HRT on the NHS vs private: how to get HRT and which route suits you

Most women in the UK get their HRT from their GP, and for a great many of them that works. Some end up at a private clinic after a year of being offered antidepressants, or because they want testosterone and nobody local will discuss it, or simply because they could not get an appointment. This article is about how to make the NHS route work if you can, how to tell when private makes sense, and how to use both without ending up with two doctors who do not talk to each other.

How to get HRT on the NHS

Book a GP appointment and say what it is for. When you book, say you want to discuss menopause or perimenopause symptoms and ask whether any doctor at the practice has a particular interest in it. Many practices have one, and it changes the appointment.

Take a list. Write down your symptoms, when they started, how your periods have changed, and what you have already tried. Ten minutes goes quickly, and a list keeps it on track. Our symptom quiz gives you a structured summary to take with you.

Know what the guideline says. NICE guidance is on your side. It says that if you are over 45 with typical symptoms, you can be diagnosed without a blood test. It says HRT should be offered for flushes and sweats, and considered for low mood linked to menopause, after a discussion of the risks and benefits. It recommends oestrogen through the skin, as a patch or gel, for women with risk factors for blood clots, and body-identical micronised progesterone is now the usual choice for womb protection. If you are offered an antidepressant first for low mood that arrived with your other symptoms, it is fair to ask why.

Ask for a follow-up. The first prescription is a starting dose, not the answer. A review at around three months is standard, and you should not have to fight for it.

Sort the cost out early. In England, buy the HRT prescription prepayment certificate before your first prescription is dispensed. Our article on what HRT costs in the UK has the detail.

For complex cases, premature menopause, a history of breast cancer, or symptoms that have not responded to standard treatment, your GP can refer you to an NHS menopause clinic. These are good, and they are oversubscribed, so expect a wait of months rather than weeks in most areas.

Where the NHS route struggles

None of this is a criticism of GPs, who are doing an enormous job in a short appointment.

Time. Ten minutes is enough to start HRT in a straightforward case. It is not enough to unpick five years of symptoms that have been treated separately, or to go through the risks properly with a woman who is frightened of them.

Variation. Confidence with HRT varies a great deal between doctors. Some are excellent. Some still practise from the 2002 headlines.

Dose adjustment. Getting HRT right usually takes two or three adjustments. When each one needs a new appointment, the process stretches over a year.

Testosterone. It is not licensed for women in the UK, so prescribing it is off-label. The British Menopause Society supports its use where desire stays low on established HRT, but most GPs will not initiate it and many NHS menopause clinics have long waits. This is the single most common reason women come to us already on HRT. Testosterone for women explains what is involved.

Supply. Shortages of particular products come and go. A GP practice may not be able to switch you quickly to an equivalent.

Perimenopause. Women in their early 40s with regular periods are still sometimes told it is too early, despite the guideline. Our perimenopause guide covers what the evidence actually says.

What private HRT gets you

Time, mainly. A first appointment of 45 to 60 minutes, usually within days. A doctor who does this all day and will go through the risks for your history rather than in general. Reviews on a schedule, with the dose adjusted between them without a new appointment each time. Testosterone considered where appropriate. Blood tests where they add something, arranged without a referral.

It costs money, which is set out honestly in the cost article, and quality varies as much as it does anywhere. Before you pay a private clinic, check:

• It is registered with the Care Quality Commission and the doctors are GMC-registered. You can look both up in minutes.
• It will say no. A clinic that prescribes HRT to everyone, or testosterone at a first appointment, is not practising medicine. Ours sets out who we can and cannot treat in advance.
• It will write to your GP. Your NHS record should stay complete, and you should be able to move your care back if you want to.
• It breaks down its prices. Doctor’s time, medication and tests, separately.
• The doctors are named. You should know who is treating you.

Using both

The two routes are not exclusive, and the most common pattern we see is a mixture.

Many women start privately, get their treatment set up and stable over a few months, and then ask their GP to take over the prescribing. For standard HRT most GPs will, once they have a letter explaining what you are on and why. For testosterone most will not, and it usually stays private, which at female doses is not an expensive prescription.

A smaller number do the reverse: they have standard HRT from their GP and come to us for the testosterone conversation, or for a second opinion when something is not working. That is fine too, provided each doctor knows what the other has prescribed. We write to your GP with your consent after every consultation for exactly that reason.

If you are moving from another private clinic rather than from the NHS, switching to Arc starts with a review of your current treatment rather than a blank sheet.

Which route suits you

The NHS route first, if: you are over 45, your symptoms are fairly typical, you have no complicated history, and you can get an appointment with a GP who is comfortable with HRT. Many women do perfectly well here and should not pay for what they can get for free.

Private makes sense if: you have tried the NHS route and are still not right after six months or more; you want testosterone considered; you are under 45 and being told it is too early; your history needs a longer conversation than ten minutes allows; or the wait where you live is simply too long and your symptoms are affecting your work and relationships now.

Neither, yet, if: your periods stopped before 40, you have bleeding after the menopause or between periods, or something else needs investigating first. Those need a referral, and a good clinic, private or NHS, will make it rather than prescribe.

What we do at Arc

A 60-minute video consultation with a UK GMC-registered doctor, a written plan, and treatment built around your particular symptoms rather than a standard prescription. If you start treatment, a membership that covers four reviews a year and the clinical team in between, with medication at close to cost. Testosterone reviewed and monitored where it is appropriate, which is more often than most women have been led to believe. And a letter to your GP every time, so the door back to the NHS stays open.

Our guide to HRT in the UK covers the treatment itself in detail. If you have read that and this and are still unsure which route is right for you, a consultation with no commitment to go further is a reasonable way to find out.

The bottom line

Start with your GP if you can, armed with a symptom list and a working knowledge of what NICE recommends. Go private if the NHS route has stalled, if you want testosterone considered, or if the wait is costing you more than the fee would. Whichever you choose, insist on a doctor who will say no, who writes to your GP, and who tells you exactly what you are paying for.