Pharmaceutical interventions: the unsung heroes of preventative health policy

Prevention is at the core of health policy agendas far and wide. And for many years, preventative efforts have largely been focused on public health interventions, such as the ‘sugar tax’ and vaccines.

Recently, however, preventative drugs have been in the ascendancy. Indeed Wes Streeting recently announced that the NHS may be offering weight-loss jabs, such as Ozempic or Mounjaro, to unemployed people struggling with obesity.

Critics are right to argue the effectiveness of these interventions is still yet to be determined. But it is also true some pharmaceutical interventions remain underutilised. This is because, as with Ozempic, such interventions are not without their controversy.

Hormone Replacement Therapy (HRT), for the treatment of menopause, demonstrates potential prevention opportunities. But following a misunderstood clinical trial linking long-term HRT use to an increased risk of breast cancer, its use has declined. Yet evidence is increasingly suggesting HRT is well overdue an exoneration: both for the treatment of menopause and the prevention of a wide range of long-term conditions.

Aside from being one of the more effective treatments for the plethora of highly unpleasant symptoms of menopause, evidence has shown HRT can have significant positive effects in preventing osteoporosis, cardiovascular disease, colon cancer and (maybe) dementia. As well as being deeply unpleasant for patients, these long-term conditions increasingly dominate healthcare use. And yet, HRT is underused. Less than 40 per cent ?of those who seek GP help for menopause symptoms are even offered HRT.

In large part, the underuse of HRT is a result of the infamous, yet widely misunderstood, findings of a Women’s Health Initiative study from the early 2000s. The study reported a 26 per cent increase of breast cancer in those who took HRT, leading to widespread panic and women stopping their HRT immediately. Regulatory changes in many countries also followed this report. And the number of women in the UK taking HRT fell by 66 per cent .

However, the 26 per cent statistic from the early 2000s was based only on those women taking a specific combination of HRT, for five years or longer. Many other combinations of HRT were, and are, available and did not pose the same risks. Yet the advice and regulatory changes did not reflect this.

Today, we know it is only a few specific progestins — progestins being a synthetic replacement for progesterone — which can lead to an increased risk of breast cancer. Yet HRT, in all its forms, remains a convicted health villain in the eyes of many.

All the while, the vast majority of menopausal women experiencing symptoms do not even seek medical help, despite the unpleasantness of the symptoms and the strain it places on both their personal and professional lives.

If easing the symptoms of menopause — along with the associated detrimental consequences — wasn’t a good enough reason for HRT to be prescribed, the preventative case is increasingly compelling. There is extensive evidence HRT usage is effective in preventing the development of osteoporosis — a common bone fragility condition affecting one in three older women. A growing strain on the NHS, osteoporosis-caused hip fractures rose 44 per cent ?from 2006 to 2020, reaching over 100,000 instances in 2020. However, HRT users are in a much better position. Those on HRT experience 33 per cent fewer hip fractures and this benefit persists for over a decade even if HRT is stopped.

Adding to the preventative case, HRT reduces the risk of cardiovascular disease and the risk of colon cancer . Exciting new evidence also suggests that fine-tuning the start time of HRT usage could increase the preventative benefits. There is even recent evidence that HRT usage could reduce the chance of developing Alzheimer’s or dementia, especially if body-identical forms of progesterone are used.

Medical science does not always offer clear routes to the prevention of severe ill health. When it does, like with HRT, policymakers should embrace them as a crucial part of a reimagined health system.