Hi Dr Currie
It's fantastic that new NICE guidelines are being developed to give GPs up to date information on which to base treatment of women during and after menopause.
Some of what I want to say has already been said earlier in the threads but you asked for comments in relation to the draft scope so these are just some thoughts on the whole issue generally - sorry it's a bit late and also long!
I had a look at the draft scope and I wondered how far the review will recommend areas for future research and also what the relationship is between guideline development and drug companies?
The document says that recommendations will mainly base the review on licensed products and methods but only exceptionally otherwise, if supported by evidence.
Personally I feel that this is a very important area – and especially in relation to unequal treatment of women. Currently those women living in geographical areas where leading (research and practising) gynaecologists practise on the NHS, are able to access their (gynae) expertise and due to their knowledge are able to receive individualised treatment in a way that they cannot from most GPs. Similarly, those who can afford to do so, go to private gynaecologists at considerable cost for similar treatment and prescription. Also many areas are not served by NHS menopause clinics.
I would hope that the new guidelines would do something to try to lessen this inequality so that all women have access to the best possible treatment and with the latest knowledge and research.
In order to do this there are still a lot of areas where research is needed to provide the evidence on which to base treatments.
Topics that are discussed frequently on this forum include: long cycle HRT (other than Tridestra - the single proprietary brand currently available) – ie longer than monthly, and long term use of HRT particularly in the over 60's – with many still being asked to stop at 60 or before. I note the guidelines only refer to looking at the effectiveness of HRT and other treatments in the short term (5 years) but some of these can also be present long term eg urogenital symptoms and others. Many of us would like to stay on HRT for life if possible and this is an area where up to date studies and research are needed, and especially using what is thought to be lower risk transdermal bio-identical estradiol and progesterone.
A major area needing research and licensing in UK is evidence and dosing for using other forms of progesterone currently available in other countries or off licence here ie Cyclogest, Crinone gel and vaginal use of Utrogestan.
Other areas which seem to need more research are : long term vaginal use of local oestrogen; if possible a bit more precision in the dose of progestogen to oppose specific doses of oestrogen especially micronized progesterone, in preventing hyperplasia (at the moment often standard amounts are prescribed by GPs irrespective of oestrogen dose).
An area many of us know very little about but which urgently needs more research and proper treatment with hormones if necessary is reduced libido and treatment with appropriate women specific formulations of testosterone and the availability of testing and treatment for this on NHS rather than mainly privately as now.
I don't know how the drug companies relate to the Dept of Health but will it be possible to commission or recommend additional products eg re-introducing Vagifem 25 mcg for those for whom 10 mcg is not effective? The studies on which this was based were very small and as always based on a percentage of women and statistical significance – so what about the rest ie the percentage of women for whom that dose is ineffective?
For progesterone intolerant women – the need to re-introduce dydrogesterone as a separate product to enable better adjustment of dose in relation to bleeding – currently only available as combined tablet.
The need also to produce greater variety in dosage of progesterone eg lower strength vaginal gel, half strength micronized progesterone to enable splitting the dose daily ( eg 2 x 50 mg) and also to enable reduced dose for those on very low dose oestrogen (patches or gel).
These are just my thoughts as a menopausal woman based on my limited knowledge and experience – as I don't know what guides research and how the drug companies work.
Many thanks for consulting us and we look forward to hearing more in due course
Hurdity x