The NHS should offer cognitive behavioural therapy (CBT) to women in England as an option for treating troublesome symptoms of menopause, the National Institute for Health and Care Excellence (NICE) said.
New evidence suggested that CBT reduced the frequency and severity of hot flushes and night sweats and should be considered alongside—or as an alternative to—hormone replacement therapy (HRT), the regulator said in draft guidance.
The evidence also showed that CBT helped with depressive symptoms and sleep problems related to menopause, including how long it took to fall asleep and how long before waking. The psychological therapy should be considered to help women experiencing these distressing symptoms, the guidance stated.
NICE also updated the list of available options for talking therapy to include CBT delivered online.
Guidance on Hormone Replacement Therapy
NICE last issued a guideline on menopause eight years ago, when it said evidence on taking HRT had become clearer. The regulator had reviewed the effects of HRT on overall health outcomes, including breast, endometrial, and ovarian cancer; cardiovascular disease; dementia; and life expectancy for women, trans men, and nonbinary people registered female at birth who were experiencing menopause or early menopause. These risks—set out in tables—could be used by patients and healthcare professionals when discussing whether to start HRT.
Professor Jonathan Benger, chief medical officer at NICE, said that because the impact of menopause symptoms on quality of life varied between individuals, it was "important that healthcare practitioners take a personalised approach when discussing treatments, using evidence-based information tailored to individuals' circumstances".
Combined or oestrogen-only HRT should not be offered for primary or secondary prevention of cardiovascular disease, or for dementia prevention, NICE stressed. For those with a history of coronary heart disease or stroke, combined or oestrogen-only HRT should be discussed with, and—if appropriate—initiated by, a healthcare professional with expertise in menopause.
Whilst it was important that women, trans men, and nonbinary people registered female at birth were made aware of some increased risks associated with HRT, it was also important that they were made aware that it was "unlikely to increase or decrease their overall life expectancy," NICE pointed out.
In early menopause—ages 40-44 years—there was a lack of evidence about the effects of taking or not taking HRT on overall health outcomes, and more research was needed, NICE said.
Management of Genitourinary Symptoms
The updated draft guideline also included new recommendations on the management of genitourinary symptoms such as dryness, painful sex, and vaginal discomfort or irritation.
A choice of vaginal oestrogen—such as cream, gel, tablet, pessary, or ring—should be offered to women, trans men, and nonbinary people registered female at birth, including those on systemic HRT, and treatment should be continued for as long as needed to relieve symptoms.
Vaginal laser treatment for troublesome genitourinary menopause symptoms should only be used as part of a randomised controlled trial, the guidance stated.
Professor Gillian Baird, chair of the menopause guideline committee, said that the evidence-based information would help both women and healthcare practitioners. "This gives women more choice and enables them to make informed decisions for their personal circumstances," she reassured.
The British Menopause Society called for investment to be prioritised into areas where NICE had identified the need for further research.
A consultation on the draft guideline closes on 5 January 2024.
