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Official HRT Guidelines in France

Updated: Feb 7

Official guidelines around HRT in France are a bit confusing at first look. For both citizens, and, to be fair, for general practitioners. What's going on? Let me explain (and maybe you'll have some more sympathy for your family doctor after reading this...).

HAS vs CNGOF when it comes to official HRT Guidelines in France

photo by RDNE Stock Project for Pexels

Surprise! Bureaucracy and administration is a big issue when it comes to health guidelines in France. Ok, not so surprising for anyone who has lived in France for awhile.

The issue here in France is that there is no cohesive, independent authority like there is in other countries. For example, in the UK, the National Institute of Health and Care Excellence (NICE) puts out guidelines that, while are on topics decided by the government, go through an independent approval process involving large teams of different health professionals.

Isn't the 'HAS' (Haute Autoritie de Santé) that kind of authority?

Yes, the HAS is the governmental arm of all things health. But... as one French health authority explains (direct translation), "The French state is a poor public health operator. It has multiple non-integrated health agencies, constituting an impotent state device to predict, anticipate and plan." And note that they as a government entity over an independent authority, they are not bias-free over things like what medications get promoted.

In summary, in France there is politics over health, and unresolved disagreement and different authorities that don't agree or work together. And the Haute Autorité de Santé are notoriously unorganised and archaic. How archaic?

The HAS is still publishing guidelines around menopause created in 2004. Guidelines that reference research that has since been debunked (the infamous WHI study). Yes, you read that right. 2004. They revisited and republished these guidelines in 2006, and made a comment on them in 2014, but essentially, these are guidelines decided on a DECADE ago.

The guidelines aren't awful. They are practical and reasonable in some ways. But they still recommend that HRT is only safe for five years, for example. You can read them in English here.

New guidelines put out in 2021 by the CNGOF

In 2021 the CNGOF (Collège National des Gynécologues et Obstétriciens Français) took matters into their own hands. They released their own updated HRT guidelines more in line with international standards. (Their new advice is discussed below). So why did the HAS not take note and update things their end?

I talked about this with my gynaecologist. It was a brief conversation, time slots with French doctors being what they are.

But she told me that the HAS is first of all a mess. A simple decision gets bogged down in bureaucracy, so it's an extremely slow-moving beast. And that also, they are terrified of law suits if they update the guidelines. We both gave the French eye roll at this, given that when it comes to HRT, new medications are shown as safer for our health, and that the HAS warnings are, again, based on the infamous and now debunked WHI study.

So why doesn't my doctor know about these new CNGOF guidelines?

We are in socialist territory here, ladies, not the capitalist terrain that we existed in in America, Canada, the UK, etcetera. You work to live in France, not live to work. Which means many professionals do not feel under pressure to make extra effort. They do what is required, and that is seen as good enough and what their job is, no more and no less. (Note that their counterparts in the UK and USA are also better paid).

A general practitioner is supposed to be familiar with HAS guidelines. Yes, the outdated ones from 2004. There seems to be no rule they have to take into account other specialised guidelines. And given all the worries presented in the HAS guidelines from that WHI study, they might be nervous step outside the lines.

But I saw a gynaecologist who was following old guidelines

But what about the gynaecologist I saw who didn't seem to be updated, you ask? Well in that case, it's a bit more troubling. Apparently they are obliged to keep up with and follow the guidelines of the CNGOF... but there is no monitoring or repercussions if one doesn't.

On a positive note, there are gynaecologists out there who not only know these newer guidelines, they feel they are not even good enough. Such practitioners go above and beyond, prescribing to international standards. This means they will, for example, prescribe to a woman who is only peri and not fully menopausal.

So as I always say, half the battle of getting a good HRT regime in France is finding the right doctor.

"Wait a second, the new French guidelines don't recommend prescribing in perimenopause?!" Unfortunately not. Let's discuss what they do suggest.

What do the newer French HRT guidelines recommend?

Here is a brief summary of what the CNGOF guidelines say.

1. HRT is to be prescribed after you have not had a period for one year. And then later states that it’s only recommended to prescribe HRT once menopause is certain, as otherwise there is a risk of having oestrogen excess.

Oestrogen excess is NOT seen as a big issue in other countries, where they frequently prescribe to women in perimenopause. Particularly given that research shows absolutely no proof of oestrogen excess in women, other than in those with evident medical issues such as endometriosis. And the idea of oestrogen excess is from a book whose research and conclusions were disproven.

Yet because of this warning, some doctors, even if they buck the guidelines, will unfortunately only prescribe progesterone if you are perimenopausal. But again, a full regime is possible in France in peri if you get the right doctor. I had not one but five doctors offer me a full regime, as explained in my book.

2. You can’t start on HRT, on the other hand, if your periods stopped ten or more years ago.

The recommended limit to starting HRT is ten years from when your periods stopped. This ten year 'ideal window' is also used in other countries, so this is fairly normal. It's in place as the efficiency of HRT lowers if started later, even as the risks rise. Some doctors can be found who will still prescribe outside this window, but it's rare.

3. There is no recommended limit to how long you can be on it.

If your doctor is saying you can only stay on HRT for 5 years, they have not read the new guidelines. Which now state that there is no recommended limit. While the guidelines do suggest that coming off it as soon as possible is ideal, they also support that it needs to be decided on an individual basis.

4. The guidelines say to prescribe body identical progesterone or dydrogesterone.

While all oestrogen* on the HRT market is essentially 'body identical', progesterone has 'synthetic' versions. These new guidelines recommend body identical, 'micronised' progesterone be prescribed. Or dydrogesterone, which is a synthetic. They do NOT recommend any other synthetic.

Dydrogesterone is the only synthetic that seems to do well in studies. It's a medication that has been prescribed since the1960s, and I think the French respect its historical efficacy. Note that countries like the UK now prescribe body identicals more than dydrogesterone.

I personally take the micronised progesterone as it mimics the progesterone already in your body. Dydrogesterone isn’t really progesterone, but a 'progestogen', a type of medication that produces effects in the body similar to natural progesterone.

Note that progesterone is added for women who have not had a hysterectomy, to prevent the risk of endometrial cancers. If you’ve had a hysterectomy you are generally given oestrogen only.

(*The guidelines do however recommend against oestrogen tablets, as taking oestrogen orally has a higher risk of blood clots.)

5. There is no mention of testosterone in the recommendations.

Testosterone is not mentioned in these official guidelines, or indeed licensed for use here as part of HRT for menopausal women. But I met a doctor who told me her colleagues have recently been discussing how it should indeed be prescribed. Plus I had four different doctors agree to give it to me here by now. So the testosterone issue has a growing tide of disagreement starting.... keep the hope ladies!

Andrea-Marie has lived in France for the better part of a decade. She is the author of 'HRT in France'.

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