guidelines

menopause

detailed summary of nice ng23: hrt regimens (oestrogen only vs combined), utrogestan dosing, and vaginal oestrogen.

last reviewed: 2026-02-13
based on: NICE NG23 (last updated 07 Nov 2024)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Diagnosis: Clinical (Vasomotor symptoms + Age >45). FSH is NOT required unless Age <45 (POI) or hysterectomy with ovarian conservation.
  • Benefit/Risk: Benefits (symptom relief, bone protection, CV reduction if started <60) usually outweigh risks (small breast ca risk, VTE).
  • Golden Rule: If Uterus present -> Must have Progesterone (Endometrial protection).

HRT Prescribing Algorithm

  • 1. Estrogen (The Benefit):
    • Transdermal (Preferred): Patch (e.g., Estradot 50mcg) or Gel (e.g., Oestrogel 2 pumps). Safest for VTE/BMI >30.
    • Oral: Elleste Solo 1mg/2mg. (Avoid if BMI >30, VTE history, or Gallstones).
  • 2. Progesterone (The Protection): Required if uterus present.
    • Micronised Progesterone (Utrogestan) - Body Identical: Best safety profile for breast/mood.
      • Sequential (Perimenopausal/Cycles): 200mg (2 caps) nocte for days 15-26 of cycle.
      • Continuous (Postmenopausal/No bleed >1y): 100mg (1 cap) nocte every night.
    • Mirena IUS: Gold standard for endometrial protection (licensed for 5 years for HRT).
    • Synthetic Progestogen: (e.g., Provera) if Utrogestan not tolerated.
  • 3. Genitourinary Syndrome (GSM):
    • Vaginal Estrogen (Vagifem / Ovestin). Can be used indefinitely and ALONGSIDE systemic HRT. No progesterone needed if used alone.

Testosterone

  • Indication: Low libido despite optimal systemic HRT.
  • Product: Testogel/Tostran (off-label use common in UK, follow BMS guidelines). Pea-sized amount.
  • Review: Check levels at 3-6 months. Stop if no benefit by 6 months.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.