New guidance issued for women using HRT for menopause symptoms 'gives new options'

Health watchdog the National Institute for Health and Care Excellence (Nice) has reinforced its guidance on tackling menopause symptoms, placing hormone replacement therapy (HRT) at the forefront of treatment options. This comes with an advisory that GPs should offer HRT as the 'preferred, recommended approach' when discussing with patients the various risks and benefits associated with treating problems such as hot flushes, insomnia, and low mood.

The emphasis on HRT marks a shift from Nice's previous draft guidance last November, which hinted at equal weight being given to cognitive behavioural therapy (CBT) as a potential alternative or supplementary option to HRT; a proposal that sparked debate at the time. Now, CBT is positioned as an additional aid alongside HRT, or a substitute only for those who either cannot use HRT or prefer not to.

Nice has also clarified in its updated advice that HRT does not influence life expectancy, countering any fears that it might shorten or lengthen women's lives.

Professor Jonathan Benger, chief medical officer and interim director of the centre for guidelines at Nice, in a briefing, stressed how the organisation has "worked hard to ensure that the place of CBT" was clear, pointing out "a number of changes have been made to emphasise that".

He stated: "HRT is our recommended first-line treatment for vasomotor symptoms (hot flushes and night sweats), and we recommend that that should be offered to women, providing that it meets their needs, and following an informed discussion."

"We have revised the guideline to be really clear that CBT is an adjunct, it’s an add-on therapy, and it can help people manage the symptoms... in addition to HRT, or some women may choose not to take HRT, or they may not be able to take HRT, and therefore that’s where CBT can be useful."

"But we are very keen to emphasize that HRT is our recommended first-line therapy for vasomotor symptoms and for symptoms of menopause."

Prof Berger added that "what we’re not saying is that these are not real symptoms that women are experiencing – these are real troubling symptoms and HRT can be very effective."

"The purpose of CBT is it can help people manage those symptoms more effectively, so that they’re less troublesome to them, but those symptoms are real and they exist."

Marie Anne Ledingham, a consultant clinical advisor at Nice, explained that the initial draft wording regarding CBT had ignited "controversial" views and extensive time had gone into "reviewing the wording and the placement of CBT within the guideline and how it ranked in relation to the other recommendations."

When announcing the draft guideline last November, Nice highlighted its aim of offering "more treatment choices for menopause symptoms," indicating that CBT "should be considered alongside or as an alternative to HRT".

The draft guidance recommended that doctors "consider CBT" for tackling sleep issues, depression, and menopausal-related sleep disturbances. The latest update now advises that CBT can be an additional option alongside HRT, or for individuals who either cannot or choose not to take HRT.

On the same day, Nice also released a "for GPs and patients, including data on how HRT can slightly increase the risk of some health conditions such as breast cancer and blood clots, while lowering the risk of osteoporosis.

Prof Berger emphasised that the discussion aid will "help clinicians offer personalised advice to women considering starting HRT."

He added: "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."

Ms Ledingham remarked: "Menopause care should be individualised and those seeking treatment for menopausal symptoms have the right to make informed decisions about their care."

She added: "The experience of menopause differs substantially between women, but for those seeking treatment for hot flushes and night sweats, this updated guideline offers new options and new evidence about HRT that will support their choices."