In April 2025, the British Menopause Society (BMS) published new clinical guidance to support healthcare professionals managing women who are prescribed both incretin-based therapies and hormone replacement therapy (HRT). This comes at a crucial time, as GLP-1 receptor agonists such as semaglutide and tirzepatide are increasingly prescribed for type 2 diabetes, obesity, and cardiometabolic risk reduction, often overlapping with the menopausal years.
This blog summarises the guidance and outlines practical strategies for implementation in primary care and community pharmacy settings.
Why This Guidance Is Important
Incretin-based therapies are known to delay gastric emptying, which can interfere with the absorption of orally administered medications. This includes oral oestrogens commonly used in HRT. With many women now receiving GLP-1 RAs alongside HRT, clinicians must consider how these treatments interact and how to maintain effective symptom control and endometrial protection.
Summary of BMS Recommendations
- Gastrointestinal Delays May Reduce Oral HRT Absorption
Delayed gastric emptying caused by incretin therapies may result in reduced bioavailability of oral HRT, potentially leading to a resurgence of menopausal symptoms or changes in bleeding patterns. - Transdermal HRT is Preferred
The BMS recommends prescribing non-oral oestrogen (patches, gels, sprays) for women using GLP-1 RAs, as this avoids gastrointestinal absorption and ensures more consistent delivery. - Review Symptom Control and Bleeding Patterns
Clinicians should monitor for changes in vasomotor symptoms, cycle regularity, and general efficacy of HRT. If symptoms return or worsen, consider switching from oral to transdermal formulations. - Do Not Discontinue HRT Solely Based on Weight Loss
Weight loss from GLP-1 therapy does not automatically negate the need for HRT. Clinical decisions should be based on symptom burden and overall quality of life. - Ensure Adequate Progestogen Coverage
In women with an intact uterus, it is essential to maintain adequate progestogenic protection, especially when HRT regimens change. This is critical to minimise the risk of endometrial hyperplasia. If you’re unsure what constitutes an adequate dose, see our blog:
➤ Understanding the Adequate Dose of Progestogen in HRT
Primary Care Networks (PCNs) and GP Practices
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Structured Medication Reviews (SMRs):
PCN pharmacists and GPs should identify patients prescribed both HRT and incretin therapies during SMRs. Assess HRT formulation, symptom control, and adherence. -
Electronic Clinical Templates:
Update EMIS or SystmOne templates to include prompts for HRT review when prescribing GLP-1 therapies, or when reviewing menopausal symptoms. -
Multidisciplinary Collaboration:
Facilitate joint working across menopause clinics, weight management services, and diabetes teams to optimise care pathways and avoid fragmented treatment.
Community Pharmacy
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Patient Counselling at the Point of Dispensing:
When dispensing semaglutide, tirzepatide, or similar agents, enquire if the patient is taking HRT. If oral HRT is used, advise them to consult their GP or prescriber for a review if they report any return of symptoms. -
Education and Awareness:
Support patient understanding of the rationale behind changing to a transdermal route and help manage expectations around symptom improvement timelines. -
Referral Support:
Encourage patients experiencing reduced HRT efficacy or irregular bleeding to seek a review with their primary care team.
Final Reflections
This BMS guidance highlights the importance of integrated, patient-centred care. As incretin-based therapies become more prevalent, healthcare professionals must ensure their prescribing practices keep pace with emerging evidence and guidance. Reviewing HRT routes proactively and educating patients on potential absorption issues can help prevent suboptimal symptom control and improve quality of life.
Access the full BMS guidance here:
Use of Incretin-Based Therapies in Women Using HRT – BMS, April 2025 (PDF)