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What’s the story?

Spend on common menopause drugs in England

Women experiencing symptoms of the menopause have been left to “suffer in silence” due to a disparity in spend on drugs across England.

Analysis of NHS prescription data shows some local health areas spend three times the amount per woman on Hormonal Replacement Therapy (HRT).

Experts said the decision-making of local health boards had contributed to a postcode lottery and that some women were not being offered the full range of options because their local health board did not fund them.

Diane Danzebrink, of the Menopause Support charity, said GPs “hands were tied”.

“Often we will hear from women who are being prescribed oral tablets as a first line, and they’re not being offered options,” said Ms Danzebrink.

“Sometimes that is because those options are purely not available on their local CCG formulary. So that sort of ties the hands of their doctors to be able to offer them choices. But we do definitely see that it seems to be in some parts of the country rather than others.”

Other reasons cited for the disparity include cultural differences.

Menopause expert and GP specialising in women’s health Dr Anne Connolly said different ethnic groups could “experience symptoms differently or manage them differently”, while Ms Danzebrink added that cultural barriers such as language could cause problems for some groups of women.

The NHS said it had increased training for clinicians.

HRT replaces hormones that are at a lower level as you approach the menopause. Not every patient will need or want HRT, and clinicians advise against it in some circumstances - including for patients with a history of certain types of cancer or blood clots.

The BBC’s Shared Data Unit analysed how much Clinical Commissioning Groups spent on common HRT treatments between April 2021 and June 2022.

  • In West Suffolk, £14.10 was spent per woman aged 45 to 60 compared to the £5.56 spent in Leicester City.
  • Some 79 of the 106 CCGs were spending at least 20% less on common HRT treatments than West Suffolk

UK menopause clinics

Patients who seek out treatment for menopause symptoms can be referred to specialist NHS clinics for further care.

But BBC analysis of British Menopause Society data shows 59% of Clinical Commissioning Group areas (CCGs) in England have no NHS clinics, including all of Devon and Cornwall and large areas in the North. The data also showed almost a third of existing NHS clinics are either in London or Surrey.

The Department of Health and Social Care said it will consider a recent Women and Equalities Committee target to provide at least one NHS menopause clinic or specialist in every CCG by 2024.

Of the 199 clinics in England, 75 are run by the NHS, with 124 operating on a private basis.

In Wales there are nine NHS clinics and three private clinics - with none at all in two of the country’s seven health boards: Powys Teaching Health Board and Swansea Bay University Health Board.

Scotland has 14 NHS clinics and five private clinics, spread across 11 of 32 local authority areas.

Northern Ireland has one NHS clinic compared to two private, all located in Belfast or South Eastern Health and Social Care Trusts.

Background information

Concerns had been growing over HRT supplies following reports of shortages of transdermal treatments, including popular gels, after an increase in demand following work by campaigning charities and celebrities to raise awareness.

In July this year, Parliamentary Under-Secretary of State for Health and Social Care Maria Caufield told a Westminster Hall debate there had been a 30% increase in demand for HRT products but said only a few products were now affected by shortages.


Methodology

The BBC’s Shared data unit analysed more than a year’s worth of prescription data collected by Oxford University. Drugs included in the research were:

  • Estradiol and Estriol with Progestogen
  • Oestrogens Conjugated with Progestogen
  • Oestrogel
  • Norethisterone
  • Dydrogesterone
  • Medroxyprogesterone acetate

For each drug we calculated an amount spent on prescription. This includes repeat prescriptions. We then used ONS population data to calculate a rate of prescription spend by women aged 45-60 in each CCG area. This could be worded as “the amount spent per woman aged 45-60 on common HRT treatments in the CCG area”.

The BBC’s Shared data unit also scraped location data for every menopause (NHS and private) clinic in the UK, with permission from the British Menopause Society. The link to their online tool that was scraped by us is here: https://thebms.org.uk/find-a-menopause-specialist/

Once we scraped the data, we took the postcodes from each location and used postcodes.io to assign each location a ccg or equivalent health area We then calculated the number of private and NHS clinics per health area.

Note: CCG areas were scrapped this year in the most recent round of NHS reorganisation. The 106 CCGs analysed have now been converted into 42 Integrated Care Boards.

The data

NHS England prescription data


Some CCG areas spend three times the amount per woman aged 45-60 on Hormonal Replacement Therapy (HRT).

  • In West Suffolk, £14.10 was spent per woman aged 45 to 60 compared to the £5.56 spent in Leicester City.
  • Some 79 of the 106 CCGs were spending at least 20% less on common HRT treatments than West Suffolk


UK menopause clinics

England


Analysis of British Menopause Society data shows 59% of Clinical Commissioning Group areas (CCGs) in England have no NHS clinics, including all of Devon and Cornwall and large areas in the North.

The data also showed almost a third of existing NHS clinics are either in London or Surrey.

Of the 199 clinics in England, 75 are run by the NHS, with 124 operating on a private basis.

Note: CCGs missing from the below table have no NHS or private menopause clinics.


Scotland


Scotland has 14 NHS clinics and five private clinics, spread across 11 of 32 local authority areas.

Note: The data is broken down by Community Health Partnership - areas which share the same borders and names as local authorities for reporting purposes.


Wales


In Wales there are nine NHS clinics and three private clinics - with none at all in two of the country’s seven health boards: Powys Teaching Health Board and Swansea Bay University Health Board.


Northern Ireland


Northern Ireland has one NHS clinic compared to two private, all located in Belfast or South Eastern Health and Social Care Trusts.


Interviews with menopause experts

Dr Anne Connolly MBE

Q. Are you surprised at the difference in the amount CCGs are spending per patient on HRT?

A. No, I think there’s been such a variability for many years in prescribing for women’s health generally and more specifically for management of menopause. I think it’s disappointing but I’m not surprised.

Menopause management isn’t as straight forward as a yes or no. There are lots of factors that play into whether somebody wants to talk about their menopausal issues, and there’s huge variability in the impact menopausal concerns will have on different women. So it’s not always straightforward as to whether a woman should have HRT or wants HRT.

There are so many myths still on the internet about HRT. Some of those are very concerning. Some women think it’s something they really don’t want, other women have done more research and found better information and might come and talk more readily about whether HRT is an option for them.

One size does not fit all for menopause management.

Some women experience really bad symptoms which really affect their life, their ability to function in the workplace, home or sexually. They often put off coming to see a GP or prescriber for a while, but then something will happen and they will decide to come and talk about it. Other women get very few symptoms, they don’t last long and they have other ways of managing if the symptoms become more concerning.

Some of it is about symptoms. A lot of it is about choice. Some women feel badly informed or have more concerns, so they put off coming to talk to us.

There are also many cultural factors. We know that different ethnic groups will experience symptoms differently or manage them differently.

Q. Do you think there are still taboos around discussing the menopause?

A. There are still many taboos generally in women’s health problems. We’re not great about talking about periods, we’re not great at talking about menopausal symptoms, we’re not great at talking about mood problems around periods. We can’t measure how bad my symptoms might be compared to somebody else’s, so we think why should I moan about it?

Education is really important, but better information on the internet and access so women can talk to each other and empower each other to ask for help if that’s what they need.

We’re certainly seeing a big drive through the media to talk about menopause. Some of that is absolutely fantastic because it’s allowing women to feel better about asking for support, some of it is a little bit realistic at times. And some of it is actually scary. I was talking to a patient the other day who said she was scared of going into the menopause now, because so many people were saying that it is so difficult. We have to be careful about the messages and information that we share.

Q. What do you think about the media coverage around HRT shortages?

A. HRT access is very variable, particularly at the moment with the big push for transdermal - patches, creams, gels. They have gone out of stock very quickly and have been hard to come by. I know manufacturers have been working really hard to respond to that, so it is being addressed.

But not every woman needs patches, or wants patches or creams. And some women are very happy to take tablets. There is still very good availability with the oral methods. It’s an individual discussion with a woman about what her individual needs and choices are.

Q. Does deprivation come into this? If women live in an area with a greater likelihood of certain illnesses, what sort of impact can that have on women?

A. We know there’s big variability in HRT prescribing. Some of that is because of patient expectations and patient requests. Some of that is in areas where women don’t want to talk about menopausal sympotoms or don’t see the need to. It’s not just about health provision, it’s also about patient demand and patient expectations.

And some of this is about healthcare provision in inner-city, more deprived areas, where we know there are fewer GPs and bigger list numbers. It’s very hard to say that this is the answer to all. We have to be better at sharing the right information in the right way and understanding what the local need is.

“It doesn’t all have to be going to specialist care or cost-heavy hospital care. It’s about looking at the local population, working with your local voluntary groups and local women’s groups to work out how we can best deliver the health messages. It’s about self-care too, as healthcare.”

Q. What can the impact be for women who don’t get the right information or treatment?

A. In the short term, some women really suffer with symptoms. We know that has an impact physically, socially, psychologically, sexually. It depends how bad the symptoms are and what those specific symptoms are.

We see big numbers of women leaving work because they feel unconfident to continue because their concentration isn’t the same. They’re tired, they have memory-loss etc. We’re losing women in the workplace because of their symptoms.

The longer term is also very important, because HRT certainly [protects] against osteoporosis which is bones thinning and therefore fracturing. So taking HRT will protect your bones. There’s mixed but still probably very good evidence that if you take HRT at the right time in your life you will have some improvement on heart disease. So some women, and often women already compromised because of their social deprivation and are more likely to have these problems are then compromised if they are not being offered HRT.

Dr Paula Briggs, British Menopause Society

Credit: British Menopause Society

Q. Are you suprised by the postcode lottery revealed when it comes to menopause care in the UK?

A. In relation to deprivation and postcode lotterys I’m aware it depends where you live whether you can access the same products. I think the HRT tzar has looked at that and that there is work in progress to solve those issues. It’s particularly frustrating in border areas. For example Liverpool and Manchester will have different local formularies for GPs so if you lived 100 yards either side you wouldn’t be able to access the same treatment from your GP.

Q. Why are we seeing NHS menopause clinic deserts across the UK?

A. It is possibly influenced by access to trainers. I think, behind the scenes, there is work going on to try to improve that. The women’s health strategy will help with the development of women’s health hubs.

Ideally, menopause care should be delivered in the community closer to home. There’s no reason why the vast majority of women need to come into a hospital setting.

I work in a hospital in Liverpool Women’s Hospital and we would see our service as providing education and research and possibly managing the more complicated cases like premature ovarian insufficiency and women with cancer.

Q. How likely are we to get a women’s health specialist in every CCG by 2024 as per the Women’s Equality Committee’s target?

A. Okay, so we’re talking about a women’s health specialist in CCGs. But actually CCGs no longer exist in England. We’ve moved to integrated care services. And that’s a really difficult time, because there’s no identified funding for these intermediate services.

So what we need is more baseline education for all GPs, if it’s part of general practice.

General practice is a really difficult job because you cannot be an expert in everything. So the development of women’s health hubs would be an opportunity to provide care for a group of practices.

So in each place, for example, you might have maybe two or three women’s health specialists working together. The kind of things that I think that they will be particularly helpful with is heavy menstrual bleeding, which is probably the first sign of the perimenopause, and menopause management. I had a community gynecology service for 10 years, and those were the two highest categories for referral. And I think if we can start managing that better, then that will have a huge positive impact on women’s health in general.

Q. Could be anything more be done to support GPs who are interested in becoming more educated about the menopause?

A. For every trainee that I take on for an Advanced Certificate in Menopause, my expectation is that the once they feel suitably experienced will become a trainer and then maybe train another 10 people, and those 10 people train another 10 people. That’s how we will improve the current situation and that would be my plan for the next five to 10 years. As the number of trainers grows, access to training will be improved.

I think what we need in secondary care is a lot more flexibility, improved communication. There is quite a big gap currently between primary and secondary care, which doesn’t help the patient. And ultimately, that’s what we want to do is improve patient care.

Q. Do a lot of NHS GPs turn to private practice after becoming menopause specialists?

A. It’s so difficult to access menopause care, that women are going privately where they shouldn’t have to. And I speak from a point of view that I deliver mostly NHS Care, but also some private care.

I would prefer for all women to be managed on the NHS. I think there’s more information available via social media, newspapers, television, about menopause. And so women who would otherwise maybe not have thought about using HRT are looking for information to make that decision.

I think all of this can be changed by GPS being supported. If one of my trainees gets the advanced certificate and sets up a private practice, that does nothing to improve NHS Care.

And whilst I have no objection to them doing some private practice, I think when it’s exclusively private practice that changes the dynamic completely.

Q. Why do clinicians move over to private practice?

A. I think it’s a gap in the [private] market that has been identified, and it’s not even necessarily doctors, nurses and pharmacists who’ve got specialist qualifications.

There are all kind of providers of different ways of managing the menopause setting up, and as a vulnerable patient that puts you in a difficult situation.

So some women may access bioidentical hormone therapy, which is not regulated and therefore may not be safe, but they don’t know that. And I think it is just so important to ensure that women are provided with the correct treatment.

That goes back to proper training, adhering to guidelines and protocols. For example, if we give women oestrogen, we need to give them enough progestogen to ensure that they don’t get excessive thickening of the lining of the womb, which can lead to cancer.

Q. What would you like to see happening in the next three to five years regarding menopause care?

A. What we need is more baseline education for more GPs. The BMS are working very closely with NHS England to produce balanced peer reviewed easy to access patient information, and a campaign for all medical professionals to ‘think menopause’.

If you’ve got a patient in front of you, who is the average age of the perimenopause, and they’re, describing menopausal symptoms like heavy menstrual bleeding and hot flushes and night sweats, instead of thinking ‘could this person have hyperthyroidism’, think menopause because that’s the most likely thing. And I think that potentially will have a huge, positive impact on the number of women being diagnosed early.

Diane Danzebrink, Menopause Support charity

Q. What do you make of the figures? Does it chime with what you see day to day?

A. I’m not particularly surprised because at Menopause Support we have a support community of just over 29,000. So, we hear from a lot of women on a daily basis and we notice ourselves the disparity around the country around what types of HRT are being prescribed in different parts of the country.

Q. What impact can this have on patients?

A. It’s multifaceted. You have issues around safety. For those who experience migraines, or perhaps have a family history of blood clot, or strokes, those who perhaps have a BMI over 30, those who smoke, the British menopause society would advise that those individuals don’t have an oral HRT. They have a transdermal oestrogen.

You also have the patient choice factor. Some people don’t like to take oral medication, some people would prefer to have a transdermal medication.

And also the fact that for many people, having HRT they’ve had to do quite a lot of research for themselves. They’ve probably come across something that they feel they will be comfortable with, to find out that’s not available to them.

Then we have the issues around what suits one person doesn’t necessarily suit another. So if you’re prescribed it and it doesn’t suit you, perhaps the choices in your CCG area are very limited. That can mean that people aren’t getting the ideal treatment for them because they don’t have the opportunity to try the options.

Often we will hear from women who are being prescribed oral tablets as a first line, and they’re not being offered options. Sometimes that is because those options are purely not available on their local CCG formulary. So that sort of ties the hands of their doctors to be able to offer them choices. But we do definitely see that it seems to be in some parts of the country rather than others.

Q. Could more deprived communities be left behind?

A. Well, I guess it all comes down to finances. It all comes down to how much the local CCG have to spend on all the medications and all the treatments that they need to offer across their local population. So if there are cheaper choices, they’re the ones that they’re going to take. I think it purely comes down to finances.

Q. More broadly regarding the menopause, are there cultural taboos in some communities? That would affect how widely it’s discussed, and what do you think needs to be done to help address that?

A. Absolutely. There are certainly cultural barriers. You’ll have some communities where there is no word for menopause. So it’s quite difficult to discuss it in clinical terms.

Also, in some communities, it is not accepted to talk about women’s health. Women aren’t encouraged to talk about their health, they’re not encouraged to seek help and support. You could also talk about not just the cultural barriers, but perhaps the language barrier. Not everybody has English as their first language. And I think this is sort of part of the wider issue that we have around sharing factual evidence based information and for people to know that there are options for support.

What we need to see is a government led public health campaign. We need to see something that is sharing education with all parts of society. And that might mean being in different languages, it might mean being in Braille.

I think it’s about thinking about all parts of the community, and what we need to do to share the right education and information to allow individuals to make informed choices for themselves.

Q. What impact has the pandemic had on all of this?

A. We’ve heard a lot about the mental health effects of being isolated. But it also meant really practical things like perhaps it taking longer to get a GP appointment than you might usually have done, because obviously, their focus was on vaccinating, etc. So I think that certainly had an impact.

I think the other impact is people would have been in the workplace, perhaps talking to their colleagues, they would have been gathering with friends: those things weren’t available to us.

What we’ve certainly seen more recently is that the lists as far as NHS menopause clinics are concerned have just got longer and longer.

Unfortunately, there are still some areas that have absolutely no provision. But where there is provision, because of what happened with the pandemic, we now see that those waiting lists are really significant.

Some waiting lists at NHS menopause clinics are18 months. We’re used to them being three to six months, but people can’t wait 18 months.

The provision isn’t there in terms of quantity, but even where it is there it’s forcing more and more people to seek private menopause care. And that can be very costly. You’re often talking about several hundred pounds, and that can go up sharply with private prescriptions.

There are going to be millions of women across the country who could never consider the idea of private menopause care and are being left to suffer in silence. In 2022, that’s a disgrace.

Right of reply

NHS England

An NHS spokesperson said:

“The NHS has a Menopause Pathway Improvement Programme, which includes increased learning for clinicians in how they can best support menopausal women, and working with clinical colleges and menopause organisations to improve awareness and understanding.

“A new Menopause Optimal Pathway will also guide clinicians and help women in the workplace during peri-menopause, menopause and post-menopause.”

Department of Health and Social Care

A Department of Health and Social Care spokesperson said:

“We have put women’s health at the top of the agenda by publishing a Women’s Health Strategy for England, appointing the first-ever Women’s Health Ambassador, and taking action to increase supply and reduce the cost of Hormone Replacement Therapy.

“We have accepted the recommendations of the HRT taskforce, including the continued use of Serious Shortage Protocols when appropriate to manage shortages, and NHS England continues to work on gathering data on maintaining and updating local formularies in England.

“The UK-wide menopause taskforce is seeking to end the taboos surrounding the menopause and considering the role workplace policies can play in supporting menopausal women, and the government’s Health and Wellbeing Fund is helping expand and develop projects which support women experiencing the menopause to remain in the workplace.”

Background:

  • We have received the Women and Equalities Committee’s report and will consider its recommendations.
  • The Women’s Health Strategy for England can be found here.
  • Specialist menopause clinics are not funded by central government. Instead, they are commissioned and implemented as local services. Integrated Care Boards are responsible for commissioning services to meet the health needs of the local population.
  • Prescribers in primary care are already able to prescribe from all licensed products using the British National Formulary (BNF). Prescribers can, and should, prescribe the medicine or appliance that’s the most appropriate treatment option for the patient, using their clinical discretion and after a shared discussion with the patient taking into account the patient’s values and preferences. Therefore, a national formulary is not required.

On support for women experiencing the menopause:

  • The Civil Service has signed the Wellbeing of Women UK Menopause Pledge committing to recognise the impact of menopause and actively support women who are affected.
  • We have taken action to increase supply and reduce the cost of Hormone Replacement Therapy (HRT) including through the introduction of a pre-payment certificate which could save women up to £205 per year. The creation of a prepayment certificate will mean women can access HRT on a month-by-month basis if need be, easing pressure on supply, paying a one-off charge equivalent to 2 single prescription charges (currently £18.70) for all their HRT prescriptions for a year. This system will be implemented by April 2023.
  • To ensure women can reliably access HRT, decisive action has been taken, including the appointment of Madelaine McTernan as chair of the HRT Supply Taskforce, and issuing of serious shortage protocols to even out distribution and provide greater flexibility to allow community pharmacists to supply specified alternatives, where appropriate.
  • We are enhancing women’s reproductive wellbeing in the workplace through the Health and Wellbeing Fund 2022 to 2025. The fund supports voluntary, community and social enterprise organisations to expand and develop projects to support women experiencing reproductive health issues – such as pregnancy loss or menopause – to remain in or return to the workplace.
  • The Department for Work and Pensions has committed £22 million to support older workers, including the appointment of 50 Plus Champions who will help jobseekers over the age of 50 get into, and progress in work, which includes navigating health issues like the menopause.
  • The cross-government response to the independent menopause and the workplace report commissioned by the Minister for Employment through the 50PLUS Roundtable co-chaired with the Business Champion for Older Worker is published here: Menopause and the Workplace: How to enable fulfilling working lives: government response - GOV.UK (www.gov.uk)
  • The response sets out the government’s commitment to helping employers recruit and retain women as they transition through the menopause. As part of this, the Minister for Employment will work with the Government’s Women’s Health Ambassador Dame Lesley Regan to build awareness and promote better working practices for businesses.
  • The Minister for Employment will appoint one or more Menopause Employment Champions to give a voice to women experiencing the menopause at work, by engaging with employers to keep people experiencing menopause symptoms in work and progressing and promote their economic contribution.