HRT should be offered as a first-line treatment for menopause, Nice says

According to the National Institute for Health and Care Excellence (Nice), women with menopausal symptoms should be offered hormone replacement therapy (HRT) as a first-line treatment, not as a therapy.

It’s final menopause guidelines for doctors in England and Wales, published on Thursday, states that HRT is the treatment of choice for managing symptoms such as hot flushes, night sweats, depression and sleep problems, in what is seen as a decline from previous wording.

A controversial draft guideline published last November states that women experiencing these menopausal symptoms could be offered cognitive behavioral therapy (CBT) “in addition to or as an alternative to” HRT.

The draft guidance sparked widespread criticism for putting CBT on a par with HRT, belittling symptoms and harming women’s health.

Nice said it has responded to the feedback and rewritten the guidelines, which now say CBT should only be considered for patients who are taking HRT and still have symptoms, or for those who cannot or do not want to use HRT.

Professor Jonathan Benger, chief medical officer and interim director of the Center for Guidelines in Nice, said: “We are not suggesting that cognitive behavioral therapy is an alternative to HRT. It’s not an either/or, and we’ve gone through the guidelines in detail to really clarify this point.

“We would very much like to emphasize that HRT is our recommended first-line treatment for vasomotor symptoms (night sweats and hot flashes) and for (other) menopausal symptoms.”

CBT is a “useful” additional treatment to help those already taking HRT with persistent symptoms, or for women who cannot or do not want to use it, he added.

The strengthened guidelines also emphasize that HRT does not affect overall life expectancy and will not shorten or lengthen women’s lives.

But responding to the guidelines, Labor MP Carolyn Harris, previously shadow minister for women and equalities, said: “I’m disappointed – it feels like a real step backwards.

“Nice, we don’t listen to women. They fail to provide a clear path to care and the reliance on cognitive behavioral therapy is, in my opinion, arrogant.”

Justine Roberts, founder and chief executive of Mumsnet, was also unhappy. She said the new guidelines risked increasing the risk of women struggling to access treatment for menopause and perimenopause.

“It ignores the evidence on which medication is safest and continues to promote largely unavailable cognitive behavioral therapy for women suffering from the debilitating effects of low hormones. Nice must do more to ensure women and doctors are equipped with the information they need.”

Campaigners also said the guidelines did not distinguish between the relative benefits of different types of HRT. In addition to the new guidelines, Nice published a ‘discussion tool’ for GPs and patients on Thursday, including data on the risks and benefits of using HRT.

The guide highlights that HRT significantly reduces the risk of osteoporosis and bone fractures, while combined HRT does not increase the risk of heart disease and dementia, but does slightly increase the risk of breast cancer and blood clots.

But Nice said it could not distinguish these risks based on the type of HRT taken. Marie Anne Ledingham, Clinical Advisor at Nice, said: “For many other medical conditions (other than stroke) there was not enough evidence available on individual HRT formulations, and this has been passed on to our surveillance team in Nice so that when the guideline is updated in the future, will be able to make individual recommendations about each specific type of HRT and in particular different types of progesterone and how that is administered, whether it is as a Mirena coil, or whether it is the newer forms of micronised progesterone. ”

Kate Muir, menopause expert and campaigner, called the guidelines “confusing and outdated”.

“Why can’t they just tell doctors what the safest HRT starter pack is for most women? It’s not much to ask,” she said.

“The most serious omission is the guidelines’ inability to clearly distinguish in the discussion of risks between safer, body-identical transdermal HRT and the older, higher-risk synthetic HRT containing progestogens.

“There is clear evidence available on the safest formulations of HRT in the 2020 British Menopause Society consensus statement on HRT, which favors transdermal estrogen and micronised progesterone.”

As a result, she said the guidelines “fail to direct physicians to the safest choices for their patients.”