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It hit the headlines at the beginning of the week: certain hormone replacement therapy (HRT) products were running low, and British women were getting desperate. Some worried that menopausal women would become like “drug mules” scouring the black market because “for a menopausal woman this HRT is as important as insulin is to a diabetic.”
But is this really true? What is HRT and its effect on women's health, and is it really so terrible if someone has to stop for a few months?
What is HRT?
When a woman experiences perimenopause and menopause, her body doesn’t produce as much oestrogen. Hormone replacement therapy ‘tops up’ the woman’s body with oestrogen, progesterone, and in some cases testosterone.
The replacement oestrogen helps replace the body’s natural loss of this hormone during perimenopause and menopause. It is usually provided through a skin patch, as a gel, as a spray or as a tablet. If a woman still has a uterus then they are also usually prescribed progesterone as well as oestrogen. This is because there is a risk to taking oestrogen just on its own, as it can thicken the lining of the womb, increasing the likelihood of cancer. Taking a combined HRT with both hormones reverses this risk. Women can get progesterone from a pill or through another route such as the Mirena coil. The exact combination of hormone replacement needed should be established with a doctor, looking at a woman's health history and any underlying medical conditions.
So why do women need all these hormones? Well without them women can experience a wide range of symptoms at both the perimenopausal and menopausal stages.
These symptoms include:
Hot flushes
Night sweats
Mood changes
Anxiety
Vaginal dryness
Reduced sex drive
Sleep problems, including insomnia
Brain fog, forgetfulness and difficulty concentrating
Headaches
Joint pain
It’s pretty easy to see how these symptoms can be seriously life-limiting, especially for women who are suffering from severe symptoms. Without HRT, many women find it hard to concentrate at work, have regular social interactions with friends and family, have intimacy with partners and even simply rest, despite being so exhausted. When managed properly, HRT can help reduce or even eliminate these symptoms, especially when combined with other lifestyle changes.
HRT can also help prevent the thinning of bones, which can lead to osteoporosis. And it has been shown to help prevent other diseases often linked with the hormonal changes of menopause including heart disease, strokes, type 2 diabetes, osteoarthritis, bowel cancer, and depression.
So what happens when you just stop taking HRT?
There are two ways to stop taking HRT: gradually dropping the dosage until you’re weaned off, or going cold turkey. In short, gradually reducing the dosage means doctors and menopausal women can find the lowest possible dose they need to take to avoid symptoms. Since symptoms usually decline over time, a well-planned withdrawal from HRT as a woman is finishing her menopause can mean a woman doesn’t have to face any severe symptoms reoccurring. However, this should be managed by a medical professional.
Just stopping at the wrong time is not normally recommended. It usually causes symptoms to return, and it can feel like they’re back with a vengeance. Considering HRT means women feel like they can be their normal selves at home and at work, suddenly removing this treatment can be incredibly disruptive.
In an article with the i newspaper, one woman described how her HRT was prescribed to her after her perimenopausal symptoms left her feeling “completely helpless and hopeless”. She said that without HRT, she felt “much more emotional, lacking in energy, with aching joints and a brain fog which makes it difficult to work”.
Although there aren’t many serious physical health implications to suddenly stopping HRT, the return of incredibly disruptive symptoms is why 91% of doctors recommend gradually reducing treatments, instead of going cold turkey.
Mental Health Consequences
Beyond the disruptive physical symptoms of the menopause, there is increasing evidence that it can also impact a woman’s mental health, with potentially dire consequences. Due to menopause impacting hormone levels, many women can feel more than just mood swings. They can suffer from anxiety, stress, insomnia and depression. Similar to how postnatal depression can often be dismissed as the “baby blues”, mental health issues related to menopause are often misunderstood or dismissed by society and the women themselves. Women with the menopause are sometimes labelled as “hysterical”, “batty” or “mad” - all slights which can gloss over more serious mental health problems.
In a research study done by Nuffield Health one in four women said they were struggling to cope with aspects of life due to their menopause symptoms. 47% of women with symptoms said they feel depressed, while 37% said they suffer from anxiety.
This isn’t helped by the lack of support most women get when going through menopause, especially in the workplace. And to make matters worse, the risk of mental health consequences is heightened if a woman has previous mental health problems. According to the Mental Health Foundation
“While menopause isn’t a mental health condition, it can affect your mental health. Hormone changes during menopause can sometimes make mental health conditions worse. If you have a history of depression, you’re more likely to be depressed during menopause. If you have bipolar disorder, you may experience more depressive episodes. This is likely to be linked to a decrease in oestrogen. If you have schizophrenia, you may find your symptoms get worse and you need a higher dose of medication.”
For women who are suffering from mental health issues caused by hormonal changes, HRT has been proven to be one of the best forms of treatment. While there is an alternative option of cognitive behavioural therapy (CBT) and there are lifestyle improvements you can make to reduce anxiety and stress, they have not been shown to be as successful as HRT.
Women are also often prescribed anti-depressants to try to help with both mental health issues and other menopause symptoms. However, according to The Menopause Charity “Menopause guidelines are clear that antidepressants should not be used as first-line treatment for the low mood associated with the perimenopause and menopause. This is because there is no evidence that they actually help psychological symptoms of menopause.”
Research from the Office of National Statistics has even shown that suicide rates are highest for women between the ages of 45 to 55 years. So hormone replacement therapy really can be life-saving for some women.
If you or someone you know is potentially at risk of a serious mental health crisis due to a possible lack of HRT, it is essential that you speak with a doctor or menopause specialist right away so a plan can be made to manage your mental health. Your concerns, anxieties and fears are valid and should be taken seriously. There is also support from organisations such as The-Menopause-Charity and Samaritans.
What is Causing the Shortage?
As we mentioned earlier, HRT treatments come in the form of tablets, skin patches, implants, vaginal creams and rings, and gels. It’s the gels (specifically Oestrogel) and some of the patches that are in short supply.
The supply issues are partially down to increased demand as prescriptions for HRT have doubled in the past five years, due to an increase in awareness and a large amount of media coverage around its effectiveness. This has been exacerbated by new changes to prescriptions which means women are getting 6-12 month prescriptions at one time and some manufacturing challenges caused by COVID. There is also the challenge that you can only pick up the specific HRT treatment you have a prescription for. So women can’t get an alternative brand of gel, for example, without going back to their doctor to get a new prescription.
The frustrating thing is that there are lots of different options for HRT for women, but through a lack of knowledge around different options, a lack of menopause clinics and NHS specialists, supply bottlenecks and now panic buying, the issue is rapidly becoming a crisis, causing fear and anxiety to drive women to go to extreme lengths to find the HRT treatment they need.
So, is it true? Are women really taking extreme measures to get HRT?
We’ve read the articles so you don’t have to, and this is what we’ve found.
Some women are saying they are desperate to find the gels that give them so much relief. But none of the articles we’ve seen has anyone claiming to search the black market and resorting to becoming drug mules. Instead, women are scouring the internet to find a pharmacist with the gel in stock. They are paying nearly £50 for a month’s supply online (when soon, on the NHS they’ll pay £12.50 for a year’s supply). They are going to private pharmacies. They are trading supplies with friends and neighbours, and some are going to Spain to buy oestrogen gels that are supposedly similar though perhaps weaker, but available to buy over the counter.
However, none of this is quite as extreme or sensational as some of the media is saying. Most of the attention-grabbing phrases are from quotes by politicians who are critical of the government’s response to the shortage. And painting women as "going mad" or "hysterical" is just a continuation of the trope of women overwhelmed by their biology. In reality, these women are simply trying to do all they can to get medicine that is critical to their quality of life.
And while women aren’t quite going full Breaking Bad, they are getting angry. There are a number of campaigns being launched backed by well-known celebrities and MPS like Carolyn Harris who are trying to draw attention to the crisis and get politicians to intervene in both the current shortage and the long term costs of HRT.
What should women be doing, then?
The truth is, it’s not illegal to bring over the counter treatments from Spain or scour the (legitimate) internet or check every pharmacy within 100 miles or go to a private pharmacist. These are all things that are available to women with certain abundances of time and money, however, and it’s understandable that others might resort to more desperate measures.
Professor Martin Marshall, chair of the Royal College of GPs, said to the Guardian: “While we appreciate the seriousness of the current situation and the frustrations women are experiencing, we urge them not to share HRT medication as this could lead to serious side-effects.”
In short, trading treatments or buying treatments online without the guidance of a doctor who understands your health history can be dangerous - as dangerous as trading any other prescription medication. There is also increasing concern about women mixing different types of HRT medication and the possible side effects.
The government insists the shortage will be resolved by “roughly around June”, but there are things you can do if you can’t wait that long. First, speak to your doctor to see if there are other forms of treatment that can be as effective, but aren’t as in high demand.
One of the medications in short supply is Oestrogel and there are several other formulations of oestrogen replacement that could potentially be useful instead. There is a helpful table available in an article by the menopause expert Dr Louise Newson giving equivalent doses for alternative oestrogen regimes What-to-do-if-you-cant-obtain-your-usual-estrogen-gel/.
You may also try out some lifestyle changes to see if they can improve symptoms:
Get regular exercise and add in relaxing exercises like yoga or tai chi
Eat a balanced diet
Wear loose layers to help with hot flushes
Sleep in a cool, well-ventilated room
Cut down on caffeine, alcohol and spicy foods, which are linked to triggering hot flushes
Try to reduce stress in your life
Give up smoking
The NHS has a list of other alternative treatments, including tibolone, clonidine and other therapies which may also provide some relief, at least until the shortage has passed.
Again, any women who are facing serious physical or mental health consequences from the lack of HRT should speak with their doctor or seek out a menopause specialist so they can help come up with a plan that will mean that women’s specific health needs. Advice and support from communities and other women can also help. Here is a list of some of the resources we’ve found, but there are even more online with local support groups often organised on social media sites like Facebook.