What the NICE menopause guideline says

A menopause appointment doesn’t always need a hormone blood test. NICE says otherwise healthy people aged 45 or over can be assessed without lab tests if they have the typical symptoms. Hot flushes or sweats that have recently started, together with changes to your periods, can help a clinician recognise perimenopause.

The NICE menopause guideline was updated in November 2024. This advice changed recently. NICE also reviewed the guideline on 15 April 2026 and changed its advice about bleeding while taking systemic hormone replacement therapy (HRT). Systemic HRT works throughout the body. The 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 situation only. It can’t explain every change in bleeding.

Younger people may need tests. NICE says clinicians can consider an FSH blood test for people aged 40 to 45 who have menopause symptoms and a change in their cycle. Premature ovarian insufficiency (when the ovaries stop working normally at a young age) needs its own check. One blood test can’t confirm it.

CBT is an option alongside other care

NICE recommends offering HRT for hot flushes and sweats caused by menopause. It also says to consider cognitive behavioural therapy (CBT) designed for menopause. This can be used alongside HRT, when HRT can’t be used, or when someone would rather not take it.

The guideline includes menopause CBT for sleep problems linked to hot flushes and sweats. Ask what a local programme covers and how the sessions work. Talk about what you’d like help with as you think about your treatment options.

Reading the HRT risk tables

NICE looks at combined HRT and oestrogen-only HRT separately. Combined HRT is usually offered to people who have a womb. Oestrogen-only HRT is offered after a total hysterectomy (removal of the womb and cervix). The tables set out the risks and benefits for each health outcome separately.

Outcome	What NICE says
Breast cancer	Combined HRT raises the risk, and the risk is greater the longer you use it. Oestrogen-only HRT has very little or no rise in risk.
Blood clots in veins	HRT taken by mouth raises the risk. Transdermal HRT, absorbed through the skin, does not.
Fragility fractures	The risk falls while you take HRT. The benefit fades after treatment stops.
Life expectancy	Overall, combined or oestrogen-only HRT is unlikely to change it.

The breast cancer comparisons apply to people who have never had breast cancer. If you have had breast cancer, ask your clinician which guidance applies to you.

NICE also describes a very small rise in deaths from breast cancer with combined HRT. The guidance looks at getting breast cancer and dying from it separately. If your clinician uses a figure, ask what outcome it measures and over what time.

What the newer fezolinetant recommendation adds

Fezolinetant is an option for moderate to severe hot flushes and night sweats when HRT isn’t suitable. The current NICE guideline points to TA1143, 2026. This appraisal says the NHS in England must fund it for the people it’s recommended for, when it’s the most suitable option.

NICE says the evidence shows it works better than a placebo (a dummy treatment). It’s less clear how it compares with other non-hormonal medicines. The FDA warns of rare but serious liver damage. It requires liver blood tests before and during treatment. Your prescriber needs to talk through those checks with you.

Contact your prescriber straight away (UK, US and elsewhere), or an urgent medical service if you can’t reach them, if you get new unusual tiredness, nausea or vomiting, unusual itching, yellow skin or eyes, dark urine, pale stools, or swelling or pain in your tummy while taking fezolinetant. Follow the urgent safety instructions in the leaflet straight away. Don’t wait for a routine blood test or a call back before you follow them.

Where BMS and US advice differ

The British Menopause Society (BMS) welcomes the updated guideline, but points out the limits of a partial update. Its statement supports using the guidance with care, as it can’t cover every situation.

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

The FDA has also approved changes to the boxed warning for a first group of six hormone therapy products. These removed statements about the risk of heart and blood vessel disease, breast cancer and probable dementia. NICE’s risk tables are still separate UK guidance. Ask about the current information for the product you’re considering.

When to ask for a review

Book a GP review in the UK, or see your doctor in the US and elsewhere, if treatment isn’t helping or side effects carry on. NICE recommends a review at 3 months, then once a year, or sooner if needed. It recommends specialist menopause advice if symptoms don’t get better or side effects don’t go away.

Contact your prescriber soon (UK, US and elsewhere) about unplanned bleeding while using systemic HRT. This matters most if it is heavy or long-lasting, or first starts more than six months after starting or three months after changing HRT. Don’t wait for your yearly review. What happens next depends on your bleeding pattern, your HRT and your medical history.