Nada Khan is an Exeter-based GP and an NIHR Academic Clinical Lecturer in General Practice at the University of Exeter. She is also an Associate Editor at the BJGP.
It is good news that women, and clinicians are talking more about the menopause and its management. What’s not such good news is that there is a lot of conflicting information rife about menopause, its treatments, and how GPs will or won’t support women through this stage. With menopause ‘influencers’ and messaging from some menopause specialists inconsistent with current guidelines, sifting through the different options and safety profiles can be difficult.
BBC’s Panorama show recently highlighted oestrogen prescribing practices at Newson Health Menopause and Wellbeing Centre, a clinic established in 2018 to support women with treatment options in peri/menopause. The programme suggests that some women receiving hormone replacement therapy (HRT) from the Newson clinic are prescribed increasingly high doses of oestrogen disproportionately to progesterone, and given false reassurance around the risks of higher oestrogen dosing regimes. GPs are often the first point of call for women through the menopause, and it’s worth considering women’s experiences of seeking help in general practice and current guidance around oestrogen prescribing.
Women’s experiences of general practice and menopause management
Women’s experiences in consulting their GPs during the menopause can vary significantly, with some women experiencing the kind of supportive and individual care and treatment options alongside a discussion on risks and benefits to support an informed choice.
…there is a lot of conflicting information rife about menopause, its treatments, and how GPs will or won’t support women through this stage.
But other women can feel that their experiences are dismissed, and that they are offered inappropriate or unhelpful advice from GPs who don’t have the understanding or knowledge to manage the menopause.1 Where women feel that their concerns and experiences were not fully explored and they don’t have the different available options discussed with them, they may choose to seek care from specialist clinics.1 And a small minority of women attending private clinics are being prescribed a high dose of oestrogen as part of their HRT.
Newson clinic and oestrogen prescribing
The concerns raised within the BBC Panorama programme relate to patterns of oestrogen prescribing above currently licensed maximum amounts from the Newson Health clinics. The current highest product licensed dose of oestrogen is 100mcg per day, with the National Institute for Clinical Excellence (NICE) recommending an individualised choice of HRT preparation with the aim to prescribe the lowest dose for the shortest possible duration. So why are some women being started on, or titrated up to doses up to three times higher than the company Summary of Product Characteristic monographs for oestrogen?
The Newson Health website has a webpage focussing on why some women are prescribed higher doses of oestrogen which focusses on women who are ‘poor absorbers’ and do not absorb transdermal oestrogen preparations effectively, leading to what the clinic suggests is suboptimal oestradiol levels.2 The website suggests that there is not enough evidence to suggest that higher doses of oestrogen lead to harm, or in their words, ‘absence of evidence does not mean proof of harm’.2 But, evidence of lack of harm is not evidence of patient safety. The front page of the Newson Health clinic states that they ‘provide evidence-based care’, but that definition is fluid from the clinic’s perspective, with a recent article on the Newson clinic website stating that ‘evidence based medicine is based not only on clinical trial data, but also a clinician’s experience and expertise individualised to a patient’s values and preferences’.2 This is not entirely wrong, but is somewhat misleading, with expert opinion based on clinical experience valued, but much lower down on the levels of evidence-based medicine.3 There is a dearth of evidence in women’s health, I’ve written about how this gender-bias in research holds us back in evidence-based practice here in the BJGP.4 One thing we can all probably agree on is that women’s health, including menopause treatment, has been historically under-funded and under-researched, and future work needs to continue to look at the efficacy, patient experience, and safety of different oestrogen dosing regimes to shore up the levels of evidence available to guide treatment choices.
Current guidance
Current guidance does not support prescribing of above-licensed doses of oestrogen in HRT. Paula Briggs and Janice Rymer, who both feature in the Panorama episode, wrote a timely editorial for the September 2024 Women’s Health issue of the BJGP describing how clinicians need to be supported by a robust evidence base to support safe prescribing in the menopause. In their editorial, they urge caution over media messaging that suggests all issues or symptoms around the time of the menopause are due to hormone deficiency which then needs replacement.5 HRT is for many women the best way to improve menopausal symptoms and improve overall quality of life. But individualised care, which is a hallmark of GPs who know their patients and their circumstances, can help support a holistic approach in women, care that can often include HRT prescribing, but alongside an patient’s informed choice, sometimes doesn’t.6
Disruptors have a place in challenging current practice, but it’s worth considering the balance of opinion on prescribing high doses of oestrogen when some of the main bodies representing general practice and women’s health oppose the practice based on safety grounds. The British Menopause Society (BMS) has previously responded to reports that some private clinics are prescribing above the licensed doses of oestrogen. They reiterate that ‘no guidelines recommend that the dose of oestrogen provided should be increased out of license’, and that the clinicians prescribing at higher doses are ultimately responsible for putting patient safety at risk.7 In their response to the recent Panorama programme, the BMS emphasises their guidelines are evidence-based and peer-reviewed, and that evidence of lack of harm relating to high dose oestrogen prescribing is not evidence of patient safety.8
Current guidance does not support prescribing of above-licensed doses of oestrogen in HRT.
The BMS, the RCGP, the Royal College of Obstetricians and Gynaecologists alongside the Society of Endocrinology and the Faculty of Sexual and Reproductive Healthcare issued a joint safety alert in 2023 focussing on high dose prescribing of oestrogen above product licensing.9 The guidance re-emphasises using the lowest effective dose of oestrogen, but when oestrogen is being prescribed above licensed doses to ensure that women are informed that the treatment is above currently recommended safety evidence. And, that the progestogen is increased proportionately.
Menopause management and the GPs role
Management of the menopause mostly happens in general practice, where new prescriptions for HRT have been steadily increasing over the past decade.10 With more women coming through to discuss menopause and its management, one step we can all take is to try and keep up to date with current guidelines. Here in the BJGP, Rima and Rina Chakrabarti have published a useful clinical practice article around prescribing HRT in practice, working through some of the key considerations and appropriate route and dose of HRT to start on.11
Women initiated on higher than licensed doses of oestrogen from independent clinics may come back to their GP for advice or further management, or further prescriptions. It’s important to explore and understand why they are on that dose of oestrogen, and if they have been counselled of the potential risks. It’s worth ensuring that woman on higher dose oestrogen have adequate endometrial protection, and to be especially wary if they have additional risk factors for endometrial cancer such as obesity, or a history of polycystic ovarian syndrome. Decisions about prescribing above licensed doses, or continuing doses above 100mcg/day initiated in a specialist clinic will fall to individual GPs who must then take responsibility for any associated risks. And If a woman wants to seek specialist care from a private provider, suggest a BMS accredited menopause specialist who will manage women according to national guidance. There is a lot of conflicting information about menopause management, but it would be a good outcome if more women feel they can trust their GPs, rather than independent clinics, to work with them to guide them through this stage of life.
References
- Consulting the doctor about the menopause: Health Talk Online; 2018 [Available from: https://healthtalk.org/experiences/menopause/consulting-doctor-about-menopause/.
- HRT is not a “one size fits all treatment”: Newson Health; 2024 [Available from: https://www.newsonhealth.co.uk/wp-content/uploads/2024/09/dosing-article-LRN.pdf.
- Tenny SV, M. Evidence Based Medicine StatPearls; 2022 [Available from: https://www.ncbi.nlm.nih.gov/books/NBK470182/.
- Khan N. Breaking the Bias in Women’s Health. Br J Gen Pract. 2022;72(717):147. https://doi.org/10.3399/bjgp22X718817
- Briggs P, Rymer J. Managing the menopause in general practice: a tale of pragmatism, caution, and optimism. Br J Gen Pract. 2024;74(746):388-9.
- Hamoda H, Mukherjee A, Morris E, Baldeweg SE, Jayasena CN, Briggs P, et al. Joint position statement by the British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology on best practice recommendations for the care of women experiencing the menopause. Post Reprod Health. 2022;28(3):123-5.
- BMS statement – HRT prescribing: British Menopause Society; 2022 [Available from: https://thebms.org.uk/2022/12/bms-statement-hrt-prescribing/.
- British Menopause Society statement published in response to BBC One Panorama programme 30 September 2024: British Menopause Society; 2024 [Available from: https://thebms.org.uk/2024/10/british-menopause-society-statement-published-in-response-to-the-bbc-one-panorama-programme-30-september-2024/.
- Joint BMS FSRH RCGP RCOG SfE and RCN Women’s Health Forum safety alert: British Menopause Society; 2023 [Available from: https://thebms.org.uk/2023/04/joint-bms-fsrh-rcgp-rcog-sfe-and-rcn-womens-health-forum-safety-alert/.
- Alsugeir D, Wei L, Adesuyan M, Cook S, Panay N, Brauer R. Hormone replacement therapy prescribing in menopausal women in the UK: a descriptive study. BJGP Open. 2022;6(4).
- Chakrabarti R, Chakrabarti R. Prescribing hormone replacement therapy: key considerations for primary care physicians. Br J Gen Pract. 2023;73(732):330-2.
Deputy Editor’s note: see also –https://bjgplife.com/the-davina-effect-menopause-and-general-practice-responses-to-celebrity-stories/
