NICE has emphasised the importance of HRT in new guidance and clarified that cognitive behavioural therapy (CBT) should be an ‘add on’ treatment for menopausal symptoms.

In its updated guidance, NICE has encouraged healthcare professionals to have ‘informed conversations’ with patients about the risks and benefits of HRT, and included a new ‘discussion aid’ to use when doing so.

A draft version of the guidance was published last year with a new recommendation for CBT to treat vasomotor symptoms associated with menopause, but this addition was ‘controversial’ according to NICE.

NICE has therefore clarified the wording around this treatment, as ‘one of the key changes’ made in the final guidance.

Dr Marie Anne Ledingham, a consultant clinical advisor at NICE, said they have ‘been very, very clear that CBT is an adjunct therapy, and the use of HRT does not preclude the use of CBT’.

She continued: ‘The wording of the guidance has been changed to provide more clarity for GPs and patients on when it’s appropriate to offer CBT, it remains a softer “consider” recommendation rather than a firmer “offer” recommendation.’

Professor Jonathan Benger, chief medical officer and interim director of the Centre for Guidelines at NICE, said that some people fed back concerns that CBT was ‘too prominent’ in the draft guidelines, or some ‘misinterpreted’ the guidance as saying that CBT should be used ‘instead of HRT’.

He said that the updated guidance now makes it clear that HRT is the ‘recommended first line treatment for vasomotor symptoms’ .

It also emphasised the effectiveness of HRT as a treatment for menopause-associated symptoms, and makes it clearer to patients that HRT is ‘unlikely to affect life expectancy’.

Key recommendations in NICE menopause guidance

  • Offer HRT for hot flushes and night sweats (vasomotor symptoms), and talk with patients about the benefits and risks associated with different types of HRT and the duration and dose
  • GPs should tailor information about HRT benefits and risks based on age, individual circumstances, and any potential risk factors
  • For people over 40, clinicians should consider CBT as an option for vasomotor symptoms associated with menopause in addition to HRT, or for people for whom HRT is not advised, or for those who prefer not to take HRT
  • Consider CBT as an option for people who have depressive symptoms in association with vasomotor symptoms, or for people who have sleep problems in association with these symptoms
  • For management of genitourinary symptoms such as vaginal dryness, painful sex and vaginal discomfort, a choice of vaginal oestrogen (cream, gel, tablet, pessary or ring) should be offered
    • Treatment should be reviewed regularly and continued for as long as it is needed to relieve symptoms
  • Ensure that trans men or non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past and have symptoms associated with menopause can discuss these with a healthcare professional with expertise in menopause
  • When discussing HRT as a treatment option for menopause-associated symptoms, GPs should explain that, overall, taking either combined HRT or oestrogen-only HRT is unlikely to affect life expectancy
  • Be aware that people from some ethnic minority backgrounds and people with some lifelong conditions may experience menopause at a younger age

Source: NICE

Professor Benger said a ‘simple summary message’ clinicians could use when speaking to patients is: ‘There are some risks and benefits of HRT. They kind of balance out, and it’s a very effective treatment for menopausal symptoms, and on average, it doesn’t just change your life expectancy.’

He also said there is ‘good evidence’ that not all patients are getting ‘high quality care’ for menopause symptoms, but recognised that there is ‘a lot of pressure in general practice’.

Dr Ledingham clarified that there is no ‘prerequisite’ to provide information about menopause symptom treatment, but GPs are encouraged to have ‘tailored’ conversations with patients.

The new discussion aid document – which NICE said is an ‘unusual step’ – includes visual prompts showing the benefits and risks of HRT with patients, including the effects on breast cancer, cardiovascular disease, dementia, endometrial and ovarian cancer and the risk of stroke.

There is no new evidence on risk contained in the updated guideline, but NICE said the existing evidence has been made clearer for both GPs and patients.

There are approximately 13 million women over the age of 45 in the UK, which makes up around a third of the female population, meaning the guidance could have ‘far-reaching potential implications’, according to NICE.

This article was initially published by our sister publication Pulse