Reading articles in the press recently about the shortage of Hormone Replacement Therapy (HRT) gave me a sense of déjà vu. Yes, I’ve seen this all before.  Apparently some oestrogen  patches have been in short supply since some manufacturers had to stop producing them following supply issues in China.  So the popular news sites have been running articles on how women are suffering-

“Thousands of women are struggling to sleep or work as a result of a nationwide shortage of hormone replacement therapy (HRT) that has left some feeling suicidal,” campaigners have warned.(The Week.) “Women risking their health to source HRT amid shortages”, UK GP chief warns; (the Guardian), and “The Week” also asked  “is medical sexism causing the  menopause drugs crisis?”  

Now, as a woman and previously a GP, I am very aware and sympathetic to women complaining of menopausal symptoms. But what is happening now is basically a re-run of the rush to push HRT onto women that happened in the early 90’s.  When I was working then, I must have prescribed tons of the stuff,  at the behest of scientists writing articles about the benefits of HRT, doctors  (often paid by the pharmaceutical companies) recommending its use, and direct marketing from medical representatives who beat a trail to all women GPs to try to increase their sales.  The fact is that the ingredients, oestrogen and progesterone, are very cheap, and the profits that can be made by Big Pharma by developing new formulations and methods of delivery, from tablet regimes to patches, are huge. 

As I continued to prescribe HRT, I slowly realised what was happening. More and more, the menopause was made into an illness, and many everyday problems such as lack of libido, lack of sleep, and tiredness were put down to the menopause, to be cured by HRT of course (although mostly it didn’t). Women’s magazines were full of the benefits, the evidence was skewed, and the known side effects were downplayed. It got to the point where women were told that the health benefits were such that  every menopausal and post-menopausal woman  should go on HRT to prevent heart attacks.  I took HRT myself for several years, with marginal symptomatic benefit. By the early 2000s it was being noted that only 37% of post menopausal women were actually taking it and shouldn’t we doctors be doing more to persuade the rest? 

Then in 2002 came the results of the Women’s Health Initiative study. * This was a randomized placebo-controlled clinical trial of therapeutic and dietary interventions influencing postmenopausal women’s health.  It comprehensively debunked all the false claims that were being made. In detail, 8,506 women participants received standard HRT in 1 tablet, and 8,102 women received a placebo (an inactive tablet which looked the same). The results were that in the group that took HRT there were 7 more heart attacks (a 29 per cent increase), 8 more strokes (a 41 per cent increase),
8 more pulmonary embolisms (blood clot which went to the lungs), and 8 more invasive breast cancers. There were some benefits  – 6 fewer colorectal cancers and 5 fewer hip fractures (due to the beneficial effect on osteoporosis).  The effects were all small as you can see, but if you were one of the unlucky ones  who got breast cancer or a stroke, it was tragic. Menopausal symptoms are not life-threatening. 

So there was overall harm from HRT, and as a result of that study and several others like it, we GPs were told only to prescribe HRT for short term treatment for menopausal symptoms and we should not prescribe it at all for women past the menopause. There was then a dramatic worldwide decrease in its use. While I drastically reduced the amount of HRT I prescribed, I don’t remember any difficult conversations with women who ought to stop it. They accepted the evidence and gradually the symptoms went away, as they do. In cases when symptoms were severe and the health risks had been discussed, of course  I did prescribe it,  but I didn’t see lots of rebound effects due to the lack of HRT, and there were no headlines about this. 

In 2012 some scientists reworked the results of the trial and indicated that HRT may actually be safe in younger women. However, the article’s authors, from South Africa, Germany and the UK, admitted that they had all acted, or continue to act, as consultants for pharmaceutical companies that make HRT, and presumably this is the result they would like to see.  Since then it has become clear that HRT is indeed making a comeback. Demand has certainly risen.  About 512,000 scripts were written in England in February, compared to 265,000 in March 2017, data shows. According to the Daily Mail – “Prescriptions of HRT have doubled in just five years as women and GPs become increasingly aware of the excruciating and wide-ranging symptoms of the menopause”.  Campaigners have also blamed “medical sexism and a lack of training” for women being left to suffer debilitating menopause symptoms, which also include depression and brain fog”,  (The Guardian). Research suggests that “14m working days a year are being lost to the UK economy as a result of menopausal symptoms,” the paper reported. However the Mail on Sunday was much nearer the truth when it said the cause was  “Celebrity campaigns, political action and greater media coverage of the menopause,” and pointed to “waning concerns about HRT’s possible side-effects.” So the bandwagon is back. Yes, HRT is an invaluable help to some women suffering hot flushes and  other symptoms, but it is not life-saving and it is not without risks.  Labour MP Carolyn Harris, co-chair of the UK menopause task force, has been appointed hormone replacement therapy (HRT) tsar to address the problem. According to her, “Women have not been listened to, women have been ignored, they’ve been prescribed and diagnosed with other conditions and the menopause wasn’t even considered”. She added, “For a menopausal woman this HRT is as important as insulin is to a diabetic,” she added. That is certainly not the case.  Insulin is a life-saver, HRT is for symptom relief only. And I found that some women were so convinced by the hype that they wrongly put all their symptoms down to HRT.  In one case the woman actually had a brain tumour and the diagnosis was delayed as she insisted on trying HRT first. So Carolyn Harris should not be so partisan.  Of course, with the current “Me-Too” campaign, anything relating to women and their health is good copy, but you can also see how the media is manipulating the situation to get women to ask for it. There is not much doubt columnists and reporters are being paid to do this by drug companies, who are hoping to make lots more money if HRT can be rehabilitated. 

This increase in use of HRT is undoubtedly one of the reasons for the shortage. There are long-standing structural problems in the medicines supply chain which have been exacerbated by the pandemic and in Britain possibly by Brexit, which are also found in many other industries. Drug shortages will continue to be an issue in healthcare.  It is extremely important that essential drugs are available at all times and it is not sensible to drum up support for non-essential drugs and so stress the situation even further.  I do hope that reporting the subject is more balanced than it was when I was working and so many women were misled.

* Ref https://doi.org/10.1001/jama.288.3.321