Who should be taking HRT?
Briggs adds that another concern is variation in the makeup of the prescription. “You just wouldn’t know what you’re getting from one prescription to the next,” she says. “And they market it as bespoke HRT – they are testing hormone levels in blood and saliva and saying ‘this is your unique product’, but you can’t do that, because hormone levels will change continuously.”
This is a controversial point. Many campaigners argue that scare stories have led to the medication being underused, and that far more women would benefit from taking HRT than currently have prescriptions for it. However, some experts are concerned the message now being sent is that every woman who is going through perimenopause needs HRT.
“In reality, there are some women who will have little or no symptoms [of menopause], and there are other women who will have extremely severe and debilitating symptoms,” says Jayasena. “The advice is that you should take HRT if it will help you. Clearly if you have no benefits because you feel perfectly fine the advice is that you shouldn’t take it.”
Briggs agrees: “You’ve got the extreme end who say women are being overmedicalised. And then the other end [saying] that everyone should have HRT because it’s a deficiency state. And neither of those are right.
“It should be there for women who are symptomatic, who have no contraindications and who want to take it,” Briggs says. “[But] being made to feel that you need to be taking something when you might not want to, that’s not right either.”
It is also important to note that some women cannot take HRT because it is not compatible with other aspects of their health, or may simply not want the medication. One concern about the drive to increase uptake is that while the risks from HRT – such as a small, increased risk of breast cancer associated with progestogen-containing forms – are low, they do exist.
According to the NHS, there are around five extra cases of breast cancer in every 1,000 women who take combined HRT for five years. This is a small uptick in risk but, if all women took such HRT, Jayasena says the number of women affected by uncommon complications would be large.
“The more people who take this without any tangible benefits, the more breast cancer cases you will create unnecessarily,” he says, adding that there is a concern that increased awareness of HRT might now be catapulting women from being undertreated to being overtreated.
But that isn’t to say HRT is reaching all those who might benefit from it.
Brauer says research has suggested prescribing rates are higher among women who are more affluent, while there are also differences based on ethnicity, revealing there could be access issues at play among some groups. She also notes there have been calls for greater access to HRT for women who experience mental health problems, and a proportion of women experiencing anxiety and low mood as a result of hormonal changes could benefit from having HRT rather than antidepressants.
Yes, there have been some exciting developments in recent years. Among them, Jayasena and colleagues have been working on a drug called Veoza, also known as fezolinetant, that prevents hot flushes.
“It’s brand new,” says Jayasena. “It’s not what we would call HRT, because it doesn’t have the holistic effects. In other words, it’s not going to help your bone density, it’s not going to help your mood. It’s not going to help libido. But what it does do is target the reason why people get flushes when they have low oestrogen.”
While Veoza has been approved by both the FDA in the US and the UK’S Medicines and Healthcare Products Regulatory Agency (MHRA), it is not yet available on the NHS – although a review by the National Institute for Health and Care Excellence (Nice) is expected to begin this year which could change that.
Jayasena says the active ingredient is a neurohormone, meaning it is suitable for some women who may not be able to take conventional HRT. “In someone who cannot have HRT because they have breast cancer, and they have horrendous flushes, then this is a brilliant treatment to make their life much, much better,” he says.