Women with menopause symptoms should be offered hormone replacement therapy (HRT) as a first-line treatment, not therapy, according to the National Institute for Health and Care Excellence (Nice).
Its final menopause guidelines for medics in England and Wales, published on Thursday, state that HRT is the preferred treatment for managing symptoms such as hot flushes, night sweats, depression and sleep problems, in what is seen as a climbdown from previous wording.
Controversial draft guidance published last November said women experiencing these menopausal symptoms could be offered cognitive behavioural therapy (CBT) “alongside or as an alternative to” HRT.
The draft guidance provoked widespread criticism that it put CBT on a par with HRT, thereby belittling symptoms and harming women’s health.
Nice said it has responded to the feedback and rewritten the guidelines, which now say CBT could be considered for patients on HRT who still have symptoms, or those who are unable or do not wish to take HRT.
Prof Jonathan Benger, chief medical officer and interim director of the centre for guidelines at Nice, said: “We are not suggesting that CBT is an alternative to HRT. It’s not an either/or, and we have worked through the guidelines extensively to really clarify this point.
“We are very keen to emphasise that HRT is our recommended first-line therapy for vasomotor symptoms [night sweats and hot flushes] and for [other] symptoms of menopause.”
CBT is a “useful” additional treatment to help those already taking HRT with persistent symptoms, or for women who cannot or choose not to take it, he added.
The strengthened guidance also emphasises that HRT does not affect overall life expectancy and will not shorten or extend women’s lives.
But, responding to the guidance, Labour MP Carolyn Harris, previously a shadow minister for women and equalities, said: “I’m disappointed – it feels like a real step backwards.
“Nice are not listening to women. They fail to give a clear pathway to care and the reliance on CBT is, in my opinion, arrogant.”
Also unhappy was Justine Roberts, Mumsnet founder and chief executive, who said the new guidelines risked exacerbating the difficulties women had accessing treatment for menopause and perimenopause.
“It ignores the evidence on which medication is the safest, and continues to promote largely unavailable CBT to women who are suffering with the debilitating effects of low hormones. Nice must do more to ensure that women and doctors are equipped with the information they need.”
Campaigners also said the guidelines failed to distinguish between the relative merits of different types of HRT. Alongside the new guidelines, Nice published a “discussion aid” for GPs and patients on Thursday, including data on the risks and benefits of taking 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 those risks by the type of HRT taken. Marie Anne Ledingham, consultant clinical adviser at Nice, said: “For a lot of the other medical conditions [other than that of stroke], there wasn’t sufficient evidence available on individual formulations of HRT, and that has been passed on to our surveillance team at Nice, so that, when the guideline is updated in the future, we will be able to make individual recommendations about each specific type of HRT and, in particular, different types of progesterone and how that is delivered, whether it’s as a Mirena coil, or whether it’s as the newer forms of micronised progesterone.”
Kate Muir, menopause expert and campaigner, called the guidelines “obfuscatory and outdated”.
“Why can’t they just simply tell doctors what’s the safest starter package for HRT for most women? It’s not much to ask,” she said.
“The most serious omission is the guidelines’ failure in the discussion of risks to clearly differentiate safer body-identical transdermal HRT from the older, higher-risk synthetic HRT containing progestins.
“There is clear evidence available on the safest formulations of HRT in the 2020 British Menopause Society consensus statement on HRT, which favours transdermal oestrogen and micronised progesterone.”
As a result, she said the guidance “fails to signpost doctors to the safest choices for their patients”.
• This article was amended on 7 November 2024. An earlier version said the revised Nice guidelines say CBT “should only be” considered for patients on HRT who still have symptoms, or who cannot or do not wish to take HRT. The wording of the published guidelines is that CBT “could be” considered for these patients; the relevant reference in our article has been revised to reflect this.
