Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
Medication shortages are no new thing. It’s not uncommon to see alerts from our friendly pharmacy team warning us of shortages in antidepressants, or medications such as H2-antagonists. But I can’t think of a more prolonged or complex shortage than what we have seen with hormone replacement therapy (HRT). The most recent HRT shortage relates to Oestrogel, but years of HRT shortages have left patients frustrated and GPs scrambling to find alternatives. Recent newspaper headlines warned that some women are turning to the black market to access HRT medications. How have we ended up here, and what should we as clinicians be doing about it?
NICE guidance published in 2015… recommended prescribing HRT as first line treatment for patients under the age of 60 with menopausal symptoms.
HRT used to have a relatively unfavourable reputation. This was in some part due to early findings from the Women’s Health Initiative study and confusion over using combined (oestrogen and progesterone) HRT and the risk of stroke, breast cancer and thrombosis.1 NICE guidance published in 2015, however, recommended prescribing HRT as first line treatment for patients under the age of 60 with menopausal symptoms.2 Given the increasing coverage of menopause in the media and societal shifts in prescribing and taking HRT, rates of HRT use have increased substantially; OpenPrescribing data demonstrates an increase of over 200,000 prescriptions for HRT medications from January 2017 to January 2022.3
So, whilst women are increasingly requesting HRT to help manage symptoms of their menopause, and GPs gain confidence in prescribing for different menopausal symptoms, manufacturers have said that this pressure has caused a supply and demand problem. Besins Healthcare, which manufactures Oestrogel, blames the ‘exceptionally high demand’ for Oestrogel over recent months for a depletion of stocks4. Pharmaceutical companies need to forecast which medications will be in demand 12-18 months into the future,5 but have not been able to keep up with the demand in HRT. In some ways this is puzzling, especially as international supply shortages of HRT have been ongoing since 2018; and it is unclear when they will ease.
Fear not; the British Menopause Society regularly publishes updates on HRT supplies, and provides guidance on HRT preparations and equivalents…
Where does that leave clinicians? At the coalface, shortages in HRT mean that the scripts we issue for specific HRT preparations might not be available to the women who need them. And this is a problem; the effects of menopause can be debilitating and for many women, HRT is part of the solution to navigating this stage of their reproductive health. There are plenty of alternatives to each specific HRT mediation, and women should be offered these medications. For some clinicians, prescribing HRT can be a murky challenge; there are numerous preparations, and it can be difficult to work through equivalent preparations. Fear not; the British Menopause Society regularly publishes updates on HRT supplies, and provides guidance on HRT preparations and equivalents,6 which is a handy tool when dealing with prescription queries. I have personally found the advice of pharmacists exceedingly helpful when prescriptions bounce back. However, like other hormonal preparations (contraceptives spring to mind) some women will prefer specific brands to others. Menopause is a time of life where individualised care must take precedence; working with a patient to find a solution or alternative formulation that suits them.
It is a good thing that we are all talking about menopause more, and although it is frustrating that HRT availability is yet to fully catch up, it is a problem we can try to solve through working through the issues openly with women and supported, but creative prescribing.
- Robinson L. HRT: The history: Women’s Health Concern; 2020 [Available from: https://www.womens-health-concern.org/help-and-advice/factsheets/hrt-the-history/.
- Menopause: diagnosis and management. 2015.Contract No.: NICE guideline NG23.
- Prescribing O. 6.4.1: Female sex hormones and their modulators[Available from: https://openprescribing.net/bnf/060401/.
- British Menopause Society update on HRT supply 2022 [Available from: https://thebms.org.uk/news/british-menopause-society-update-on-hrt-supply/.
- Backhouse T. HRT: Why are some women finding it so hard to access Hormone Replacement Therapy? Women’s Hour: BBC Radio 4; 2022.
- Society BM. HRT preparations and equivalent alternatives 2022 [Available from: https://thebms.org.uk/wp-content/uploads/2022/03/15-BMS-TfC-HRT-preparations-and-equivalent-alternatives-01D.pdf.