Abstract
Background:
The use of menopausal hormone therapy (MHT) was significantly reduced following the publication of the Women’s Health Initiative study results and has remained low ever since. However, from 2015 onwards, the UK has seen a substantial increase in MHT prescribing compared to other European countries.
Objectives:
To evaluate the factors contributing to the shift in women’s and healthcare professionals’ (HCPs) perception of MHT in the United Kingdom and to provide learning points for other European countries.
Design:
An exploratory, descriptive and qualitative study
Methods:
An interactive virtual panel discussion in which seven UK-based HCPs with a special interest in the menopause discussed the evolution of its management in the United Kingdom.
Results:
In the last 8 years, there has been a substantial increase in MHT prescriptions in the United Kingdom due to improved menopause awareness and acceptance of MHT. Accessibility to accurate, scientific, information and guidance from respected institutions is one of the main drivers of this change. Social media has increased that reach with ‘influencers’ empowering women to seek help. Women are demanding access to menopause health care so that they can receive holistic and individualized treatment based on their clinical conditions and needs. Standardized education of HCPs is an essential pillar to provide appropriate and equitable care to menopausal women and to guarantee safe prescribing of MHT. Furthermore, up to date and factually correct menopausal education would benefit all the population.
Conclusions:
Publication of new scientific data reporting a more favourable benefit/risk ratio with MHT, production of national guidance and an increased awareness via social media have led to the significant rise in MHT prescribing and improvement of menopause care in the United Kingdom. The lessons learned may benefit other European countries.
Introduction
About three-quarters of women suffer menopause-related symptoms that adversely affect their daily activities and worsen their quality of life.1,2 Menopausal hormone therapy (MHT), also known as hormone replacement therapy, is often prescribed to alleviate these symptoms3 –6 and usually comprises an oestrogen and a progestogen component in women with a uterus given cyclically or continuously or as oestrogen-only therapy in hysterectomized women. 6
In 2002, the Women’s Health Initiative (WHI), published the first of their scientific papers reporting an increase both in breast cancer and heart disease prevalence associated with MHT use (conjugated equine oestrogens and medroxyprogesterone acetate) compared to placebo. 7 This finding resulted in menopausal women worrying about the safety of MHT and stopping their medication. Many healthcare professionals (HCPs) subsequently refused to prescribe MHT.8,9 In addition, the media failed to publicise any dissent about this study after analyses of the results suggested that there was less negative impact on health. As a consequence, many ongoing research studies were stopped. This significantly reduced the available evidence on MHT in the last 20 years.
In the last two decades formulations with lower doses and safer profiles have become available and new data reporting a more favourable benefit/risk ratio has been published.10 –15 The use of MHT in clinically suitable menopausal women has been recommended in good quality clinical guidelines, consensus documents and position statements.3 –6,16,17 However, despite this new evidence, the prescribing and use of MHT remains low in most countries8,18 due to continuing fear among the population and HCPs failing to update their knowledge about the improved MHT benefit/risk ratio. 19 The insufficient prescribing of MHT has led to untreated symptomatic women, and to a higher risk of long-term consequences associated with menopause. 19
In contrast, the United Kingdom has seen a substantial increase in MHT prescribing from 2015 onwards. 20 The change in women perspective about menopause and MHT in particular was already pointed out in a previous European expert panel organized by Viatris Pharmaceutical to identify barriers to prescribe and use MHT in Europe. 19 To investigate this further, an exploratory, descriptive, qualitative study was conducted in which a group of UK HCPs with special interest in menopause met and gave their expert views about the changes in menopause management, the drivers and the lessons learnt.
Methodology
On 9 October 2023, an interactive virtual panel discussion was held, in which seven UK HCPs with special interest in menopause discussed the changes in MHT prescribing in the United Kingdom. The panel members were selected to represent diversity in gender (five female and two male HCPs), training and background (two gynaecologists, two general practitioners (GPs), two nurse prescribers, one pharmacist prescriber), clinical settings (private and National Health Service (NHS) clinics) and geographic location (both affluent and deprived areas).
The objectives of the panel discussion were: (1) to evaluate the factors contributing to the shift in perception of MHT in the United Kingdom, (2) to understand how the changes in women’s perception of MHT has influenced clinical consultations with HCPs and (3) to facilitate an informative and robust conversation about the evolution of menopause care and its management in the United Kingdom that would serve as learning points for other European countries. To address these objectives, the session was divided into four sections: (1) changes in women’s perspective and attitude towards menopause and MHT in the 2020s; (2) current situation of MHT prescribing in the United Kingdom (qualitative analysis); (3) rationale for MHT prescribing and (4) lessons learnt from the United Kingdom experience to guide other European countries. A moderator introduced each section and guided the discussion, allowing all panel members to give their views on each topic. The panel discussion lasted 3 h.
This article describes the experts’ views on the topic and the evidence supporting their views. This publication is intended for European HCPs and other stakeholders involved in menopause management seeking to understand why there was a steady increase in MHT prescribing in the United Kingdom, particularly within the last 5 years, identifying the drivers, opportunities and challenges to help guide other European countries.
The prescribing and use of MHT in the United Kingdom in the last 8 years (2015–2023)
Increase of MHT prescriptions
In the last 8 years, there has been a substantial increase in MHT prescriptions in the United Kingdom. 20 Recent data from the NHS in England reveal that 7.8 million MHT items were prescribed between April 2021 and April 2022 and 11 million MHT items in the same period the year after, representing an increase of 47%. It has been estimated that around 1.93 million women were prescribed MHT items in 2021–2022 and 2.3 million women in 2022–2023, which was a 29% increase (Figure 1). 21
Number of prescribed MHT items and women with prescribed MHT items in England from 2015 to 2023 (June). 21
This increase in MHT prescriptions is a consequence of improved menopause awareness and acceptance of MHT. Women with menopausal symptoms became empowered to seek help, including those previously considered unsuitable for MHT, for example post-cancer or dialysis patients.
Main drivers of change
In the last 10 years, there have been a series of events that have contributed to this substantial increase in MHT prescribing as a result of improving menopause awareness and acceptance of MHT (Figure 2).
Timeline of main events that contributed to the increase of MHT prescribing in the United Kingdom in the last 8 years.
Accessibility to information is recognized as one of the main drivers of change. Mainstream media, social media and influencers have had an important impact on women and HCPs’ perception of menopause management. A television documentary led by a famous female broadcaster that aired in 2021 explored the issues faced by menopausal women in the United Kingdom and encouraged them to seek help. 22 This documentary and a subsequent programme shown in 2022 was discussed widely 23 and led to a number of menopause support organizations being overwhelmed by women demanding help.
Many HCPs’ perceptions about menopause and MHT have changed in the last decade due to the publication of new scientific evidence, updated national guidelines (National Institute for Health and Care Excellence (NICE)) and information provided from respected institutions such as British Menopause Society (BMS) about MHT safety.6,11,12,16 Some HCPs who have not kept up to date are still reluctant to prescribe MHT while younger clinicians who are not heavily influenced by the initial results of the WHI study are keen to learn more. Many HCPs have recently been trained in menopause management, including allied health professionals such as nurses, pharmacists and physician associates.
Current menopause management in the United Kingdom: opportunities and challenges
The increase in MHT prescribing in the United Kingdom has highlighted several opportunities and challenges in the current management of menopause (Table 1).
Opportunities and challenges identified in the United Kingdom experience.
HCPs: healthcare professionals; MHT: menopausal hormone therapy; PC: primary care.
Provision of menopause care
In the United Kingdom, women with straight-forward menopausal symptoms are managed by primary care (PC) teams which include GPs (family doctors), pharmacists, nurses, healthcare assistants and physician associates. When a woman contacts the PC team, she is assigned to a specific HCP depending on the reason for the consultation. Often, first consultations are remote and may be with a nurse, pharmacist or physician associate who have a high level of expertise, and therefore make it unnecessary for GPs to be the first point of contact.
More complex cases should ideally be referred to specialized centres and see physicians with specialist training in menopause care. Most UK gynaecologists are not menopause specialists and they too, refer complex patients to more specialized HCPs or ask for their advice. This approach varies across the United Kingdom and complex patients may wait 6–12 months to see an NHS menopause specialist. This has led to an increased provision of menopause care by the private sector thereby limiting the access to prompt care for many due to financial barriers.
In addition, there has been an increase in the development of women’s health hubs at the local level as an opportunity to provide healthcare tailored specifically to women’s needs, including menopause management. These hubs represent a significant step forward in the provision of menopause care with the potential to improve the management of menopause symptoms for women across the United Kingdom by offering more accessible, specialized services directly within community settings. This approach not only aims to provide immediate relief and support but also seeks to mitigate the need for secondary care referrals, thereby alleviating pressure on the broader healthcare system.
Rational and safe prescribing of MHT
The group felt there should be a holistic approach to the care of menopause patients and not limiting only to the provision of MHT. Recommendations about following a healthy lifestyle, including exercise, improving nutrition, normalising body mass index, reduced alcohol consumption and smoking cessation should be made.
Prescribing MHT requires individualization of the treatment for each patient. When prescribing oestrogen to patients, a range of options in terms of dose, formulation and route of administration should be considered. The MHT formulation should be chosen according to the patients’ needs and medical risk factors such as those at increased risk of the venous thromboembolism. When prescribing progestogens, the group felt that its type and steroid receptor affinity should be considered as this may alter MHT’s side effect profile. Other characteristics such as dose equivalence between different formulations must be considered since they will be subject to significant individual variations in absorption and metabolism. This is of utmost importance when switching patients between formulations. Nevertheless, MHT practical prescribing should always be guided by symptom control and the patient’s clinical background.
There has been an increased demand for testosterone prescribing from menopausal women who complain of low sexual desire. Testosterone supplementation should only be considered after a biopsychosocial approach has excluded other causes such as relationship issues, psychological problems and medication-related Hypoactive Sexual Desire Disorder. 24 Furthermore, there is no licensed testosterone product for women in the United Kingdom and off-label ‘male’ products are being used. Combined hormonal and psychosexual approaches may be beneficial in certain cases.
The woman should be at the centre of the MHT discussion because prescribing separate oestrogen and progestogens can result in adherence issues leading to vaginal bleeding and possible increased risk of endometrial hyperplasia and cancer. 25 Oral or transdermal products that combine oestrogen and progestogen in fixed doses may be preferred in this situation because they improve compliance and may reduce adverse events for some patients.
Despite the publication of updated local guidelines, there is a misconception among some HCPs that the use of transdermal options such as oestrogen patches and gels, along with micronized progesterone, are the best suited option for all menopausal women. The group thought that MHT transdermal options are now automatically prescribed by non-specialist HCPs and in private clinics rather than individualizing care. This misconception has spread among menopausal women leading them to question HCPs when their treatment decisions differ from transdermal therapy. The group also felt that when MHT fails to treat symptoms such as fatigue, mental health issues or sleep problems, there is a tendency among non-specialized HCPs, to increase doses over the maximum recommended by the product licence, instead of reassessing the patient and considering other options.
Bioidentical MHT is often used as a marketing term to define compounded bioidentical MHT, which are unregulated duplicates of human hormones, produced by specialist pharmacies.26,27 This term is often confusing for women and generates unrealistic expectations. Many HCPs avoid this term and try to make women understand that the final choice would depend on safety, patient preference and availability.
The group have seen non-specialized HCPs prescribing MHT formulations that may not be appropriate for the patient because of their body mass index or pharmacists dispensing insufficient quantities of progestogen due to supply issues.
Patient information on the use of MHT
Providing the right instructions to patients for the correct use of MHT is paramount. However, when consultations are limited to 10–15 min per patient this can present a challenge to providing accurate and concise information to patients. Due to time pressures, it is important that patients receive the necessary information to safely take their medication using appropriate and simplified language. Correct instructions will prevent misunderstandings as patients often turn to social media to adjust their MHT doses based on variations of non-measurable symptoms or discontinue treatment due to a lack of expected benefits.
In this regard, technology can be an important tool to provide information to patients. Accurx (Accurx Ltd, London, United Kingdom) is a program that can be added on to a prescribing system and that automatically sends videos on how to use the medication prescribed for each patient. However, the access to technology varies among areas and hospitals.
Training of HCPs
Standardized training of PC HCPs in menopause management is needed to guarantee equitable care and safe prescribing of MHT. Publication of local guidelines has facilitated local GPs to keep up to date. However, some GPs are still reluctant to prescribe MHT because they are not aware of the latest evidence about its risk/benefit profile. There are problems accessing menopause training as it is expensive with few trainers available across the United Kingdom. Some of the group commented that once HCPs have completed their NHS training in menopause care, they move on to private practice.
To fill the menopausal knowledge gap within PC teams, more specialized HCPs are providing education and training to the PC team. As an example, some specialist services provide ‘Advice and Guidance’ via an e-referral system to educate the HCP and avoid unnecessary referral of patients who can continue their care with their GP.
Besides NHS training, other training platforms are available in the United Kingdom. Although training platforms such as the BMS 28 or International Menopause Society 29 base their content on updated evidence, there are other platforms whose content does not follow a guideline-based approach to recommend MHT. Therefore, providing evidence-based training to the new generation of HCPs and avoiding misinformation is still an important challenge in the United Kingdom.
Advanced training targeted to menopause specialists is necessary for the management of complex cases. However, due to a shortage of trainers, advanced training can be difficult to access.
Other specialists also need specific training, including HCPs in breast teams and endocrinologists. They are usually concerned about the risk of breast cancer, and they often discourage patients from using MHT. In contrast, the group felt that modern-day oncologists are in general keen to learn about MHT and to support its use as part of the holistic approach including improving quality of life for cancer sufferers. In this regard, discussions about complex patients between oncologists and menopause specialists can be very enriching.
Difference in menopause care across the United Kingdom
Quality of menopausal care varies across the different UK countries. There are differences in the availability of NHS specialists: HCPs with special interest in menopause and trainers are scarce. Therefore, menopausal women who seek help may feel unsupported, receive suboptimal care or feel their only option is to go to a private clinic.
Additionally, there is a lack of consensus across the country in terms of diverse local guidelines and availability of MHT formulations on formularies. This situation compromises equality of access to all therapeutic options among different areas and prevents patients from having the opportunity to receive the best personalized treatment.
Education of the population
Menopausal women are becoming better educated and aware of the treatment options to alleviate their symptoms, including MHT. However, there is still part of the population who are not familiar with MHT or that fear it. Over 80% of women under 40 have a significant lack of knowledge surrounding the menopause. 30 To fill this gap, menopausal education is provided now in schools and in workplaces. 31
Additionally, education of men on menopause and MHT may represent an extraordinary opportunity to increase awareness of menopause. Successful talks for women and men have been already organized by social prescribers in some areas. Nevertheless, it would be useful to deliver sessions for men only groups, to raise awareness and create an atmosphere where they feel comfortable to ask questions and generate discussion.
Influence of media
Media, including social media, is an important source of information and it has shown to be an exceptional way to reach women with menopausal symptoms and has empowered them to face their feelings and want to seek help. 32 However, media can also create unrealistic expectations among patients and generate conflicts with GPs and specialists if patients are not prescribed what they expect. In some cases, these patients go to private clinics, visiting several specialists until they get the treatment that social media tells them they should use.
Another example of unrealistic expectations created by social media is the use of testosterone promoted to treat low sexual desire in menopausal women, which has translated into an increased demand of testosterone prescriptions and long waiting lists to access a specialist to prescribe it.
Improvements in the menopause management with MHT
Several areas of improvement have been identified to guarantee appropriate and equal care to menopausal women in the United Kingdom (Table 2). In general, these improvements must be directed to provide the right information to the right audience, preventing misinformation and unrealistic expectations about the use of MHT. Importantly, actions should be focused on guaranteeing safe prescribing of MHT for menopausal women.
Areas of improvement in the menopause management with MHT in the United Kingdom.
HCPs: healthcare professionals; MHT: menopausal hormone therapy.
Lessons learned to be guidance for other European countries
Although every country has its own healthcare system with its own particular features, there are several key lessons learned from the United Kingdom experience that may be of use for other European countries.
Firstly, it is essential to define the best strategy for menopause management based on the individual healthcare systems. Women with menopausal symptoms should be able to quickly access the best care according to their needs. The objective should be to direct patients according to their needs and their medical history to the most appropriate HCP that has the right level of expertise. Women’s health hubs at a local level represent a promising opportunity to provide localized, specialized care that can contribute to better health outcomes and a more efficient healthcare delivery model for menopausal women. Importantly, the translation of these initiatives into clinical practice should be regularly assessed.
It is recommended to build the clinical practice on national evidence-based guidelines, which should be frequently updated. Guidelines should be easy-to-follow and transferable to any HCP. In this respect, it is important to have a resource that interprets data obtained from research.
Technology can improve healthcare services and facilitate automatization. Artificial intelligence is an excellent tool to incorporate in the health system that may assist not only HCPs but also menopausal women.
Education of HCPs is also an essential pillar to provide appropriate care to menopausal women. 33 Consequently, as previously mentioned, it is important to adapt the education content to each professional profile and level of expertise, with it being essential to provide basic menopausal education in medical school and nursing school. Importantly, HCPs who are the first point of contact with patients, should receive appropriate education for the first assessment and referral. To make the education programmes attractive to the target audience, it would be beneficial to adapt them to the current needs and expectations of the students and HCPs. In addition to face-to-face courses, there should be self-directed, online programmes that regularly assess the students’ knowledge in a standardized manner. Small in-person sessions may be an option to discuss specific topics and ask questions or explore unclear aspects with peers.
Finally, to provide easily accessible and accurate information to the population, it is highly recommended to have a scientific prestigious body at a national level, comparable to the BMS in the United Kingdom, that would coordinate initiatives that will give the public the right information based on the latest evidence about the use of MHT, in an appropriate and simplified language and using social media.
Strengths and limitations
This work provides the expert views of a diverse group of HCPs, who routinely prescribe MHT to women in the United Kingdom, ensuring a comprehensive understanding of MHT practices from multiple professional perspectives. The inclusion of both male and female clinicians in the expert group provides a more balanced and coherent understanding of various viewpoints, enriching the study’s insights. Additionally, the HCPs of the group operate in both private and NHS clinics located in affluent and deprived areas. This diversity underscores the broadness and inclusivity of the study, offering a well-rounded view of MHT practices across different socio-economic environments. However, this work has some limitations due to the qualitative nature of the work, including subjectivity, potential biases and challenges in generalizability. Another potential limitation of this study is that not all participating HCP have experience working outside the United Kingdom, which may limit the group’s ability to compare and incorporate international best practices into the findings. Nonetheless, this is an area of ongoing work, and the group is actively seeking to integrate innovative ideas and successful practices from other countries to further enhance MHT services in the United Kingdom.
Conclusions
The huge leap in MHT prescribing in the United Kingdom resulted from the publication of scientific data reporting a more favourable benefit/risk ratio. This led to NICE producing national guidance for the management of menopause care. Social media enabled women, including many influencers, to widely share their menopause problems, thereby raising awareness. More accessible training to help support HCPs managing women with menopausal issues and evidence-based information available for all to combat the unrealistic expectations emanating social media are now needed. The group hope that sharing their UK experience will help other countries improve menopause care for their population.
