Women attend their local general practitioner with symptoms such as hot flushes, brain fog, night sweats or mood swings. They are assessed by their doctor, and hormone replacement therapy (HRT) is often prescribed to help relieve these symptoms, which are associated with menopause and perimenopause.
But many of these patients say the cost of this medication is a prohibitive factor, doctors and pharmacists have said, with some women spending between €30 and €70 per month on HRT.
Dr Ciara McCarthy, the Irish College of General Practitioners (ICGP) and HSE clinical lead in women’s health, says patients often tell doctors about the impact this expense has on their lives.
“While for some people that might not seem like a large amount of money, we know it is prohibitive for some women, meaning they don’t fill their prescription every month or they may not fill it at all,” she says. “And my other worry would be that we also maybe don’t see some women who are struggling with symptoms because a menopause consultation may be prohibitive for them and they may have a lot of competing financial demands and so they may not opt for menopause care at all.”
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But this could all be about to change. The Irish Times reported this week that Minister for Health Stephen Donnelly is advancing plans to make HRT freely available for all those who need it.
There are different types of the HRT, with the medicine coming in tablet form, skin patches, gels and vaginal creams or pessaries. The medication replaces hormones that decline during perimenopause and menopause.
Menopause usually happens between the ages of 45 and 55, with the average age in Ireland for a woman to reach menopause being 51. A woman reaches menopause when she has not had a period for 12 months, according to the HSE.
Up to now HRT has only been provided by the State for those who have a medical card or under the drug payments scheme (DPS), at a cost of circa €4 million per year. In 2022 Donnelly said the HSE estimated the total cost of providing free HRT to all those who require it would be in excess of €10 million per year, though this does not take account of any associated loss of prescription charge income, relevant future demographic changes or how the introduction of free provision could impact on uptake.
But even with the two State schemes available currently costs can still remain a barrier, according to Dr Caoimhe Hartley, a GP specialised in women’s health, and who leads the complex menopause clinic in the Rotunda Hospital.
“[HRT] is often a combination of two or three different hormones, and these things are given in different routes and different doses and different brands, all of which carries different costs. Some of the medications that we want to prescribe to someone aren’t available on the DPS or the medical card,” she says.
Hartley says there is a category of women who are particularly affected by cost, namely those who enter menopause or perimenopause at a younger age. About 1 per cent of women under the age of 40 and 5 per cent of women under the age of 45 experience this.
“It is really really essential for their long-term health. They’re advised to take HRT to protect their bones and their heart and their general wellbeing until they get to the average age of menopause which is 50. And so if cost is a barrier that can have consequences. The hope would be this new scheme would expand not just accessibility but also the options that we have for women, and in particular younger women.”
The symptoms of menopause and perimenopause can have a hugely detrimental impact on a woman’s quality of life, and HRT can often be a lifeline for these individuals.
According to a 2022 survey, conducted by B&A polling company on behalf of the Department of Health, more than half of Irish women experiencing menopause or perimenopause describe it as a negative experience. The average woman in menopause said they have constant symptoms, and can experience up to seven symptoms at any given time, the research found.
Women reported that their most intense menopause symptoms were temperature changes (76 per cent); changes in periods (73 per cent); tiredness (72 per cent); sleep issues (68 per cent); changes in body shape (58 per cent); cognitive issues (56 per cent); mood changes (54 per cent) and joint pain (53 per cent).
Victoria Jones, owner of Bonnybrook pharmacy in Coolock, Dublin and a menopause specialist pharmacist, says the symptoms that tend to be the most debilitating among younger women, meaning those in their late 30s or early 40s, are anxiety, mood changes, rage and depression.
“Not wanting to go out and meet your friends. Not wanting to go out and do the things you normally do. Not having the confidence to drive at night or to drive on the M50,” Jones says. “They just don’t feel themselves. They ruminate at night time, or catastrophise. And it can last up to 10 years, because your hormones are fluctuating so much day to day, hour by hour.”
But despite menopause affecting so many people something of a taboo around the topic persists in Ireland which results in a lack of awareness, according to Loretta Dignam, chief executive and founder of The Menopause Hub.
Although menopause affects 50 per cent of the population the other half are either “directly or indirectly” affected due to having women in their lives, she says. As a result she believes it’s important for everyone to have an understanding of just how life-changing the symptoms can be.
“In my own case I didn’t even know about perimenopause. All I knew was no periods and hot flushes, and I would consider myself to be reasonably educated. And then these symptoms happened and it was like, I wasn’t forewarned.
“I was terrified of HRT, I tried all sorts of different things such as magnets in my underwear, all this kind of thing. Eventually I went on HRT. I had about 26 symptoms and all of my symptoms went and I felt fantastic. But that can cost me between €70 and €80 a month. I’m lucky I can afford it, but I know a lot of people who simply cannot.”
Dignam says: “We meet women all the time who are in the squeezed middle, who don’t qualify for various schemes, and that financial burden [of HRT] is immense.”
But cost is not the only deterrent for some people. In 2002 a study called Women’s Health Initiative was published which linked HRT to the causation of breast cancer. The findings have now largely been debunked, with modern HRT having a very good safety profile. However, while the number of women opting to take HRT has returned to higher levels than in the immediate aftermath of the study, there remains caution from some women around the use of the treatment, according to those working in the sector.
McCarthy says this is why conversations with their GPs can be so invaluable, so an individual has all of the required information to make an informed decision.
“Any treatment comes with risks and benefits. And it’s always about weighing up the balance of those risks and benefits. This is particularly relevant when it comes to HRT because some women experience symptoms that are incredibly disabling and impacts significantly on their quality of life.
“It’s about balancing and improving their sleep, their general wellbeing with a very small increased risk of breast cancer if they use HRT for more than a certain period of time. For many women that benefit will outweigh that small increased risk because it is so detrimental to their overall functioning and quality of life.”
Now that Ireland looks set to make this “game-changer” medication available free for those who need it, does that mean the country is a trend setter? Or is it taking its lead from other jurisdictions?
All prescriptions are free in Wales, Scotland and Northern Ireland, including HRT. Last year England launched a new system called prescription prepayment certificate to reduce the cost of HRT, which reduced prescription costs to £19.30 (approximately €22.50) per year.
Post-implementation this move in Ireland could potentially benefit hundreds of thousands of women. But those working in the sector stress that HRT is one of a suite of options available, and that a percentage of women enter menopause without any symptoms at all.
Pharmacist Victoria Jones says HRT is “not a one size fits all”, and that menopause also requires a “holistic approach” in terms of exercising, reducing alcohol and stress.
She adds: “It is also a lot to do with those unsexy things your doctor tells you about that are actually really important.”
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