledingham said.

Prescriptions for HRT have grown considerably in recent years in the UK.

Professor Jonathan Benger, chief medical officer at NICE, said that awareness of the impact menopause symptoms can have on women has grown in recent years.

But he said more could be done to improve support for women from ethnic minority backgrounds and from poorer areas "who are often unaware of or unable to access treatments that could help them".

“Women need to feel confident that they will be offered advice and options that meet their needs, and that they will be supported to make the choices that are right for them," said Prof Benger.