As revolutionary as the Pill: UK set to turn down the heat on menopause

When the BBC reflected on the 50 things that made the modern economy a few years back, of course it included the pill. Oral contraception ushered in a revolution some 60 years ago that freed women to plan their lives. It meant many could enrol in graduate programmes and pursue professional careers, raising long-term income levels and spurring far-reaching economic change.  

There is no obvious equivalent today. And yet a new move in Britain to address inequalities in health care could prove almost as revolutionary for women — and for a country that, like many others, is experiencing slowing long-term growth trends and an ageing population that is living longer. 

The UK government promised last year to “reset the dial” on women’s health and its new strategy is due to be published in spring there. We’ll have to reserve judgment until then, but last week Britain’s medicines regulator took a step forward with a proposal to make hormone replacement therapy (HRT), used to treat menopause symptoms, available over the counter and at negligible charge. 

There is now a consultation to make a single product — Estradiol, a vaginal oestrogen — available to women over the age of 50 without a prescription. Like the UK’s decision last year to make two forms of oral contraception available over the counter, this move comes with extremely low risks and takes a little pressure off over-stretched doctors. It would be a small change, but also a milestone.

For decades conversation around menopause was either overheated, inhibited or just misinformed. The pressure to change that has come from non-profits such as the British Menopause Society, a bipartisan group of UK lawmakers, royals, celebrities, the media and economic reality. A third of the UK workforce is now aged over 50 and this demographic is the fastest-growing segment of workers.

A minority are lucky enough to breeze through menopause. But three in four women will have symptoms that alter their quality of life, including trouble sleeping, hot flushes, brain fog, irritability, low moods or anxiety and urogenital problems. The fun lasts seven years, on average, but can go on for a decade or more. A quarter of women will experience severe symptoms, according to the British Menopause Society.

Globally about 1-billion women have reached menopause. By 2050 that will be an estimated 1.6-billion women.

For most, things really kick off around 50, but menopause has phases and many women experience symptoms from their mid-40s. This is lousy timing on nature’s part. It comes just as women are at a high point in their careers or are ready to launch new ones, and when they are dealing with the joys and strains of teenagers, older children leaving home or caring for elderly parents.

It’s hard to find concrete data on the impacts on women’s work outcomes, but there’s no doubt menopause affects careers. In a UK survey three out of five menopausal women reported their symptoms affected their work lives; nearly a third said they had taken sick leave because of symptoms, though only a quarter disclosed the reason to their managers. An October survey found a quarter of those with serious symptoms left their jobs.

Until relatively recently this was all just too bad. Many women understood little about what was happening. They stuck their head in a freezer, unleashed on the nearest family member or suffered in silence. A 2012 study found more than 60% coped without help from a healthcare professional, relying on family or social networks for support, but the vast majority felt they had little information to guide them.

HRT became widespread in the 1960s with the use of oestrogen. Over the decades it has variously been described as a wonder drug and a carcinogen, and a mass of different products and studies has left many women scared or confused.

Sales of HRT dropped off a cliff in the early 2000s when two large-scale studies, one in the UK, the other in the US, raised concerns about it increasing the risk of breast cancer and other chronic diseases. Britain’s regulators issued an urgent safety notice telling doctors to prescribe only the lowest possible dose for symptom relief. The subject remained taboo in lots of workplaces and homes.

Gradually there has been more light and less heat. There is better analysis of the data and a more nuanced understanding of the risks and the areas of uncertainty. Robert Langer, one of the researchers behind the US study, later lamented the frequent misinterpretation of the work overstating the risk of breast cancer and heart disease. “Sadly, the issue was not the study itself, but how the conclusions were relayed in the media,” said Haitham Hamoda, a consultant gynaecologist and chairperson of the British Menopause Society. 

Scores of studies have confirmed that hormone therapy, of which there are many types, provides substantial relief from the most common symptoms. Many women find it gives them their lives back. In England women can get a virtual consultation with a GP and a prescription costing about £9 (about R190) for a three-month supply of a combined HRT (oestrogen and progestogen); the government has introduced a bill to remove those costs and set out broader menopause support services. Costs in the US, even with insurance coverage, can easily run 10 times that.

The thing is, not all women are good candidates for all HRT, and even when no complications exist there are risks to consider. It’s important that a medical professional trained in menopause treatment oversees things.

Quantifying risks isn’t simple as they vary by age, lifestyle, the kind of hormone, how long it’s taken and even the form of delivery. The UK medicines regulator says in those of average weight who use HRT for five years, there will likely be five extra cases of breast cancer per 1,000 women who use oestrogen-only HRT and 20 extra cases per 1,000 women with combined oestrogen-progestogen therapy. HRT also carries a small increase in the risk of ovarian cancer. Both increased risks are reversed when HRT is stopped, so most women are generally advised to use HRT for five years or less. 

The UK’s step towards making one targeted HRT product available over the counter may seem small. But the trend toward more menopause information and better access to a variety of treatments will bring other changes too.

Hamoda said after years of heightened fears and some continued uncertainties there is more acceptance now that the balance of benefits and risks is favourable for most women and that the risks have to be compared with other cancer risks factors, such as excess weight or lack of exercise. “If you look at it in an isolated way the risk of breast cancer is not even as high as drinking a small glass of wine a night for a person who is obese.” Studies have also shown HRT is associated with benefits for bone health, reducing risk of fractures and a small reduction in risk of colorectal cancer.

Britain’s National Institute for Health Care and Excellence (NICE) published its full menopause guidance in 2015, declaring Britain’s existing provisions of care inadequate. More employers have been setting out menopause policies with the help of various new tech-based service providers. Having so many high-profile women, from Michelle Obama to Emma Thompson and Oprah Winfrey, speak out about menopause is also driving the conversation forward.

Also, with more awareness comes more opportunity. There now seems to be an endless stream of podcasts, books and products aimed at women in menopause. The global hormone replacement market (of which menopause treatment is the largest share) was $13.4bn (about R202bn) in 2020 and is projected to grow to $21.5bn (about R325bn) by 2028. The Covid-19 pandemic, however, hit the supply and demand side of HRT. While manufacturers, including Novartis AG, Pfizer Inc and others, had trouble sourcing raw materials, many women struggled to get GP appointments or didn’t want to bother an overburdened healthcare system.

The UK’s step towards making one targeted HRT product available over the counter may seem small. But the trend towards more menopause information and better access to a variety of treatments will bring other changes too. As with the pill last century, giving women more control over their bodies means they’ll have more control over their lives.

Therese Raphael is a columnist for Bloomberg Opinion. She was editorial page editor of the Wall Street Journal Europe.

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