Decades After the Pill, Another Revolution for Women’s Health

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When the BBC reflected on the 50 things that made the modern economy a few years back, of course it included the pill. Oral contraception ushered in a revolution some 60 years ago that freed women to plan their lives. It meant many could enroll in graduate programs and pursue professional careers, raising long-term income levels and spurring far-reaching economic change.  

There is no obvious equivalent today. And yet a new move in Britain to address inequalities in health care could prove almost as revolutionary for women — and for a country that, like many others, is experiencing slowing long-term growth trends and an aging population that is living longer. 

The U.K. government promised last year to “reset the dial” on women’s health, and its new strategy is due to be published in the spring. We’ll have to reserve judgment until then, but last week Britain’s medicines regulator took a step forward with a proposal to make hormone replacement therapy, used to treat menopause symptoms, available over the counter and at negligible charge. 

There is now a consultation to make a single product — Estradiol, a vaginal estrogen — available to women over 50 without a prescription. Like the U.K.’s decision last year to make two forms of oral contraception available over the counter, this move comes with extremely low risks and takes a little pressure off over-stretched doctors. It would be a small change, but also a milestone.

For decades, conversation around menopause was either overheated, inhibited, or just misinformed. The pressure to change that has come from nonprofits such as the British Menopause Society, a bipartisan group of U.K. lawmakers, royals, celebrities, the media, and economic reality. A third of the U.K. workforce is now aged over 50, and this demographic is the fastest-growing segment of workers.

A minority are lucky enough to breeze through menopause. But three in four women will have symptoms that alter their quality of life, including trouble sleeping, hot flushes, brain fog, irritability, low moods or anxiety, and urogenital problems. The fun lasts seven years, on average, but can go on for a decade or more. A quarter of women will experience severe symptoms, according to the British Menopause Society.

Globally, about 1 billion women have reached menopause. By 2050, that will be an estimated 1.6 billion women.

For most women, things really kick off around 50, but menopause has phases and many women experience symptoms from their mid-40s. This is lousy timing on nature’s part. It comes just as women are at a high point in their careers, or are ready to launch new ones, and when they are dealing with the joys and strains of teenagers, older children leaving home, or caring for elderly parents.

It’s hard to find concrete data on the impacts on women’s work outcomes, but there’s no doubt menopause affects careers. In a U.K. survey conducted by YouGov, three out of five menopausal women reported their symptoms affected their work lives; nearly a third said they had taken sick leave because of symptoms, though only a quarter disclosed the reason to their managers. An October survey found that a quarter of women with serious symptoms left their jobs.

Until relatively recently, this was all just too bad. Many women understood little about what was happening. They stuck their head in a freezer, unleashed on the nearest family member, or suffered in silence. A 2012 study found that more than 60% coped without help from a healthcare professional, relying on family or social networks for support, but the vast majority felt they had little information to guide them.

Hormone replacement therapy became widespread in the 1960s with the use of estrogen. Over the decades, it has variously been described as a wonder drug and a carcinogen — and a mass of different products and studies has left many women scared or confused.

Sales of HRT dropped off a cliff in the early 2000s when two large-scale studies, one in the U.K and one in the U.S., raised concerns about it increasing the risk of breast cancer and other chronic diseases. Britain’s regulators issued an urgent safety notice telling doctors to prescribe the lowest possible dose for symptom relief only. The subject remained taboo in lots of workplaces and homes.

Gradually there has been more light and less heat. There is better analysis of the data and a more nuanced understanding of the risks and the areas of uncertainty. Robert Langer, one of the researchers behind the U.S. study, later lamented the frequent misinterpretation of the work overstating the risk of breast cancer and heart disease. “Sadly, the issue was not the study itself, but how the conclusions were relayed in the media,” says Haitham Hamoda, a consultant gynecologist and Chairman of the British Menopause Society. 

Scores of studies have confirmed that hormone therapy, of which there are many kinds, provides substantial relief from the most common symptoms. Many women find it gives them their lives back. In England, women can get a virtual consultation with a GP and a prescription costing just over 9 pounds ($12) for a three-month supply of a combined HRT (estrogen and progestogen); the government has introduced a bill to remove those costs and set out broader menopause support services. Costs in the U.S., even with insurance coverage, can easily run 10 times that.

The thing is, not all women are good candidates for all HRT, and even when no complications exist there are risks to consider. It’s important that a medical professional trained in menopause treatment oversee things.

Quantifying risks isn’t simple, as they vary by age, lifestyle, the kind of hormone, how long it’s taken, and even the form of delivery. The U.K. medicines regulator says that in those of average weight who use HRT for five years, there will likely be five extra cases of breast cancer per 1,000 women who use estrogen-only HRT, and 20 extra cases per 1,000 women with combined estrogen-progestogen therapy. HRT also carries a small increase in the risk of ovarian cancer. Both increased risks are reversed when HRT is stopped, so most women are generally advised to use HRT for five years or less. 

Hamoda says that after years of heightened fears and some continued uncertainties, there is more acceptance now that the balance of benefits and risks is favorable for most women and that the risks have to be compared with other cancer risks factors, such as excess weight or lack of exercise. “If you look at it in an isolated way, the risk of breast cancer is not even as high as drinking a small glass of wine a night for a person who is obese.” Studies have also shown HRT is associated with benefits for bone health, reducing risk of fractures, and a small reduction in risk of colorectal cancer.

Britain’s National Institute for Health Care and Excellence (NICE) published its full menopause guidance in 2015, declaring Britain’s existing provisions of care inadequate. More employers have been setting out menopause policies with the help of various new tech-based service providers such as Peppy Health. Having so many high-profile women — from Michelle Obama to Emma Thompson and Oprah Winfrey — speak out about menopause is also driving the conversation forward.

With more awareness comes also more opportunity. There now seems to be an endless stream of podcasts, books, and products aimed at women in menopause. The global hormone replacement market (of which menopause treatment is the largest share) was $13.40 billion in 2020 and is projected to grow to $21.49 billion by 2028. The pandemic, however, hit both the supply and demand side of HRT. While manufacturers, including Novartis AG, Pfizer Inc., and others, had trouble sourcing raw materials, many women either struggled to get GP appointments or didn’t want to bother an overburdened healthcare system.

The U.K.’s step toward making one targeted HRT product available over the counter may seem small. But the trend toward more menopause information and better access to a variety of treatments will bring other changes too. As with the pill last century, giving women more control over their bodies means they’ll have more control over their lives.

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