4 Thursday February 3 2022 | the timestimes2
Health Initiative report, which linked
HRT to a small increase in breast
cancer, after which the number of
British women taking HRT more than
halved. Since then, despite more
balanced evidence emerging,
prescribing by GPs has been
variable. No wonder when,
according to an investigation
by Menopause Support,
41 per cent of UK medical
schools do not give
mandatory menopause
education.
High-profile women started
filling the vacuum: Sophie,
Countess of Wessex spoke of
the “tragic” impact the
menopause can have on
women at work; Michelle
Obama even recalled having
a hot flush on Marine One:
“everything started melting”.
Women described being
fobbed off about symptoms
or even directly denied HRT.
A host of celebrities wrote
books or made TV shows
about how they were forced to
pay privately for the gold-star
treatment of tests, tweaks and
added testosterone (the last not
generally available for women on
the NHS).
Obviously this isn’t the solution
for most. Is over-the-counter
HRT a cut-price way for ordinary
women to bypass those GPs who
are outdated or underinformed?
Whitcroft says that the idea is
intriguing but is concerned about
safety, especially in regard to the
balance of oestrogen and
progesterone needed.
Anne Henderson is a
menopause-specialist consultant
gynaecologist who spent nearly two
decades leading one of the NHS’s
largest menopause clinics. “I think the
idea is good for debate,” she says. “My
worry is that there will be a tendency
to draw a parallel between getting
over-the-counter contraception and
HRT, because they are chalk and
cheese. HRT comes in a huge range of
different formulations. It’s potentiallyA new oestrogen treatment may be
available over the counter
soon. Will further HRT
follow, asks Helen Rumbelow
W
hen wizards
reach the
age of 11
they get a
magic
summons
on their
birthday.
There is now popular support for the
same to happen to women when they
reach the age of 45. Except that on this
birthday all British women should be
sent, courtesy of well-wishers, a tube
of medicine described by many users
as “magic”, which sort of turns back
time on their vaginas. I know this
paragraph has taken a surprising turn,
but still, doesn’t that sound more
useful than those cards with the
“When I get old, I shall wear purple”
poem on it, which you get and say,
“Thanks love”, then later cry a bit
about becoming a shrivelled-up crone?
Yesterday the country woke up to
some confusing headlines about
hormone replacement therapy (HRT).
The government, via a body called the
Medicines and Healthcare products
Regulatory Agency (MHRA), was
apparently consulting on a radical
proposal to make all HRT available
over the counter at pharmacies. Cue
pandemonium: this news seemed to be
the culmination of many recent high-
profile celebrity campaigns, from
Davina McCall to Mariella Frostrup to
Gwyneth Paltrow, to make HRT less
taboo for a generation of ill-served
middle-aged women. But was the idea
of “just popping out for a pint of milk
and, oh, might pick up some oestrogen
on my way back” a step too far?
“I’ve been seeing patients all
morning and they were so excited
about getting HRT from the chemist
whenever they wanted. ‘Whoop-de-do,
I can buy it at Tesco,’ ” says Sovra
Whitcroft, who is one of the country’s
leading gynaecologists specialising in
the menopause and a fellow of the
Royal College of Obstetricians and
Gynaecologists (RCOG). “So the
reality is a little disappointing.”
By lunchtime the government had
clarified things on its website: it was
consulting on making one specific
oestrogen treatment, which one
doctor described to me as “happinessfor your vagina”,
available over the counter.
This treatment, applied
directly to the vagina, is quite different
from the pills and patches normally
understood as HRT, since the
oestrogen in it is too weak to cause
any of the risks that mainstream HRT
does. Still, it wasn’t nothing: in
McCall’s documentary last year
entitled Sex, Myths and the Menopause,
one interviewee moots the idea of “all
women being sent vaginal oestrogen
cream on their 45th birthday” and
several experts explain — I’m
paraphrasing here — how this would
be a lovely gesture, since like so many
menopause treatments, too few
women know about it.
I am on the phone to Edward
Morris, the president of RCOG, when
the news breaks on the government
website. I can hear his delight.
“Myself and several colleagues have
been working for many years with the
MHRA on this product, that is very
much suitable for over the counter,” he
says. “I mean, it has a licence for
indefinite use. How many treatments
do you know that have a licence for
use in perpetuity? That’s how safe it is,
and it’s incredibly effective.
“I’ve even offered it to women who
are suffering from symptoms in their
vaginas who’ve had breast cancer in
the past. A lot of breast cancer
surgeons support that because almost
nothing enters the bloodstream, that’s
why it’s considered so safe.”
This does indeed sound amazing,
and all of the menopause-specialist
gynaecologists were fully in support of
the product being sold over the
counter. I even have the courage to
ask Morris about the “45th birthday”
treat of a tube of vaginal happiness.
“I have heard that idea,” he says
gamely. “I don’t think every woman
should necessarily be given it, but yes
every woman should be informed how
it works and how it might help them
as the years go by.”
But this leads us back to the deeper
point where we started the day: the
politicisation and privatisation of
British menopause treatment. The
medical establishment’s resistance to
HRT dates back to the 2002 Women’sThere’s no mandatory
menopause training
for doctors
Michelle Obama, Sophie, Countess of
Wessex and Gwyneth Paltrow have spoken
publicly about the menopauseThe ‘magic’
menopause cream
— coming to a
chemist near you?
the times | Thursday February 3 2022 5times2
I was heading for a split but
lockdown saved my marriage
The divorce rate went down in 2020. Here, one
man describes how enforced intimacy helped
I was upset too but, no question,
I was responsible. That’s where the
pandemic helped. A divorce is like
a fire. I dropped the match but, to
achieve the sort of intensity where it
can burn down the whole house, that
fire needs oxygen. And that oxygen
is friends telling the aggrieved party
they are right to leave and to come
and stay. It’s lawyers reassuring them
that they are doing the right thing.
But in March 2020 lockdown
came and suddenly all that oxygen
disappeared. My wife’s friends
hunkered down to deal with home
schooling or their own domestic
crises. Lawyers closed their offices.
No one was encouraging her to ditch
me. And although the fire didn’t
exactly go out, the flames abated.
We were both furloughed. It was
just us at home and, of course, the
first weeks of lockdown were
difficult. I slept in the spare room.
We endured almost silent meal
times. But when our daughter came
home from university and told us
that she had been having a toughtime, we had someone else to focus
on. I think we remembered just how
good we are as a team.
By early summer Katy felt there
was something worth salvaging.
Lockdown gave us back something
that real life had taken away:
intimacy. She had been working
crazy hours and spending half the
week in a different city. Like a lot of
people, we began to rethink what the
whole point of our working lives is.
She decided to work from home
more and I am going to find a new
job. Eventually we’ll get off the
treadmill and take early retirement.
Lockdown has shown us the value
of what we have.
I don’t think I have felt more
relieved than when Katy recently
showed me an email from her
solicitor apologising for the delay in
dealing with her inquiry. She said it
was due to difficulties working from
home and the sheer volume of work;
did she still want to proceed? Her
answer was no, and I have Covid
to thank for that.
Names have been changedJ
ust before Christmas 2019
I began having an affair with
a colleague at work. My wife
Katy and I live in Brighton but
she spends three nights a week
in London. It was easy. I work in
theatre and this colleague and I were
thrown together on a project based
on the fall of Rome. I get the irony
now. My blithe self-involvement
risked everything of value that I had
built up in my life.
I’m pretty sure that in ordinary
circumstances this short affair
would have signalled the end of my
marriage. But believe it or not, thepandemic saved it. Many
people thought that the
divorce rate would shoot
up during lockdown but
actually it fell. I am not
surprised.
My affair was like
driving a car off the road.
Lockdown allowed me to
experience the ensuing
crash in slow motion. I
had time to see what was
happening and what I was
really doing. Lockdown
saved my marriage. I
don’t suppose a lot of
people can say that.
No one just has an
affair. I felt we had been
in a rut for years. We
were 19 years old when
we met at university and
we had a child when I was 30.
In early 2020 I turned 50. Our
daughter was already at university
and so when it came to my marriage,
to borrow an idea from the dramatic
arts, there was a sense of “What is
my motivation for this? I need a
new plotline here.”
And I’m afraid all the stuff about
the fragile male ego is true. A friend
likens men’s egos to companies on
the stock market. Your wife doesn’t
see the value in your offering and
then someone else comes along and
says, “This has potential,” and that
she wants to invest. It’s hard not to
be flattered and tempted when
that happens.
My wife found out early in the new
year. The woman I was having an
affair with sent me a text about the
exciting 12 months ahead with one
too many kisses appended. When
confronted by my wife I just couldn’t
lie. It was horrible. It seems so wrong
that something that gave me a little
ego boost could be so devastating to
my other half.
By February 2020 my wife was so
angry she was talking about divorce.Though the fire
didn’t exactly
go out, the
flames abated
GETTY IMAGES (POSED BY MODEL)very complex in a way that
contraception isn’t.
“Second, most women do not
struggle with getting HRT. It’s getting
the expertise that advises them: what is
the correct dose? What is the correct
combination of hormones? That is the
problem. It’s much deeper-rooted. That
wouldn’t be addressed if they were just
buying something over the counter. I
mean, arguably, it might even be much
worse if they think, ‘Oh, well, Davina’s
on that. She likes that gel. I’ll have
some of what she’s having.’ I think that
could be an absolute car crash. We
don’t want women wandering around
on the wrong dose.
“What we’re doing is papering over
the cracks. What’s fundamental is that
there is no mandatory menopause
training for doctors. Even in my
specialty, in gynaecology, I have some
colleagues that what they know about
HRT you could write on the back of a
small envelope. No amount of free
over-the-counter HRT is going to
address that.
“You know what’s absolutely
shocking? There are only 200
specialists like myself in the country
and there’s something like 12 million
menopausal women. You wouldn’t get
that in diabetes.”
Morris tells me that before we get
to a debate about over-the-counter
HRT, the country needs to do two
very achievable but urgent things.
First, make sure that in every GP’s
surgery there is a specialist menopause
doctor or nurse. Second, prioritise
the changes proposed by Carolyn
Harris, the Labour MP, last year, who
called for HRT prescriptions to be
issued annually (rather than monthly
or three-monthly), reducing cost
and hassle.
“This is exciting,” Morris says.
“Women who’ve been making a lot
of appropriate noise over the past
few months are being listened to,
that’s marvellous. But we need to
make sure we are able to offer those
two changes as soon as possible. The
annual prescription change could be
done at a stroke.” This sounds a lot
like magic to me.GETTY IMAGESE
very time you make a
decision in medicine, you try
to weigh up all the potential
benefits and risks. When it
comes to HRT, I ask patients
specific questions about their medical
history, such as have you had a blood
clot in your leg or in your lungs?
Have you had breast cancer? It’s
worth noting that women can still be
prescribed HRT if they have a family
history of breast cancer.
Women over the age of 45 don’t
need to do blood tests to be prescribed
HRT. Guidance from the National
Institute for Health and Care
Excellence is that you can treat based
on symptoms alone. But for women
under the age of 45, blood tests can
be taken to rule out other causes.
There are lots of other reasons why a
woman’s period can stop, and I’d want
to ensure I’m not missing something.
If you have premature menopause
and decide to take HRT, there won’t
be any additional risks for the average
woman, because you’re just replacing
hormones that would ordinarily be
there. In general, for women starting
HRT between the ages of 50 and 60,
the benefits outweigh the risks.
Starting between 60 and 70, the risks
and the benefits are about equivocal
and starting at the age of 70, the risks
outweigh the benefits.
When discussing benefits, the first
thing to consider is symptom control,
and you cannot overestimate its
importance. HRT can give women
back their lives, their relationships,
their ability to work and to have sex.
Other potential benefits include
decreasing your risk of osteoporosis.
We’ll also discuss how some risks
can be mitigated. For example, if we
can deliver oestrogen through the skin
— using a patch, gel or cream as
opposed to an oral pill — there isn’t
an increased risk of clots. We also
have to put the risk of breast cancer
into context. Among women aged
between 50 and 59, about 23 women
per 1,000 will get breast cancer within
the next five years even if they’re not
on HRT. Having combined HRT
results in an extra 4 cases per 1,000 —
importantly, HRT does not affect your
risk of dying from breast cancer.
There are so many different ways
of delivering HRT — both the type of
hormones and the manner in which
they’re delivered. Most people now
will have some kind of oestrogen as a
patch, a gel or spray (not a cream).
Progesterone can be given as a tablet,
a patch or via the Mirena coil, which
decreases your risk of developing
womb cancer by about 20 per cent.
But it’s not one size fits all. My
patients will always come back for a
review after about three months to
ensure their treatment plan is working.
Side effects from progesterone can
include breast tenderness and
headaches; side effects from oestrogen
can include breast tenderness, fluid
retention and nausea. And you can
treat that by reducing the dose, type,
or route of oestrogen delivery.
If you decide that you don’t want to
have HRT, or it’s not suitable for you
for whatever reason, it’s important to
note that there are lots of other
options available, so consult your GP.
Dr Philippa Kaye is a GP and the
author of The M Word: Everything
you need to know about the
menopause (Summersdale, £9.99)The GP’s view
Dr Philippa Kaye