All women will experience the menopause at some point in their lives, with the majority being between the ages of 45 and 55. We know that menopausal symptoms last, on average, for more than 4-8 years and it is estimated that more than a third of women experience long-term symptoms for a number of years beyond that.1
The impact on our lives can be profound, depending on the severity and the type of symptoms we experience. As such, it is heartening to see menopause taking a front seat in discussions ranging from healthcare provision to media representation, and from workplace policies to politics.
However, despite recent progress in how we talk about the menopause, seeing the inequity in HRT choice and access across the UK as a working GP with a special interest in women’s health and an sccredited British Menopause Society menopause specialist, it is clear to me that we need to change the way in which menopause care is being delivered.
Inequity of care
HRT plays a key role in how women manage their menopause experience. However, there is current inequality when it comes to HRT access across the UK, with women from deprived backgrounds less likely to be prescribed the treatment. Recent research has shown the overall prescribing rate of HRT is 29% lower in practices in the most deprived areas compared to the most affluent.2
I undertook a small piece of research, picking big cities across the UK with published formularies, and broke those down into CCGs. I was astounded to see first-hand the enormous amount of variance when it came to HRT prescribing.
There are also differences in the prioritisation of the types of HRT products prescribed, for example oral compared with transdermal options. Some regions show significantly lower rates of transdermal prescriptions,2 whether that’s gel, patch or spray forms of oestrogen HRT, rather than the oral standard products that we've been used to for many years.
Women from deprived areas are more likely to receive oral HRT over transdermal, despite being more likely to suffer from comorbidities, such as obesity, thrombo-embolic disease and cardiovascular disease which make transdermal HRT more suitable.3,4
While the cause is not entirely understood, potential factors are likely to include conflicting national guidance, economic deprivation and a local formulary approach.
With a diverse and growing population of women reaching and living well beyond the menopause, and having a significant proportion of their working lives in peri- or post-menopause, the impact of this inequity is becoming more evident, and challenges the goal of providing personalised and effective care.
In the UK, our growing and aging population means it is vital that this inequity is assessed, and the impact identified. Only then can we work towards changing things and hopefully improving access, choice and ultimately outcomes for women.
For that reason, myself and a group of healthcare professionals from across the UK convened in 2021 to make recommendations that support a greater equity of choice in menopause care.
The different topics and statements were divided into four key areas:
- goals to support access and choice of HRT treatment options;
- impact of inequity of HRT choice;
- the development and implementation of local HRT treatment guidelines, and
- education and partnership needed to support equality of HRT treatments.
In all, there were nine expert recommendations developed by the steering group, as outlined in a consensus paper,5 and detailed below:
- More research is needed to fully understand and address the reasons behind inequity of access to HRT and HRT options, particularly in areas of deprivation.
- Choice and personalisation of treatment options needs to be supported by local treatment guidelines, formularies and education for healthcare professionals.
- Local HRT treatment guidelines should follow British Menopause Society (BMS)/NICE recommendations and support choice and personalisation of care.
- All HRT options (whether that’s transdermal, oral or vaginal) should be included, and provided on an unrestricted basis, on any (local/regional) formularies/prescribing guidelines in the UK.
- Healthcare professionals who consult with women seeking help for symptoms of the menopause should have sufficient education about menopause and HRT to ensure effective shared decision-making and personalised care
- Development of local menopause networks for healthcare professionals and providing more qualified trainers to provide education and support would help primary care teams to optimise care provided for women seeking treatment.
- There needs to be inclusion of formal menopause training in the postgraduate curriculum of GPs, gynaecologists and sexual health specialists.
- Every organisation should have a policy to support menopause in the workplace.
- More specialist menopause clinics for complex cases and more trainers for the BMS/Faculty of Sexual and Reproductive Healthcare (FSRH) training programmes are required.
The results of the consensus paper clearly show widespread support of the need for shared decision-making and personalisation of care for women seeking treatment for menopausal symptoms.
There was also strong agreement that local restrictions on HRT choice do exist and are not justified. The guidance from the BMS needs to be universally adopted and local HRT treatment advice should closely reflect this to ensure a more consistent approach to menopause care. The need for high quality training and education around menopause was also heavily supported.
Clearly this issue is not something that can be solved overnight, but, having these conversations and attempting to understand more about the underlying reasons for inequality and deprivation across the UK is the first step.
- Dr Barber is a GP with a special interest in gynaecology and menopause and leads the community gynaecology service in Oxfordshire alongside running a private specialist menopause and women’s health clinic in Southern Oxfordshire. She previously led the tertiary menopause service at the John Radcliffe Hospital in Oxford. Dr Barber is a co-author of the consensus led recommendation paper, supporting choice and personalisation of hormone replacement therapy in menopause care.
- British Menopause Society. What is the menopause? [online] Women's Health Concerns. Available at: https://thebms.org.uk/wp-content/uploads/2022/03/17-BMS-TfC-What-is-the-menopause-01D.pdf. 2021 [Last accessed November 2022].
- Hillman, S., et al. Socioeconomic status and HRT prescribing: a study of practice-level data in England. British Journal of General Practice 2020; 70(700): e772-e777.
- Alzheimer's Society. Hormones and dementia. [online] Available at: https://www.alzheimers.org.uk/about-dementia/risk-factors-and-prevention/hormones-and-dementia [Last accessed November].
- Royal College of Obstetricians & Gynaecologists. Left for too long: understanding the scale and impact of gynaecology waiting lists. 2022. Available at: https://rcog.shorthandstories.com/lefttoolong/index.html#group-section-Foreword-LiwE2VBZtN [Last accessed November 2022].
- Briggs, P., Barber, K., Cooke, K., Hillard, T., Mansour, D., Panay, N., Pearson, K., Tanna, N. and Wokoma, T., Consensus-led recommendations supporting choice and personalisation of Hormone replacement therapy in menopause care. Post Reproductive Health 2022; 28(2): 71-78.