HRT in the UK: The culture behind the demand


      In the past year, the UK has witnessed an unprecedented rise in women requesting HRT in the public health service. In England alone there has been a 30.5 % increase in the number of patient prescriptions from the previous year. The reasons for this are many and have a variety of consequences. Brexit and the pandemic have aggravated supply chain issues and meant that women already on HRT have had to change their medication suddenly due to shortages, while others wishing to begin HRT have had to navigate what is available in a limited market. The pressures on the healthcare system to support patients have also been exacerbated by the dwindling of publicly funded specialist menopause clinics in the UK. While private healthcare providers have stepped into this gap in provision, given initial consultations start around £375, this is available to a privileged few.
      This increase in demand is unlikely to stop anytime soon. Calls in the UK to make HRT prescriptions free in NHS England (they are already free in Scotland and Wales) have been met by a new single annual payment from April 2023, which will make HRT a more financially viable option for many.
      The increases in demand have been widely attributed to ‘The Davina Effect’, where UK celebrity presenter Davina McCall's two documentaries on the menopause have been watched by over 5 million people. Other high-profile and public voices have also begun to discuss menopause, particularly in terms of support in a work environment, and are helping to reverse enduring misconceptions around HRT as well as encourage women to shed the stigma around menopause and challenge broader negative cultural perceptions around becoming an older woman.
      The impact of this increasing attention to menopause has been widely reported as having a profound effect on healthcare systems, most recently discussed in the British Medical Journal,
      Howards, S. (2002) GPs caught in media menopause spotlight. BMJ, 379:
      2Howards, S. (2002) GPs caught in media menopause spotlight. BMJ, 379:
      with an unfortunate reference to menopause ‘hysteria’, a term that has a problematic history surrounding sexist attitudes to women's bodies. There are valid concerns about how to ensure the healthcare infrastructure can deal with increasing patient requests, including those presenting to practitioners who may not be experiencing menopausal transition. It is also unlikely that every menopausal woman contacting her general practitioner about HRT will eventually be prescribed. Many will choose from the variety of other ways to support their health and wellbeing during menopausal transition. Likewise, we do not know if this swell of HRT demand is distributed evenly across socioeconomic or ethnic minority groups, or replicates uneven geographies and inequalities in health-seeking behaviours.
      Riach, K., & Rees, M. (2022). Diversity of menopause experience in the workplace: Understanding confounding factors. Current Opinion in Endocrine and Metabolic Research, 100,391.
      3Riach, K., & Rees, M. (2022). Diversity of menopause experience in the workplace: Understanding confounding factors. Current Opinion in Endocrine and Metabolic Research, 100,391.
      But let's be clear: the challenges that demands for HRT pose to the healthcare system are not a burden or problem that should be charged against patients themselves. It is unfair to blame women for a lack of knowledge surrounding menopause or how to approach it, given that a historical shroud of secrecy and stigma has prevented broader menopause education and awareness taking place.
      Rather, we should view HRT demands as the consequence of the Pandora's Box in a society that has struggled for too long to acknowledge, support and make adequate provision for menopause and women's health more broadly. What we currently witness in the UK is that HRT has become a ‘holding device’ – a legitimate and socially recognisable thing that seeks to facilitate a conversation about a larger stigmatised or unknown phenomenon. In other words, requests for HRT are not simply about requests for HRT, but often a way to seek support and start the conversation about menopausal experience and how women can live and work well through this transition.
      Whatever the reasons surrounding HRT demand, the increase in conversations about menopause around the world means we will see similar rising demands in GP and OB-GYN clinics internationally. A lot of this has emerged from a concern around women's retention in the workforce as they go through menopause. Support for this group to enable continued economic participation after 45 is particularly important given that older women are more likely to face poverty in later life due to nonlinear work trajectories and experiencing biographical ‘shocks’, such as divorce. These patterns have a significant effect on their current and future financial security.
      We receive a number of emails each week from employees, managers, organisations and training consultants keen for information about menopause and work. While these have normally been from around northern Europe and Australia, over the past six months, requests have come from the Middle East, Scandinavia, India and increasingly the US. The message that menopause is not something to endure privately will be reflected in more pressure on the broader ecosystem around menopause transition. However, during conversations, we have also come across managers who do not understand why women do not just ‘take an HRT pill’ as a quick fix to prevent menopause disrupting their professional lives. This suggests that pressure to seek HRT may be coming from workplaces too, and not always with the best or most realistic intentions.
      At the same time, managers are increasingly suffering from a similar burden of expectations as GPs when it comes to supporting menopause. Both groups are vital in providing an affirming and supportive first encounter with women going through menopause: we know that instances of underdiagnosis, misdiagnosis and late diagnosis of menopause can have a profound effect on menopausal experience, while supervisor and line management support is one of the most important factors influencing whether women are able to work through the menopause or not.
      At the same time, GPs and managers are rarely given the time, resources and support they require to make valuable and supportive interventions. The extent to which menopause adequately features on the medical school curriculum has been questioned, while line managers are often saddled with being responsible for supporting their employees but are given little time to understand the full impacts and relationship between menopause and work.
      In short, HRT demands may simply be the symptom of a broader challenge that needs to be addressed: how we ensure that valuable, accurate and timely information around menopause is widely available and accessible. During the pandemic we saw the critical role of public health messaging and communication in empowering society with information, and this might serve as a blueprint for menopause education and awareness. At the same time, we also need to think about how key stakeholders such as workforce and healthcare practitioners can collaborate to create sustainable and inclusive spaces for people to learn and talk about menopause. Without these, HRT demand will continue to be a symptom of a broader lack of recognition of, and general knowledge about, menopause.


      The two authors contributed equally to the preparation of this editorial.


      No funding from an external source was received for the preparation of this editorial.

      Provenance and peer review

      This article was commissioned and was not externally peer reviewed.

      Declaration of competing interest

      The authors declare that they have no competing interest.