New NICE guidance clarifies HRT as 'first line treatment' for menopause symptoms

NICE has emphasised to GPs the importance of HRT and clarified that cognitive behavioural therapy (CBT) should be an ‘add on’ treatment for menopausal symptoms.

In its updated guidance, published today, NICE encouraged GPs to have ‘informed conversations’ with patients about the risks and benefits of HRT, and included a new ‘discussion aid’ for GPs to use when doing so.

A draft version of the guidance was published last year with a new recommendation for CBT to treat vasomotor symptoms associated with menopause, but this addition was ‘controversial’ according to NICE.

NICE has therefore clarified the wording around this treatment, as ‘one of the key changes’ made in the final guidance.

Dr Marie Anne Ledingham, a consultant clinical advisor at NICE, said they have ‘been very, very clear that CBT is an adjunct therapy, and the use of HRT does not preclude the use of CBT’.

She continued: ‘The wording of the guidance has been changed to provide more clarity for GPs and patients on when it’s appropriate to offer CBT, it remains a softer “consider” recommendation rather than a firmer “offer” recommendation.’

Professor Jonathan Benger, chief medical officer and interim director of the Centre for Guidelines at NICE, said that some people fed back concerns that CBT was ‘too prominent’ in the draft guidelines, or some ‘misinterpreted’ the guidance as saying that CBT should be used ‘instead of HRT’.

He said that the updated guidance now makes it clear that HRT is the ‘recommended first line treatment for vasomotor symptoms’ .

It also emphasised the effectiveness of HRT as a treatment for menopause-associated symptoms, and makes it clearer to patients that HRT is ‘unlikely to affect life expectancy’.

Key recommendations in NICE menopause guidance

Offer HRT for hot flushes and night sweats (vasomotor symptoms), and talk with patients about the benefits and risks associated with different types of HRT and the duration and dose
GPs should tailor information about HRT benefits and risks based on age, individual circumstances, and any potential risk factors
For people over 40, GPs should consider CBT as an option for vasomotor symptoms associated with menopause in addition to HRT, or for people for whom HRT is not advised, or for those who prefer not to take HRT
Consider CBT as an option for people who have depressive symptoms in association with vasomotor symptoms, or for people who have sleep problems in association with these symptoms
For management of genitourinary symptoms such as vaginal dryness, painful sex and vaginal discomfort, a choice of vaginal oestrogen (cream, gel, tablet, pessary or ring) should be offered
- Treatment should be reviewed regularly and continued for as long as it is needed to relieve symptoms
Ensure that trans men or non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past and have symptoms associated with menopause can discuss these with a healthcare professional with expertise in menopause
When discussing HRT as a treatment option for menopause-associated symptoms, GPs should explain that, overall, taking either combined HRT or oestrogen-only HRT is unlikely to affect life expectancy
Be aware that people from some ethnic minority backgrounds and people with some lifelong conditions may experience menopause at a younger age

Source: NICE

Professor Benger said a ‘simple summary message’ GPs could use when speaking to patients is: ‘There are some risks and benefits of HRT. They kind of balance out, and it’s a very effective treatment for menopausal symptoms, and on average, it doesn’t just change your life expectancy.’

He also said there is ‘good evidence’ that not all patients are getting ‘high quality care’ for menopause symptoms, but recognised that there is ‘a lot of pressure in general practice’.

NICE said it will work closely with the RCGP to ‘ensure the guideline is used and implemented and changes the care and outcomes for women with menopausal symptoms in this country’.

But Dr Ledingham clarified that there is no ‘prerequisite for GPs’ to provide information about menopause symptom treatment, but they are encouraged to have ‘tailored’ conversations with patients.

The new discussion aid document – which NICE said is an ‘unusual step’ – allows GPs to use visual prompts to discuss the benefits and risks of HRT with patients, including the effects on breast cancer, cardiovascular disease, dementia, endometrial and ovarian cancer and the risk of stroke.

There is no new evidence on risk contained in the updated guideline published today, but NICE said the existing evidence has been made clearer for both GPs and patients.

There are approximately 13 million women over the age of 45 in the UK, which makes up around a third of the female population, meaning the guidance could have ‘far-reaching potential implications’, according to NICE.

Professor Azeem Majeed, a GP and professor of primary care and public health at Imperial College London, said the updated guidance is ‘useful’ and will ‘help GPs optimise menopause care’ to ensure patients receive support which is ‘tailored to their unique circumstances’.

He added: ‘The new discussion aid will help GPs present evidence-based risks and benefits of HRT to support informed decision-making by their patients.

‘It’s good to that the guidance highlights the importance of equitable care, particularly for minority and lower-income patients who may be less likely to come forwards for the treatment of menopause-associated symptoms.’

RCGP chair Professor Kamila Hawthorne said ‘GPs want to do their best for women going through the menopause’ and will come up with treatment plans which are ‘tailored’ to individual needs.

She continued: ‘To this end, the new guidance from NICE which suggests a range of treatment options – and decision aid to support conversations between GPs and patients – should be very helpful.

Professor Hawthorne also emphasised that GPs are well trained to deal with menopause symptoms, noting that it is a ‘key part of the RCGP curriculum’.

She continued: ‘On completion of training all GPs need to demonstrate continued professional development that is reflective of the full breadth of the work of a GP throughout their career.

‘The College has worked closely with partners, including the British Menopause Society, the Royal College of Obstetricians and Gynaecologists and NHS England, to develop resources to support GPs and our teams to deliver the best possible care for women.’

Professor Aimee Spector, professor of clinical psychology of ageing at University College London, said that ‘many felt’ that the recommendation for CBT treatment published last year ‘might risk undermining the impact of hormonal changes and imply that symptoms were purely “in the head”’.

‘I am pleased that the guidelines clarify that CBT might be a useful addition to HRT, or an alternative for the many people unable to take it – myself included as someone who has recovered from breast cancer and has struggled with menopausal symptoms,’ she added.

On the availability of NHS CBT, Professor Spector added: ‘A significant challenge, highlighted by NICE; will be implementation. NHS waiting times for CBT in people with anxiety and depression tend to be huge and this will create significant new demand.

‘But we need to see the bigger picture; investments in wellbeing will ultimately save costs in terms of working hours and quality of life for millions.’