Understanding your GP – Four reasons why some women might not be able to obtain certain types of HRT

Some women are still struggling to obtain the right type and/or dose of HRT from their GPs or other healthcare professionals. Here we have outlined a number of challenges that GPs may face when prescribing HRT, along with the most up to date information that may help women get the right treatment for their needs.
 

Challenge 1 – Outdated local prescribing guidelines

There are prescribing guidelines drawn up for each Clinical Commissioning Group (CCG), which are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area (previously called Primary Care Trusts). In many areas, the CCG’s HRT prescribing guidelines have not been updated with the current evidence about HRT which means that when GPs prescribe they are warned by their computers that certain HRT products should not be prescribed.

What the patient needs to know

If there is evidence to support the reason for the prescription and it is in line with current guidance, then the GP can prescribe a medication that is not on the formulary (another name for a list of medicines).
 

Challenge 2 – Outdated information leaflets accompanying HRT

It is important to also be aware that the wording inside the accompanying leaflets in HRT packaging has often not been updated for many years, which is why you will still see products such as estrogen gels accompanied by a small print warning saying that it is not to be used by those with a history of clots in the past.

What the patient needs to know

Up to date research shows that estrogen gels can safely be used by those with a previous history of clots.
 

Challenge 3 – GPs concern about potential litigation

GPs are often worried they are going to be sued by prescribing HRT out of license. Weirdly, HRT is only actually licensed to be prescribed to women who are post-menopausal, and then only for vasomotor symptoms (hot flushes and night sweats).

The main test of medical negligence is the Bolam test which states that the general practitioner must show that they provided the standard of care that a reasonable body of general practitioners would regard as acceptable. The other test, Bolitho, ensures that what GPs do as doctors is logical.

What the patient needs to know

Although HRT is not specifically licensed for all the indications GPs prescribe it for, there is a wealth of evidence and guidelines to support the use of HRT in perimenopausal women with other symptoms of the menopause.

As long as the patient is appropriately counselled, then it is absolutely reasonable and logical to prescribe HRT to women during the perimenopause, which is in keeping with a responsible body of reasonably competent GPs. 

There are numerous examples where, as doctors, GPs reasonably prescribe medications outside their licensed indications. For example, the various new regimes for taking the oral contraceptive pills (ie taking more tablets consecutively and having less breaks) are not licensed, but for the same reason as above are entirely reasonable and logical.

Challenge 4 – GPs concern about prescribing unlicensed medication – (eg testosterone)

Testosterone is an important hormone for many women and levels reduce with age. A low dose of testosterone can sometimes be beneficial at improving energy, mood, concentration and also sex drive (or libido).

However, there are no testosterone products for female use licensed in the UK. There is plenty of evidence which shows that testosterone for women can be both safe and effective.

What the patient needs to know

The General Medical Council (GMC) are clear that doctors can prescribe products that are not licensed if there is no suitable licensed product available, and if there is sufficient evidence to support its use and it is safe. It is obviously important that patients are given adequate information about the unlicensed treatment.

The NICE Guidance on menopause states that testosterone can be considered for those women who need it.

Testosterone can be prescribed on the NHS if the prescriber is familiar with it and is willing to prescribe it ‘off licence’. Some doctors prefer not to take this decision themselves and prefer to refer to a specialist for advice before prescribing. However, other GPs and prescribers have prescribing restrictions by their CCGs which mean they are not able to offer it to women.

Last updated: 2019