Menopause management – are new NICE guidelines 2 steps forward but one step back? 

Last year NICE released a draft of its update to its menopause guidelines and they were greeted with howls of despair from many of us who spend every day talking and consulting with women in primary care on this very hot topic. After a consultation process, the guideline is now out in its final format NICE NG23, November 2024. 

There is plenty to celebrate, but also some disappointing missed opportunities that would have made life a lot easier for GPs to navigate this complicated topic. But, first the good news! NICE have listened to the astonished horror that was widely expressed at the odd decision to downplay symptoms of the menopause and the profound impact that they can have on women’s lives. The wording now reflects our day-to-day experience that women can suffer severe symptoms, and that HRT is very much the treatment for them. They also acknowledge that depressive symptoms can arise with the menopause  and suggest HRT for this, which is a welcome clarification. 

Where they have missed opportunities though is in prioritising vasomotor symptoms (which for many women are not a dominant feature) and in not detailing the broader range of symptoms that come with the menopause such as insomnia, fatigue, brain fog and anxiety that you and I come across every day. They have left a lack of clarity on how to manage these frequent and disabling problems. We know that these symptoms are common, and that they tend to respond well to HRT, but by prioritising vasomotor symptoms it may be that women who are less well informed and less able to advocate for themselves may miss out on a treatment that could give them back their old self. 

There is some good clear, common-sense guidance on managing the genitourinary symptoms of the menopause and some clarification on women with a history of breast cancer that is very welcome.  Our old friend, breast cancer risk, gets a better handling this time around but there is still significant room for improvement both in the prescribing advice and in the decision aid. It is not as though NICE have not done their homework – the appendices are full of the discussions that were had, and the very many studies that were used to inform them. What is disappointing is that in 2024, we are STILL relying on data from the 80’s and 90’s, using HRT than none of us prescribe first line (synthetic oral oestrogen and synthetic progesterone, rather than transdermal oestradiol and micronized progesterone). In the main guideline, there is no mention of the different risks that these different types of HRT confer. They do acknowledge this deep in the discussion documents, but most sane GPs are not going to read them. In most of the research that they made their recommendations on, the time of diagnosis for the breast cancer was the mid 1990’s. We are not manging hypertension, cardiovascular disease and diabetes with 30 year old data, so why does the menopause get this treatment? Our prescribing habits have changed completely since then. 

NICE committee acknowledge that the sample sizes for micronized progesterone were too small and that more research was needed. What would have been better is to have made the pragmatic judgement that the British Menopause Society does, and give us the steer that micronized progesterone and dydrogesterone are associated with a lower risk of breast cancer. 

Osteoporosis, always the bridesmaid, never the bride, does get a look in but again it is a missed opportunity. We know the one year mortality rates following a hip fracture are dire (20-30%, much higher than that of breast cancer) and whilst the benefits of HRT in fracture prevention are discussed and shown in the decision aid  it would have been great to have a digestible infographic comparing directly the risks of dying from a fragility fracture to the risks of dying from breast cancer to help put this into perspective. 

We understand that NICE needs to be cautious and careful in its recommendations; this is of course appropriate, but when that caution may potentially lead to patients missing out on treatment that will make them feel better and probably live longer (as the BMS states, HRT prescribed before the age of 60 has a favourable benefit / risk ratio) then perhaps it is time to loosen the reins a little. The menopause management journey continues, but much like a family holiday, we have yet to reach a destination that everyone is happy with.