Oh my, things are getting really exciting now in 2024!!
Since the National Institute for Health and Clinic Excellence (NICE) came out with its updated menopause guidelines recommendations in October 2023, the proverbial sh*t has hit the fan!
Let me preface what I’m going to say here with the fact that 2023 has been an amazing year for menopause women!
More workplace trainings and policies.
More women’s health and menopause conferences, workshops, retreats etc.
More informed and educated Doctors who now know how to support midlife women.
More products, TV shows, media attention, books, podcasts…….
There has just been MORE of everything Menopause in 2023 and I think this has to be celebrated. I can’t wait to see what 2024 brings for us women in midlife!
But as there is more of an open conversation happening, more experts and more evidence there is also more confusion and opposing opinions.
And the latest furor has me TOTALLY BAFFLED!!!
So let’s start at the beginning.
In 2015 NICE came out with guidelines that were really revolutionary at the time. “Menopause: diagnosis and management” which was updated in 2019, clearly sets out three key guiding principles:
1. The individual person’s ability to make informed and educated decisions about their care together with an informed and educated medical professional.
2. Give information to menopausal women and their family members or carers about a range of treatment for menopausal symptoms including hormonal, non-hormonal and non-pharmaceutical, for example cognitive behavioural therapy (CBT).
3. The benefits of HRT. There is a detailed discussion of short-term and long-term impacts of using HRT for the treatment of a range of menopause symptoms including hot flashes, night sweats, Depression and mood change, Joint and muscle aches and pains to name just a few specifically mentioned.
These guidelines were used in part as a rebuttal of all the negative press around the health risks of HRT. Menopause experts referred to them and they were part of the paradigm shift changing the menopause conversation from anti to pro HRT use.
At the time Professor Mary Ann Lumsden, chair of the expert group which developed the NICE guideline, said “The guideline covers the treatment of symptoms and also looks again at the place of HRT in treating menopausal women. It emphasises that, for most women, HRT is a very effective treatment for several menopausal symptoms, for example hot flushing and also reduces the risk of osteoporotic fracture.”
So far so good.
In October 2023 NICE released it’s latest updated guidelines for consultation. These guidelines expanded on using CBT (Cognitive Behavioual Therapy) as another legitimate form for potentially treating menopause symptoms. Remember CBT was originally mentioned in the 2015 guidelines, but there is more focus on it now as a treatment option for symptoms throughout the 2023 document:
“The committee also agreed that evidence showed that CBT could be an option for some people (see sections on vasomotor symptoms, depressive symptoms and sleep). However, they noted that the evidence showed that several types of CBT (for example online or group sessions) were effective but did not show that one option was better than another. They therefore recommended that the options that are available should be discussed with the person.”
Professor Gillian Baird, menopause guideline committee chair said (1):
“This update includes important evidence-based information to help both women and healthcare practitioners during their discussions about the best treatment to manage their symptoms. This gives women more choice and enables them to make informed decisions for their personal circumstances.”
This is exactly what we want in the women’s health and menopause space – more choice, more information, more education, more evidence-based data. And this stance should be celebrated by everyone in the women’s health space.
Let me clarify - the 2023 draft guidelines update expands on CBT use which was already mentioned in the original 2015 guidelines and DOES NOT reject or remove the benefits of HRT use for specific symptom treatment.
And that’s when something very strange started to happen.
Rather than embrace and support the expansion of women’s choice to treat their symptoms and the improvement in research and evidence-based findings, rather than trust this organization and its very thorough research process the opposite has happened.
For some reason the UK Menopause experts got angry!!
There were claims that the new draft guidelines use “patronising” and “offensive” language and are “detrimental” to women’s health.
The menopause author and campaigner Kate Muir accused Nice of scaremongering. “This draft Nice guidance skews the science to fan flames of fear and attempts to push women away from the choice of increasingly safe forms of HRT.”
I honestly have no idea what she and others are talking about. Did they actually read the document in question?
The NICE 2023 guidelines update only ADDS information on how menopause symptoms can be treated. It has NOT removed anything about how HRT is a legitimate way to treat a range of symptoms and their long-term women’s health benefits.
In fact, Dr. Louise Newson, one of the biggest menopause experts in the UK said that the NICE guidelines were gaslighting menopause women (2). This use of language is beyond shocking. I think is exceptionally irresponsible at best and smells of the exact thing she has been campaigning against for years – advocating for the right of women to have as much information as possible and experience menopause on their own terms!
And if you read Anna Bawden’s December article in The Guardian on this issue, you would think that NICE had come out saying that women should treat their menopause symptoms by participating in an Ice Swim on Christmas Day.
The British Menopause Society (BMS) has thankfully tried to douse the flames with their statement (3):
“While the option of CBT was a main focus of the NICE press release, the advice contained within the guidelines regarding the use of HRT is in keeping with the 2015 guidelines, i.e. HRT should be offered for menopausal symptoms.
The message has not changed. When used for a clear indication with consideration of type, route and dose, for the vast majority of women HRT provides more benefits than risks. CBT was recommended as an option in the 2015 guidelines. It continues to be seen as an effective option which can be used in addition to HRT. It can also be considered for women who choose not to take HRT, or those who have medical reasons to be cautious about HRT use.”
So what is everyone getting upset about here?
In my opinion, the main issue is the battle around the HRT debate.
In 2023 we are all aware that in most cases, HRT use is a safe, reliable and trustworthy form of treating some menopause symptoms. By now that the whole 2002 WHI fiasco has well and truly been debunked and we know that HRT DOES NOT DIRECTLY lead to increased cancer risks and we can freely enjoy the benefits of HRT as a way to treat your symptoms.
However, much less emphasis has been placed on the role for alternative or integrative treatment options – whether it be CBT or anything else that is not pharmaceutical based.
Firstly I do agree with the basic premise that menopause is a normal, natural stage of a woman’s lifecycle, defined by fluctuating and eventual declining hormones. And I do agree that these hormonal fluctuations CAN lead to menopause symptoms.
However, our hormones and our symptoms are not only impacted by the natural hormonal imbalances during peri-menopause and menopause BUT also by what has gone on with our hormones in the years leading up to peri-menopause. Our hormones work in a complex and delicate system that can be pushed out of balance by lots of external triggers like stress, poor diet, lack of movement, exposure to toxins and poor sleep to name just a few. All these external triggers can then exacerbate the normal, natural hormonal fluctuations of peri-menopause and menopause.
And there is more and more evidence (and if only there was more funding for research in this area!) showing that there are LOTS of ways to help us support our hormones and by extension our symptoms:
- Managing our stress and regulating our nervous system using breathwork and/or medidation, yoga and other relaxing techniques
- Improving your diet, removing trigger foods (sugar, carbs) and improving overall gut health.
- Improving and boosting our feel good hormones by being out in nature, moving our body, and socializing with loved ones.
- Adding important supplementation (vitamins and herbs) to our diet, like Vitamin D, magnesium and Omega 3s.
As a menopause educator and coach I believe in looking at ALL the ways that could potential support you and with the right guidance and support find the things that work for you.
That could mean HRT TOGETHER with many other things.
It could mean an integrative approach with only localized hormonal treatment like an estrogen cream for vaginal dryness.
It could mean a thoughtful protocol on vitamin supplements and dietary changes.
Each of these decisions should be made in an informed way, be appropriate for where you are on your menopause journey, be practical and easy to implement so that you feel empowered and supported.
For leading menopause experts to employ scaremongering tactics and negative language to dissuade women from using CBT or any other evidence-based non-pharmaceutical protocol and touting HRT as THE ONLY reliable way to treat menopause is, in my opinion, an abuse of the power and trust that mid-life women have given them.