What the NICE menopause guideline says

A menopause appointment does not always need a hormone blood test. NICE says otherwise healthy people aged 45 or over can be assessed without laboratory tests when they have the relevant symptoms. Newly started hot flushes or sweats together with menstrual cycle changes can support a clinician’s assessment of perimenopause.

The NICE menopause guideline was updated in November 2024. Advice has changed recently: NICE also reviewed the guideline on 15 April 2026 and amended advice about bleeding while taking systemic hormone replacement therapy (HRT). Its recommendations now include the separate fezolinetant appraisal.

What assessment without tests means

For menopause itself, NICE’s approach in this age group includes having no period for at least 12 months while not using hormonal contraception. This guidance applies to that particular situation. It cannot explain every change in bleeding.

Younger people may need tests. NICE says clinicians can consider an FSH blood test in people aged 40 to 45 who have menopause-associated symptoms and a change in their cycle. Premature ovarian insufficiency needs a separate assessment; a single blood test cannot confirm it.

CBT is an option alongside other care

NICE recommends offering HRT for hot flushes and sweats associated with menopause. It also says to consider menopause-specific cognitive behavioural therapy, or CBT, alongside HRT, when HRT cannot be used, or when someone prefers not to take it.

The guideline includes menopause-specific CBT for sleep problems associated with hot flushes and sweats. Ask what a local programme covers and how the sessions work. Discuss what you would like help with as you consider the treatment options.

Reading the HRT risk tables

NICE separates combined HRT from oestrogen-only HRT. Combined HRT is generally offered to people with a womb; oestrogen-only HRT is offered after a total hysterectomy. The tables set out the risks and benefits for each health outcome separately.

Outcome	What NICE says
Breast cancer	Combined HRT increases risk, with greater risk as use lasts longer. Oestrogen-only HRT has very little or no increase in risk.
Blood clots in veins	Oral HRT increases risk; transdermal HRT, absorbed through the skin, does not increase it.
Fragility fractures	Risk falls while taking HRT; the benefit decreases after treatment stops.
Life expectancy	Overall, combined or oestrogen-only HRT is unlikely to change it.

The breast cancer comparisons apply to people without a personal history of breast cancer. If you have had breast cancer, ask your clinician which guidance applies to you.

NICE also describes a very small increase in death from breast cancer with combined HRT. The guidance considers developing breast cancer and dying from it separately. Ask the clinician to explain the outcome and comparison period behind any figure they use.

What the newer fezolinetant recommendation adds

Fezolinetant is an option for moderate to severe hot flushes and night sweats when HRT is unsuitable. The current NICE guideline points to TA1143, 2026. The appraisal says it must be funded in NHS England for the recommended population when considered the most suitable option.

NICE says evidence supports improvement compared with placebo, but comparisons with other non-hormonal medicines remain uncertain. The FDA warns of rare but serious liver injury and requires liver blood tests before and during treatment. Your prescriber needs to discuss those checks with you.

Contact your prescriber immediately (UK, US and elsewhere), or an urgent medical service if unavailable, if you develop new unusual tiredness, nausea or vomiting, unusual itching, yellow skin or eyes, dark urine, pale stools, abdominal swelling or pain while taking fezolinetant. Follow the leaflet’s urgent safety instructions immediately; do not wait for a routine blood test or a callback to follow them.

Where BMS and US advice differ

The British Menopause Society welcomes the updated guideline while highlighting limitations in the partial update. Its statement supports careful use of the guidance, which cannot cover every clinical situation.

US wording differs in some areas. The Menopause Society lists certain antidepressants, gabapentin and oxybutynin as off-label options for hot flashes. NICE says antidepressants and clonidine should not routinely be the first treatment for hot flushes and sweats alone.

The FDA has also approved changes removing cardiovascular disease, breast cancer and probable dementia risk statements from the boxed warning for an initial group of six hormone therapy products. NICE’s risk tables remain separate UK guidance. Ask about the current information for the product being considered.

When to ask for a review

Book a GP review in the UK, or see your doctor in the US and elsewhere, if treatment is not helping or side effects continue. NICE recommends review at 3 months, then annually, with earlier review when needed. It recommends specialist menopause advice when symptoms fail to improve or side effects persist.

Contact your prescriber promptly (UK, US and elsewhere) about unscheduled bleeding while using systemic HRT, especially if it is heavy or prolonged, or first appears more than six months after starting or three months after changing HRT. Do not wait for your annual review. Assessment depends on your bleeding pattern, HRT regimen and medical history.