Menopause might be a normal life event and something every woman will experience. But their experiences of symptoms will differ and will have an impact, both physically, psychologically or both.

According to the NHS symptoms of the menopause include hot flushesnight sweats. vaginal dryness and discomfort during sex, difficulty sleeping, low mood or anxiety, reduced sex drive, problems with memory and concentration.

Approximately 13 million women in the UK are either peri- or post menopausal. Symptoms can last up to 15 years. Over 60% of women experience symptoms resulting in behaviour changes. One in four women will experience severe debilitating symptoms.

HRT shortages: the state of pay

The value of HRT as a way of relieving symptoms is well publicised. However, for the past year many women in the UK have been unable to access their hormone replacement therapy (HRT), causing distress patients, clinicians and pharmacists.

“We understand the HRT supply situation should be improving now and the range of products which supply 70% of the HRT patch market will soon be re-introduced to the UK market. However, a number of HRT medications remain unavailable, some until the end of this year, and some with no timeline as to when they will be back on the market,” says Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists.

Lila Thakerar, superintendent pharmacist, Shaftesbury Pharmacy, Harrow, says, “the shortages have been going on for a year now, and it’s a desperate situation”. When it comes to HRT supplies she finds, “each week is different”.

“There’s so much uncertainty about the availability of stocks of products.  And when they do arrive there’s a backlog owed to patients, so stocks quickly clear and then the cycle starts again until we get the next batch of prescriptions,” says Ms Thakerar.

She says her pharmacy is getting updates and rough guidance from manufacturers on when HRT products are available.

Dr Louise R Newton, a general practitioner and menopause specialist in Stratford upon Avon who runs My Menopause Doctor, says the HRT shortage situation “is terrible”. “There’s hardly any HRT patches, and things are not getting better.”

And with the recent coronavirus (COVID 19) outbreak, the situation with HRT shortages is likely to get worse. Last month [26 March 2020] the Royal College of Obstetricians and Gynaecologists, the British Menopause Society and the Faculty of Sexual and Reproductive Healthcare issued a joint statement regarding HRT prescribing advice during Covid 19.

The health bodies stated: “We recognise that many women are likely to experience difficulties in obtaining HRT supplies due to the current coronavirus situation. We also appreciate that continuing HRT intake is likely to help many women control their often difficult menopausal symptoms, which is particularly relevant given the additional stress some women may be under in view of the strains of the current situation on society.

The health bodies acknowledged that general practitioners’ surgeries “have also been put under additional pressure, with consultations and advice prioritised to dealing with serious and potentially life-threatening medical issues”.

Reasons for a HRT shortage

It is difficult to pinpoint the reasons for the lack of HRT products, health professionals say.  “It remains unclear why there is a shortage in the first place or when the normal supply of the products might resume, says Dr Morris.

For Ms Thakerar, the route of the problem is not suppliers but manufacturers, and began with Brexit.  “Brexit talks had a knock on effect of manufacturing HRT. A lot of ingredients weren’t available from Europe for wholesale manufacturers to make these products,” she says.

Another reason for shortages is an increase in the uptake of HRT as “the media is giving advice to take it as a ‘cure all’ for menopause”. However, with these underlying supply and manufacturing issues, demand has outstripped supply, and organisations are unable to cope with women’s HRT prescribing expectations”, she believes.

Impact of HRT shortages

The lack of medication, and uncertainty about when supplies will be available, is distressing for clinicians, patients and pharmacists. “Thousands of women have been adversely affected by this ongoing situation and they deserve better,” said Dr Morris.

Whilst HRT shortages are creating “huge problems for a lot of women”, they also resulting in “a lot of completely unnecessary work for GPs”, says Dr Newton. GPs are having to deal with patient queries, but lack information on how to deal with the shortages.

GPs are also having to deal with messages from pharmacists saying that a HRT product “isn’t available and won’t be available for weeks”, Ms Thakerar points out.

GPs are also communicating with Ms Thakerar, “asking for HRT availability dates and checking for what alternatives are available”. She sends them links she receives from organisations that give HRT updates, including manufacturers and menopause support specialists.

The impact on women of shortages has been “drastic” says Ms Thakerar. “There are women who desperately need HRT and are struggling to treat their symptoms. Some are suffering. These women need this medication and are finding it difficult to cope without it,” she says.

Addressing the HRT shortage

With HRT shortages having such an impact on both women’s health, and health professionals’ time and resources, Dr Morris stresses it  is “absolutely crucial that the issue is resolved fully as soon as possible and future shortages are avoided to prevent harm to women.”

This February, the Royal College of Obstetricians and Gynaecologists, the British Menopause Society and the Faculty of Sexual and Reproductive Healthcare wrote to the Secretary of State for Health and Social Care, Matt Hancock, calling for a working group to be set up to address these ongoing supply constraints.  “We remain in regular contact with the Department of Health and Social Care and will continue to assist them as they work to improve supplies,” the health bodies said.

But when it comes to tackling HRT shortages, Ms Thakerar believes: “We are at mercy of government and manufacturers. All we get is a message to say ‘expect the supply and medication on certain dates. But that’s not guaranteed and there’s no explanation why.”

What health practitioners can do to support women

Faced with these obstacles, health practitioners still need to support women requiring HRT. Recognising the current constraints, the BMS, RCOG, RCGP and FSRH recommends that GPs and healthcare providers consider advising women about menopause issues “through telephone and virtual consultations where at all possible to reduce face to face engagement, and with easy access to repeat prescriptions of HRT supplies (especially to women who have been on HRT and have not been experiencing any problems with their intake).

“This will help to avoid the need for many women to visit their GP surgery to discuss these issues and assist with obtaining repeat prescriptions,” the health bodies said.

 Dr Morris says GPs and pharmacists “can use the British Menopause Society’s information to help their discussions with patients. This explains what is understood about the shortages and what alternative options are available.”

Mr Haitham Hamoda, chair of the British Menopause Society, says: “We are continuing to provide advice to prescribers on alternative products available and we are keeping our website updated on what treatments are available based on information from the manufacturers.

“For the majority of women, supplies of alternative HRT products are available and women affected should discuss alternatives with their doctor.”

Pharmacists can communicate and maintain contact with GPs on availability of HRT stock and what is available and when – “and most importantly, what alternative supplies are available”, says Ms Thakerar.  As these are prescription only products, she says she doesn’t make suggestions about HRT alternatives to patients, but signposts them to their GPS for a consultation.

Dr Newton says GPs can suggest women used to patches could convert to gel HRT products, however, she warns that in the light of shortages patients may still need to wait for products.

Ultimately, she feels “It’s incredibly frustrating that HRT isn’t seen as a priority for women. Some women, for example, are struggling with, mood swings, and anxiety. It’s so important to have the right treatment for them.”  

And, as Mr Hamoda stresses, “It is very frustrating that we still do not know why these shortages are happening, and why they seem to be unique to the UK. While we understand the DHSC is working with suppliers, we remain concerned about these shortages, which need to be addressed urgently.”

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