Menopause specialists Dr Louise Newson, Hayley Berry and Amanda Worsey explain the shortages of HRT and how nurses can advise and support patients who are struggling to access their usual treatment
Why is there a shortage of HRT?
In our experience the current shortages of HRT are mainly due to increased demand. Women are much more aware of the benefits of taking HRT as well as the treatment options due to media attention to the menopause and perimenopause, conversations with friends and recent interviews with medical experts and women sharing their experiences. MPs speaking in Parliament about the menopause may also have made women more aware of treatment. This had a big impact on women seeking HRT and surgeries have then been overwhelmed with requests for HRT following recent documentaries.
The menopause is now more a common topic of conversation – it is no longer quite the unspoken taboo subject it may have been previously, and as more women are finding that their symptoms improve on HRT, they are talking to their friends and family members about this and raising the profile of HRT and hence the demand we are currently seeing.
In addition, healthcare professionals have been training and upskilling and are now more likely to prescribe HRT confidently. There is also greater awareness of the range of symptoms – it’s not just about hot flushes or amenorrhea. Many women are diagnosed with depressive symptoms that are related to the menopause. The Balance app menopause symptom chart can be helpful for identifying symptoms and monitoring progress with treatment.1
As more information is available we are also seeing women coming for treatment at an earlier stage to protect their future health, as they are more aware of the long-term health benefits HRT offers such as for bone and cardiovascular health.
When are the shortages likely to ease?
It is hoped that at least some of the supply issues should ease over the coming months. The Government has introduced Serious Shortage Protocols (SSPs) on certain HRT medicines to help manage increased demand in the short term.
These SSPs mean pharmacies are unable to dispense more than three months’ worth of certain HRT drugs at a time. The SSPs are intended to ensure equal access to treatment for as many women as possible, while helping to manage the demand for the products. They should mean that women can receive their medicines as quickly as possible, as well as help to free up GP surgery time. Community pharmacists are experts in medicines and they are well qualified to support patients in line with these SSPs. The Pharmaceutical Services Negotiating Committee (PSNC) provides more detail the on the current SSPs.2
The Department of Health and Social Care has a medicines supply resilience team that is working to alleviate any pressure on supplies. There is also a UK Menopause Taskforce which has been brought together to support women across all four nations.3
The PSNC has stated that while the SSPs are a welcome step, they have increased the administrative and workload burden on pharmacy teams, who were already under significant pressure.
In addition, the SSPs only apply to certain HRT products, and women may need to talk to their pharmacist to discuss any changes made to their treatments.
Notably over 75% of pharmacies have reported being subjected to patient aggression linked to medicines supply issues, so we should encourage people to be patient with pharmacy staff who are doing all they can to help them access the medicines and support they need.
What drugs are in short supply?
There is intermittent disruption affecting certain product lines. The three medicines currently placed under SSPs are Oestrogel (estradiol 0.06% gel), Ovestin cream (estriol 1%) and Premique low dose tablets (conjugated oestrogens 0.3 mg/medroxyprogesterone 1.5mg modified-release tablets).
Disruptions to medicines supply issues can change very rapidly and on a very localised basis, however. The situation is varies depending on demand, local prescribing and existing stock levels in pharmacies, and it is difficult to gain a snapshot of where supply is sitting as it is constantly moving through the supply chain.
NHS data show significant increases in HRT drug prescribing rates. For example, the year to February 2022 saw the following increases:
- Oestrogel (estradiol, gel) by 76%.
- Estradot (estradiol, transdermal patch) by 74%.
- Lenzetto (estradiol, transdermal spray) by 1,106%.
- Sandrena (estradiol, gel) by 146%.
The British Menopause Society (BMS) also has some detail on which products are in stock and this is updated on a regular basis.4 This may be useful to discuss with your patients who are struggling with supply issues to help to come to a decision about suitable alternatives.
The manufacturer of the Sandrena gel is releasing small quantities into the market as it becomes available. For people who don’t wish to change, there may therefore be a short delay in obtaining their medication which is, unfortunately, outside of pharmacies’ control. Your pharmacy teams locally will be able to discuss this with you and will do everything they can to help.
What alternative HRT preparations can we recommend?
If patients are struggling to source their HRT and the pharmacies have no stock of the specific medicine that they need, they may come back to their prescriber to ask for an alternative.
Newson Health Menopause Society has produced an ‘Easy HRT Prescribing Guide’, which helps consider dose equivalents when switching between different HRT preparations.5 There is also a BMS guide on HRT preparations and equivalent alternatives.6
For example, women unable to obtain their usual Oestrogel prescription may switch to Sandrena gel where available. Alternatively, two pumps per day Oestrogel (1.5mcg oestradiol) may be substituted by a twice-weekly 50mcg Evorel patch (there is no shortage of Evorel patches of any strengths).
It is always key to involve the patient in the discussion and decision process to find out what preparation would work for them and how they feel about being switched. Many women have tried numerous HRT combinations to get to their current individualised treatment plan so they may be anxious that switching will mean their symptoms returning.
It is also important to choose clinically appropriate treatment – for example, in women with a uterus, we need to ensure that any swap to an alternative regime due to supply issues continues to supply necessary progestogen. An oestradiol with progesterone combination HRT called Bijuve, which is body identical (made up of natural plant-derived, rather than synthetic hormones), may be considered for those who need combination HRT and are unable to obtain an alternative.
How can we offer reassurance?
Explain to patients that there is no need to stop taking HRT if their current treatment is out of stock. Discuss alternative options, reassure them about dose equivalents and ensure that they are involved in the decision to switch to an alternative preparation. Reassure them that the processes in place mean supply issues should hopefully resolve over the coming months, and encourage them to come back and let you know how they get on – regular follow-ups can ensure that alternative treatment is suiting them and also allow signposting to help them access resources.
It is important for teams to be confident to deliver these messages and access free training available to help support your patients in this area. Do also speak to your community pharmacy team as they can offer support and signposting, and are often more accessible than trying to book appointments to see other healthcare professionals. Encourage the patient to contact their surgery if there is a clinician who specialises in the menopause or women’s health.
We also need to promote lifestyle changes as well as a tailored HRT regime to women, to help protect their future health. Having conversations with your patients linked to their lifestyle can also support their symptoms. Encourage them to think about sleep, managing stress, exercise, eating well and cutting down on alcohol and smoking; all have an impact on their symptoms alongside HRT treatment. The wellbeing section on Balance has lots of useful resources including leaflets, podcasts and articles, which offer different options to support lifestyle alongside HRT and this may help you when having consultations with your patients.
Dr Louise Newson is a GP and menopause specialist, Hayley Berry is a pharmacist with a special interest in the menopause and Amanda Worsey is an advanced nurse practitioner specialising in the menopause.
- Balance. Menopause symptom questionnaire. Link
- PSNC. Three new SSPs introduced for HRT medicines. April 2022. Link
- DHSC. UK Menopause Taskforce. February 2022. Link
- BMS. Update on HRT supply. Updated 31 May 2022. Link
- Newson Health. Easy HRT prescribing guide. 2020. Link
- BMS. HRT preparations and equivalent alternatives. 2022. Link
- Yoshany N et al. Association between lifestyle and severity of menopausal symptoms in postmenopausal women. Electron J Gen Med 2020;17(5):em222. Link
- Balance. balance-menopause.com
- Newson Health Menopause Society for healthcare professionals(with access to the Confidence in the menopause course). nhmenopausesociety.org
- NICE. Menopause: diagnosis and management. Updated 2019. nice.org.uk/ng23
- British Menopause Society. thebms.org.uk