New NICE menopause guidelines: what you need to know

Health watchdog publishes update on 2015 guideline, clarifying controversial point on CBT

Hormone replacement therapy (HRT) – not cognitive behavioural therapy – should be offered as a first-line treatment to women with menopause symptoms, according to the National Institute for Health and Care Excellence (NICE).

Guidance on menopause management published by the health watchdog says hormone replacement therapy is the preferred treatment for managing menopause symptoms.

It follows draft guidance published by NICE in November 2023 which said patients experiencing menopausal symptoms should be offered CBT ‘alongside or as an alternative to’ HRT, prompting widespread criticism from healthcare professionals and the public.

The final version now states CBT should only be considered for patients who are taking HRT but are still having symptoms, or those who are unable or do not wish to take HRT.

‘Disappointing update overall’

Balance and Newson Health founder, GP and menopause specialist Dr Louise Newson, said while it was welcome to see HRT as the preferred treatment for the menopause, it was a ‘disappointing update overall’.

‘The focus remains primarily on vasomotor symptoms – hot flushes and night sweats – which are, for many women, not the main symptoms of perimenopause and menopause,’ she added.

‘Most women experience brain symptoms – brain fog, low mood, anxiety, poor concentration, sleep disturbances, memory problems and fatigue – and these are things we know are unlikely to be alleviated in the long term by CBT, as suggested.’

The final guideline includes recommendations on:

• Individualised care, and providing information and support
• Identifying perimenopause and menopause
• Discussing management options with those aged 40 or over
• Managing symptoms associated with menopause in those aged 40 or over
• Effects of HRT on specific health outcomes in those aged 40 or over
• Diagnosing and managing premature ovarian insufficiency in those under 40
• Starting and stopping HRT
• Reviewing treatment

Dr Newson added that the guidelines also do not differentiate between older, synthetic HRT and the natural body-identical hormones now more commonly prescribed.

‘While the word “risk” is mentioned three times as often than the word “benefit”, these newer forms offer more benefit than risks,’ she said.

‘The true risk comes in not taking HRT at all, with good quality evidence showing that low hormones increases the risk of heart disease, osteoporosis, type 2 diabetes and dementia.

‘Menopause is sorely under-researched and under-funded, and this must change. In the meantime, women deserve to have a choice, and those who want to take HRT should be able to have it prescribed. That it is now the frontline treatment is refreshing, but future documents and consultations must go further to ensure women get the treatment they deserve.’

RELATED: Understanding the benefits and risks of HRT: downloadable visual aids

Hundreds urged rethink on draft guidance

Publication of the final guidance comes after more than 650 members of the public lent their voices to Newson Health’s response to NICE’s public consultation on the draft version, sharing personal stories about their symptoms, struggles to access treatment, and the impact of HRT on their lives.

Numerous healthcare professionals also contributed to our consultation response, including doctors, nurses and pharmacists. Counsellors, psychiatrists and psychotherapists also voiced concerns on the CBT recommendations contained in the draft version.

NICE chief medical officer Professor Jonathan Benger said of the final guidance: ‘We are not suggesting that CBT is an alternative to HRT. It’s not an either/or, and we have worked through the guidelines extensively to really clarify this point.

‘We are very keen to emphasise that HRT is our recommended first-line therapy for vasomotor symptoms and for [other] symptoms of menopause.’

Read the NICE guidance here