Hormone replacement therapy (HRT) should be the first treatment offered to women with menopausal symptoms, a health watchdog has said in strengthened guidance.
The National Institute for Health and Care Excellence (Nice) said that “HRT is the preferred, recommended approach” to manage symptoms such as hot flashes, insomnia and low mood, and should be offered by GPs in discussion with patients about the risks and benefits.
It comes after draft guidance from Nice in November suggested cognitive behavioral therapy (CBT) – a talking therapy designed to help people deal with their problems by changing the way they think and behave – could be offered as an alternative or at page of HRT.
It proved controversial and Nice has now rewritten the guidance to emphasize that HRT should be the first-line treatment, with CBT an option for women in addition to HRT, for people who cannot take HRT or for those who do not want to take it.
Nice has also emphasized in the updated guideline that HRT does not affect overall life expectancy and will not shorten or lengthen women’s lives.
Professor Jonathan Benger, chief medical officer and interim head of the guideline center in Nice, told a briefing that the body had “worked hard to ensure that the place of CBT” is clear and “a number of changes have been made to emphasize that”.
He added: “HRT is our recommended first-line treatment for vasomotor symptoms (hot flashes and night sweats), and we recommend that it should be offered to women, provided it meets their needs and after an informed discussion.
“We’ve revised the guidelines to be really clear that CBT is adjunctive, it’s an adjunctive therapy and it can help people manage the symptoms … in addition to HRT, or some women may choose not to take HRT, or they can’t able to take HRT, and therefore that is where CBT can be useful.
“However, we are very keen to emphasize that HRT is our recommended first-line therapy for vasomotor symptoms and for menopausal symptoms.”
Prof Berger emphasized that “what we are not saying is that these are not real symptoms that women experience – they are real distressing symptoms and HRT can be very effective.
“The purpose of CBT is that it can help people manage these symptoms more effectively, so that they are less troublesome for them, but those symptoms are real and they exist.”
Marie Anne Ledingham, clinical adviser at Nice, said the original draft wording on CBT had proved “controversial” and much time had been spent “reviewing the wording and the placement of CBT within the guideline and how it ranked against other recommendations.”
Nice announced the draft guideline last November, saying it recommended “more treatment options for menopausal symptoms” and CBT “should be considered alongside or as an alternative to HRT”.
According to the draft guidance, doctors should “consider CBT” for insomnia, depression and sleep problems linked to menopause.
The new updated guidance now states that CBT may be suitable as an add-on treatment to HRT, or for those who are unwilling or unable to take HRT.
On Thursday, Nice also published “discussion support” for GPs and patients, including data on how HRT can increase the risk of certain health conditions such as breast cancer and blood clots, while reducing the risk of osteoporosis.
Prof Berger said the discussion aid will “help doctors offer personalized advice to women considering starting HRT.
“Women need to feel confident that they will be offered advice and options that meet their needs, and that they will be supported to make the choices that are right for them.”
Ms Ledingham said: “Menopausal care should be individualized and those seeking treatment for menopausal symptoms have the right to make informed decisions about their care.
“The experience of menopause varies considerably between women, but for those seeking treatment for hot flashes and night sweats, this updated guideline offers new options and new evidence about HRT that will support their choices.”
