NICE NG23: Menopause: Diagnosis and Management
Diagnosis of Perimenopause and Menopause
- In women aged 45 and over, identify perimenopause or menopause on the basis of symptoms alone, without laboratory tests, if they have vasomotor symptoms that have recently started together with a change in their menstrual cycle (1.3.1).
- Do not use anti-Müllerian hormone, inhibin A or inhibin B, oestradiol, antral follicle count, or ovarian volume to diagnose perimenopause or menopause (1.3.4).
- In women aged 40–45 with menopause-associated symptoms, consider using serum FSH level to help confirm the diagnosis (1.3.6). FSH testing is unreliable in women using hormonal contraception.
Premature Ovarian Insufficiency (Under 40)
- Diagnose premature ovarian insufficiency in women under 40 on the basis of menopause-associated symptoms (including no or infrequent periods) together with elevated FSH levels measured on two blood samples taken 4–6 weeks apart (1.7.2).
- A single elevated FSH result is not sufficient to confirm the diagnosis (1.7.3).
- Offer psychological support to women experiencing early menopause (aged 40–44) who are distressed by their diagnosis (1.2.7).
HRT: Types, Routes, and Risk/Benefit Counselling
- Offer combined HRT (oestrogen and progestogen) to women with a uterus; offer oestrogen-only HRT to women who have had a hysterectomy (1.8.1).
- Discuss the benefits and risks of transdermal versus oral HRT with each woman (1.4.2).
- Continuous combined HRT is generally preferred over sequential regimens once a woman is postmenopausal, for endometrial protection.
- When discussing benefits and risks, refer to a discussion aid comparing the incidence of relevant medical conditions with and without HRT, to support individualised, shared decision-making (1.6.2, 1.6.3).
Risk Communication
- Breast cancer: risk with combined HRT rises with duration of use, and any increased risk declines after stopping but can persist for at least 10 years.
- Venous thromboembolism (VTE): risk is not increased with transdermal HRT; risk is increased with oral HRT.
- Stroke: risk increases with combined HRT containing oral oestrogen, particularly at higher doses and with longer duration; transdermal HRT does not show the same increased risk.
- Cardiovascular disease: do not offer combined or oestrogen-only HRT for the primary or secondary prevention of cardiovascular disease (1.6.4).
- Be aware of, and advise women about, when to seek help for unscheduled vaginal bleeding while taking systemic HRT.
Non-Hormonal Options for Vasomotor Symptoms
- Consider menopause-specific cognitive behavioural therapy (CBT) for vasomotor symptoms, either in addition to HRT or for women in whom HRT is contraindicated (1.5.2).
- Fezolinetant is recommended as an option for treating moderate to severe vasomotor symptoms when HRT is unsuitable (1.5.3).
- Do not routinely offer SSRIs, SNRIs, or clonidine as first-line treatment for vasomotor symptoms outside of these specific contexts (1.5.4).
Management of Specific Symptoms
Mood and Psychological Symptoms
- Consider HRT to alleviate depressive symptoms (that do not meet criteria for a diagnosis of depression) with onset around the same time as other menopausal symptoms (1.5.21).
- Consider CBT for women with depressive symptoms occurring alongside vasomotor symptoms, in addition to other management options or where other options are contraindicated (1.5.22).
Urogenital/Genitourinary Symptoms
- Offer vaginal oestrogen first-line for genitourinary symptoms, including to women also taking systemic HRT (1.5.5).
- Counsel that symptoms often recur when vaginal oestrogen is stopped, but treatment can be restarted (1.5.6).
- Make a shared decision on formulation — cream, gel, tablet, pessary, or ring (1.5.7).
- Consider non-hormonal vaginal moisturisers or lubricants where hormonal treatment is declined or contraindicated (1.5.9).
- Consider vaginal prasterone if vaginal oestrogen has been ineffective (1.5.10), or ospemifene (oral) if locally applied treatments are impractical (1.5.11).
- In women with a personal history of breast cancer, offer non-hormonal moisturisers/lubricants first-line (1.5.14).
Reduced Libido
- Consider testosterone supplementation for women with low sexual desire associated with menopause if HRT alone has not been effective (1.5.25).
High-Yield Exam Points
- POI diagnosis under 40: symptoms + elevated FSH on 2 samples 4–6 weeks apart — a single FSH is not diagnostic.
- Women 45+ with typical vasomotor symptoms and menstrual cycle change can be diagnosed clinically — no bloods required.
- Transdermal HRT: no increased VTE risk (unlike oral HRT) — key for counselling women with VTE risk factors.
- HRT is not indicated for primary or secondary cardiovascular disease prevention.
- Vaginal oestrogen is first-line for genitourinary symptoms and can be continued long-term/restarted on relapse.
- Fezolinetant: non-hormonal option specifically for moderate-to-severe vasomotor symptoms when HRT is unsuitable.
- SSRIs/SNRIs/clonidine are not first-line for vasomotor symptoms.
Source: National Institute for Health and Care Excellence (NICE) (15 April 2026 (originally published 12 November 2015; title: "Menopause: identification and management"))
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