What the HRT is happening with menopause care in the UK?

Menopause is a natural process that occurs as women age and marks the end of their reproductive years. However, while it’s a natural part of life, the symptoms it brings can be tough to manage for patients, impacting all aspects of their daily life.

From the better-known symptoms of hot flashes and disturbed sleep patterns to less visible psychological symptoms, menopause can be a menace that, combined with psychosocial life changes, can create a whirlwind of challenges for individuals to navigate. If left untreated, this can quickly become too much for patients to cope with alone.

Thankfully, there are treatments available to help. At present, the primary option for menopause and perimenopause is hormone replacement therapy (HRT), which supplements low levels of oestrogen and progesterone as the body stops producing them naturally. Yet, despite having multiple HRT patches, gels, sprays, implants, and tablets approved for use in the UK, women across the nation still face a range of challenges when it comes to accessing menopause treatment. From shortages and resource limitations to financial barriers and stigma, the obstacles are numerous and can be difficult to address.

After years of campaigns, shortages, and COVID-19, the subject of menopause treatment has once again reared its head in public discourse. But what is actually being done to help patients access the treatment they need to overcome menopause and perimenopause symptoms? Here, we speak to experts across industry to find out.

Traversing the current treatment landscape

For the majority of patients, the journey to treatment begins with a GP. There are two main options for those individuals who seek professional help to manage menopause, and perimenopause, symptoms – hormonal or non-hormonal. But as patients across the UK have discovered, accessing the right treatment and support can be something of a postcode lottery.

“Accessing appropriate treatment and care for menopause is often not straightforward,” explains Jody Tate, director of research at The Health Policy Partnership. “A UK survey of more than 5,000 women experiencing menopause or perimenopause found that, although 79% of them visited their GP about menopause symptoms, only 37% were given HRT. Despite national menopause guidelines clearly stating that antidepressants are not a suitable first-line treatment, 23% of the women were prescribed this treatment instead.”

To receive support during menopause, Tate notes, women must recognise the symptoms and know to reach out to a healthcare professional for advice and information about the treatment options. However, many women are not aware of what to expect from menopause and do not feel well-informed. This lack of knowledge – along with the stigma and shame around this transition and around ageing more broadly – can be a barrier to seeking treatment.

“The survey also highlighted significant delays in care, with 44% of the women who received treatment waiting a year or longer, and 12% waiting more than five years,” she continues. “As a result of this wait time, many women who can afford to pay for healthcare turn to private clinics to access treatment, contributing to health inequalities.”

In 2022, growing demand for HRT products, compounded by the impact of the war in Ukraine, Brexit, and COVID-19, saw manufacturers unable to produce enough to fulfil orders. This was not a minor increase. According to the NHS Business Services Authority, in 2021/22, 7.80 million items for HRT were prescribed in England, a 35% increase from 2020/21. Consequently, shortages began to appear across manufacturers and regions, leaving patients suddenly cut off from their medication.

“The shortage of some HRT products is a complex problem that requires continued collaboration between government, industry, and the NHS. We work closely with the government and our members to help address issues where shortages arise, including to accurately forecast future demand and to increase the supply of HRT products,” explains Ross Maclagan, distribution and supply chain manager at the ABPI.

According to the British Generic Manufacturers Association’s chief executive, Mark Samuels, generics and biosimilars have also been hit hard by recent economic events and changes to government policy, which has driven some to take the difficult decision to withdraw existing products or cancel future potential UK launches.

“Manufacturers of generic medicines operate very efficient but often complex supply chains that can stretch across the globe,” he explains.” Margins are typically tight; therefore, additional costs or taxes can have a disproportional impact compared to on-patent medicines. The latter has a greater ability to set their own prices. Inflationary increases, costs of raw materials, and the price of energy and transport all contribute to a much more unfavourable economic environment.

“If the competition is reduced, supply chains become less resilient. We need to ensure that government policy supports a sustainable generic and biosimilar market and broader industrial policy does so well.”

What can be done to improve access to menopause care?

Amid national shortages and increasing demand for HRT, the UK Government established an HRT taskforce led by Madelaine McTernan, who had previously been part of the nationwide COVID-19 vaccine rollout. According to the DHSC, the team would be tasked with working with suppliers and the NHS Business Service Authority, as well as industry bodies, to help prescribers respond to demand.

However, only four short months later, news emerged that the taskforce was disbanding, with McTernan returning to her previous role. In her parting statement, she painted a picture of a recovered HRT supply: “I am pleased to see the situation with HRT supply is improving across the country. I want to thank suppliers and manufacturers for their engagement and positive action to tackle this serious issue.”

However, while stocks of certain HRT products, such as Oestrogel, were indeed improving, the supply of some HRT patches remained inconsistent late into 2022. As such, many patients were left struggling to access their medication.

So, what could be done to help improve access to both HRT and wider menopause treatment?

One option introduced by the UK Government in April 2023 sought to address one of the biggest concerns in HRT – cost. With the new HRT prescription prepayment certificate (PPC), patients in England would be able to access eligible HRT items for a fraction of the price, with costs reduced to less than £20-a-year. The scheme, according to the DHSC, would help approximately 400,000 women to save hundreds in medication payments annually, something Minister for Women’s Health Strategy Maria Caulfield described as “a huge moment in levelling the playing field”.

Despite delays, and some early technical road bumps, the service is now underway in England, something that Ross Maclagan highlights for its potential to help address access issues.

“Every woman deserves access to treatments that might help them with the debilitating symptoms that some can experience. The introduction of annual prepayment certificates will hopefully help improve access, smooth out supply issues, and reduce inequalities in access to treatment,” he says.

“Companies understand how important it is for women to get the medicines they need and do everything they can to address shortages if they arise. Collaboration and good communication between government and industry will continue to be essential to tackle supply problems,” continues Maclagan. “Serious Shortage Protocols (SSPs), which allow pharmacists to manage available supplies by limiting prescription length, are also important. Ending variation through local formularies and making sure that GPs can prescribe the full range of available HRT treatments will also be essential.”

Generics also have an important role to play in improving access to menopause treatment in the UK. According to the BGMA, generics and biosimilars represent four out of five prescription medicines used by the NHS. When a patented drug loses its exclusivity, competition among multiple manufacturers for generic versions commences, allowing for greater availability of the drug and empowering physicians to make the optimal treatment decisions for their patients.

“We believe more needs to be invested in supporting primary care to enable holistic options and choices for women. For example, supply pressures would be alleviated if prescribing were more tailored to the individual and GPs and pharmacists were further educated and empowered to support prescribing changes and alternatives,” explains Mark Samuels. “Everyone from manufacturers to wholesalers through to dispensing pharmacists works very hard to avoid shortages, but inevitably they occur. One of the many benefits of a resilient and vibrant generics market is that it encourages many suppliers.”

Digital health services could also help to ease the burden created by menopause for both practitioners and patients alike. Menopause intersects with important personal and economically productive years for those experiencing symptoms, so services should be available to meet the unmet need for tools outside of the clinical setting. At least, this is the view of Dr Bryony Henderson, lead GP at Livi UK (Kry), who has been working to highlight the challenges that menopause presents in the workplace.

“What one patient experiences in menopause is not necessarily going to be the same as the next,” she explains. “There’s a huge spectrum as well from those who just have a bit of a regular period, stop their periods, and never anything else, to really debilitating. We know about 25% are at that debilitating end of the scale.”

Here, she notes, digital appointments, run alongside traditional face-to-face GP interactions, can help to increase the reach of specialist services, as well as provide authoritative and trustworthy information for patients.

“I think we all know that the internet is a huge place. How do women know when they go on the internet that they’re receiving information, getting information that is accurate, that’s up to date?” she asks. “All those myths that the internet comes up with, we want to dispel those myths, and there are huge amounts out there. It’s that education. It’s not only the access, but it’s the education to allow women to better understand their bodies, really, and what they’re going through. It may well be natural, but it’s not always normal what you’re experiencing. If it impacts your normal life, that is when we need to step in.”

Continuing this conversation outside of the GP setting is also a vital task if attitudes and access to menopause treatment are to improve, she explains. This includes in the workplace, where the majority of patients will actually experience symptoms on a daily basis.

“Menopause is the world’s least exclusive club,” she says. “It’s the fastest-growing workforce, so about the just under 4.5 million women over 50 in employment. That’s pre-pandemic, so that number is potentially slightly out of date now, but it’s going to rise and rise further. We know that more women than ever will be in work while experiencing menopause, and that’s why I think workplaces have a very critical role to play in supporting women and empowering them to change.”

A step in the right direction?

Of course, change doesn’t happen overnight. Although supply appears to have returned to pre-shortage levels, this momentum must be continued in order to improve the treatment landscape for all patients, not just those living in certain areas.

As the first point of contact for many patients, it is essential that healthcare professionals working in primary care are given the tools to provide the best possible care to those patients that come to them with menopause-related concerns.

“It is essential that all women, regardless of their background and personal characteristics, have access to information, support and evidence-based treatments that meet their specific needs,” she says. “Healthcare professionals working in primary care must have the knowledge and resources to support women to make informed choices around their treatment. Better care during menopause could improve the health and quality of life of millions of women.”

“While treatment may not yet be optimal, the ongoing discourse around menopause is a clear indication of how far the conversation has already progressed,” she continues. “In only a few short years, menopause has moved from a taboo topic that patients were forced to suffer in silence to a mainstream media discussion, with notable celebrities, politicians, and campaigners sharing their experiences and encouraging others to do the same.”

“I think if we compare now to even ten years ago, women didn’t mention it at all ten years ago,” she says. “Menopause was just something that happened behind closed doors. It was very secretive what people went through, and they must have felt terribly alone. Even now, I think things are far more open, but I would like to think in ten years’ time that we’re that step further.”

Eloise McLennan is the editor for pharmaphorum’s Deep Dive magazine. She has been a journalist and editor in the healthcare field for more than five years and has worked at several leading publications in the UK.

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