HRT Lottery Exposed: Middle-Class Women Three Times More Likely to Receive Treatment

First published: 13/08/2024

New data reveals that menopausal women in more affluent areas of the UK are three times more likely to be offered hormone replacement therapy (HRT) compared to those in less wealthy regions, raising concerns about a "health lottery" within the National Health Service (NHS). The analysis of NHS figures, reported by in December 2023 by The Telegraph, highlights a stark socioeconomic divide in access to this essential treatment, with middle-class women in the South West of England being the most likely to benefit.

The findings indicate a clear link between affluence and access to HRT, with the most significant provision occurring in Cornwall and the Scilly Isles. In these areas, women aged 45 to 60 are three times more likely to be prescribed HRT than those in North East London, the region with the lowest rates in England. This disparity is most pronounced in the South West, where six of the ten areas with the highest prescribing rates are located, including Devon, Somerset, Dorset, and Gloucestershire. In contrast, five of the ten areas with the lowest HRT provision are in London, along with regions like the Black Country, Birmingham, and Solihull.

Experts have raised alarms that the NHS's approach to HRT prescribing is creating a deepening divide in healthcare, particularly as new draft guidelines from the National Institute for Health and Care Excellence (NICE) suggest offering cognitive behavioural therapy (CBT) to manage symptoms such as hot flushes. Critics argue that this could exacerbate existing inequalities, as women in less affluent areas may find it even harder to access HRT, leaving them with inadequate alternatives.

Mariella Frostrup, head of Menopause Mandate, expressed her dismay at the findings, telling The Telegraph, "Yet again, women are subject to a health lottery that can, let’s not forget, leave them depressed, struggling at work and with relationships, exhausted, and even suicidal, without a prescription for HRT." She further warned that the emphasis on CBT in the NICE draft guidelines could worsen the disparity, as access to therapy is often limited and difficult to obtain, particularly for the 18 million women over 40 who may need it.

Tina Backhouse, general manager of Theramex UK and Ireland, voiced similar concerns, highlighting the difficulties women face in accessing HRT. "It’s really important that HRT isn’t seen as just a white, middle-class thing, as something you have to have sharp elbows to obtain," she said. Backhouse criticised the NICE guidance, fearing it would create an additional barrier to treatment. "There’s no doubt that CBT generally will help with anyone’s anxiety, inability to get to sleep – but many of us fear that this is medical gaslighting. That this is telling women their symptoms are in their mind, not their body," she added, pointing to a broader issue of "medical misogyny" in the healthcare system.

The NHS prescribing data, which covers the 12 months up to September 2023, underscores a widening gap in HRT provision between the richest and poorest areas. Before the Government published its Women’s Health Strategy in August, the gap between the most and least deprived areas amounted to 850 units of HRT per 1,000 women aged 45 to 60. Since then, this gap has widened to 950 units, demonstrating that recent efforts to improve access have disproportionately benefited the middle classes.

Caroline Nokes, chairman of the Women and Equalities Committee, condemned the postcode lottery in HRT provision, stating, "Sadly this is exactly the sort of postcode lottery we have highlighted in the Select Committee. We also know that in too many cases women have to be persistent and insistent to get HRT."

In response to the criticism, a NICE spokesperson defended the draft guidance, insisting that HRT remains a recommended treatment for women with "troublesome vasomotor symptoms (hot flushes and night sweats)" and that CBT is being offered as an additional option. "This is about giving more treatment choices, not less," the spokesperson said, emphasising the importance of personalised care.

The Department of Health and Social Care echoed this sentiment, noting that women’s health is a top priority for the government. A spokesperson highlighted the launch of the Women’s Health Strategy and the introduction of HRT prescription payment certificates, with more than 464,000 issued since April.

Despite these assurances, the new data suggests that unless more targeted interventions are implemented, the existing inequalities in HRT access will continue to deepen, leaving many women in the UK subject to an unjust healthcare lottery.