People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
NICE guidelines set out the care and services suitable for people with a specific condition or need, and people in particular circumstances or settings. We aim to improve quality by ensuring that people receive the best care and advice. Using inclusive language in healthcare is important for safety, and to promote equity, respect and effective communication with everyone.
Some recommendations in this guideline do not use inclusive language because:
the evidence has not been reviewed, and expert opinion is that groups covered by these recommendations cannot be extended or
the evidence has been reviewed, but the information available for some groups was too limited to make specific recommendations.
Healthcare professionals should use their clinical judgement when implementing the recommendations, taking into account each person's circumstances, needs and preferences, and ensuring all people are treated with dignity and respect throughout their care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
This guideline covers women, trans men and non-binary people registered female at birth, who currently have menopause-associated symptoms or who will experience menopause in the future. The guideline does not cover people who are currently having gender-affirming hormone therapy. For trans men and non-binary people who have taken such therapy in the past and are no longer taking it, only recommendations 1.5.34 and 1.5.35 in the section on gender affirming therapy and the recommendation for research on the impact of hormone replacement therapy (HRT) on health outcomes for these groups of people apply. All other recommendations apply to women, trans men and non-binary people registered female at birth who have never taken gender-affirming hormone therapy.
Tailor your approach to the person at all times when identifying, discussing, investigating and managing menopause, and adapt the approach if symptoms change over time. Follow the recommendations in NICE's guideline on patient experience in adult NHS services. [2015]
For general principles on how to discuss symptom management plans with people, including how to communicate risks, benefits and consequences, see NICE's guideline on shared decision making. [2024]
Share information about menopause with people who have associated symptoms or are approaching menopause, and their family members or carers (as appropriate). This information should include all of the following:
what menopause is, including that it is a life transition which:
usually takes place in mid-life and
can also happen earlier because of surgery or medical treatment, an inherited condition, or an unknown cause
commonly associated symptoms (see recommendation 1.2.2)
interventions, or changes the person can make to support their health and wellbeing. [2015, amended 2024]
Explain that symptoms associated with menopause may vary from minor to severe and be experienced over short or long time periods. As well as changes in menstrual cycle, symptoms may include:
vasomotor symptoms (hot flushes and sweats)
genitourinary symptoms (for example, vaginal dryness)
effects on mood (for example, depressive symptoms)
musculoskeletal symptoms (for example, joint and muscle pain)
sexual difficulties (for example, low sexual desire). [2015]
Share information about contraception with people who have menopause-associated symptoms. See, for example, the Faculty of Sexual and Reproductive Healthcare guidance on contraception for women aged over 40 years. [2015]
Give advice on bone health to people experiencing menopause and discuss bone health with them at review appointments (see NICE's guideline on assessing the risk of fragility fracture in people with osteoporosis). [2015]
Explain to people experiencing menopause the importance of maintaining muscle mass and strength through physical activity. [2015, amended 2024]
Offer support and provide information about menopause and fertility to people who are likely to experience menopause as a result of medical or surgical treatment. Do this before and after they have their treatment. [2015, amended 2024]
Offer psychological support to people who are experiencing early menopause (that is, menopause between the ages of 40 and 44) and are distressed by their diagnosis or its consequences. If needed, refer them to psychology services. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see rationale and impact section on psychological support for early menopause.
Full details of the evidence and the committee's discussion are in evidence review I: early menopause.
Identify the following, without laboratory tests, in otherwise healthy women, trans men and non-binary people registered female at birth who are aged 45 or over and have menopause-associated symptoms:
perimenopause, if they have vasomotor symptoms that have recently started and any changes in their menstrual cycle
menopause, if they have not had a period for at least 12 months and are not using hormonal contraception
menopause, in those who have had a hysterectomy, based on the type and combination of symptoms they have (for example, vasomotor symptoms). [2015]
Take into account that it can be difficult to identify menopause in people who are taking hormonal treatments, for example, for the treatment of heavy menstrual bleeding. [2015]
Be aware that people from some ethnic minority backgrounds and people with some lifelong conditions may experience menopause at a younger age. [2024]
Do not use the following laboratory and imaging tests to identify perimenopause or menopause in people aged 45 or over:
anti-Müllerian hormone
inhibin A
inhibin B
oestradiol
antral follicle count
ovarian volume. [2015]
Do not use a follicle-stimulating hormone (FSH) blood test to identify menopause in people using combined oestrogen and progestogen contraception or high-dose progestogen. [2015]
Consider using the person's serum FSH level to confirm menopause only:
in people aged 40 to 45 with menopause-associated symptoms, including a change in their menstrual cycle
in people under 40 in whom menopause is suspected (see also diagnosing and managing premature ovarian insufficiency). [2015]
See also the recommendations on offering psychological support to:
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on identifying perimenopause and menopause.
Full details of the evidence and the committee's discussion are in evidence review I: early menopause.
This section only covers people aged 40 or over. For younger (under 40) women, trans men and non-binary people registered female at birth, see the recommendations on diagnosing and managing premature ovarian insufficiency, including what to discuss with the person.
Discuss with the person the benefits and risks associated with each potential management option for menopause-associated symptoms. [2024]
When discussing hormone replacement therapy (HRT) as a possible treatment for menopause-associated symptoms (in line with the recommendations on managing symptoms associated with menopause in people aged 40 and over), talk about the benefits and risks associated with:
combined versus oestrogen-only HRT (see the recommendation and its rationale on indications for combined and oestrogen-only HRT, in the section on starting HRT about which of the 2 types of HRT the person would be offered, and why)
transdermal versus oral HRT
types of oestrogen and progestogen
dose and duration. [2024]
Tailor the information about benefits and risks to the person's age, individual circumstances and potential risk factors. Use the information in managing symptoms associated with menopause in people aged 40 or over, and in the effect of HRT on specific health outcomes in people aged 40 or over to support this discussion.
If a person chooses to take HRT:
discuss the possible duration of treatment at the outset
at every review, rediscuss the benefits and risks of continuing treatment (see the section on reviewing treatment for anyone)
explain that symptoms may return when HRT is stopped and discuss the option of restarting treatment if necessary. [2024]
When discussing cognitive behavioural therapy (CBT) as a possible management option for symptoms associated with menopause, explain what CBT is (including menopause-specific CBT) and talk about the available options, taking into account the person's preferences and needs, for example:
face-to-face or remote sessions
individual or group sessions
self-help options. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on discussing management options with people aged 40 or over.
Full details of the evidence and the committee's discussion are in:
Explain to people with menopause-associated symptoms that the efficacy and safety of unregulated hormone preparations are unknown. [2015]
Explain to people who wish to try complementary therapies for menopause-associated symptoms, that the safety, quality and purity of constituents in unregulated preparations may be unknown. [2015]
Explain to people that there is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms associated with menopause. However, explain that:
multiple preparations are available, and their safety is uncertain
different preparations may vary
interactions with other medicines have been reported. [2015]
Advise people with a personal history of, or at high risk of, breast cancer that, although there is some evidence that St John's wort may help relieve vasomotor symptoms associated with menopause, there is uncertainty about:
appropriate dosage
persistence of effect
variation in the nature and potency of preparations
potential serious interactions with other medicines (including tamoxifen, anticoagulants and anticonvulsants). [2015]
This section only covers people aged 40 or over. For younger (aged under 40) women, trans men, and non-binary people registered female at birth, see the recommendations on diagnosing and managing premature ovarian insufficiency.
For information about how comorbidities, contraindications and medical history might affect management choices, see taking medical history into account before offering treatment.
The benefits and risks of hormone replacement therapy (HRT) described in this guideline only cover the use of HRT within the licensed dosages.
Making decisions using NICE guidelines has information about prescribing medicines.
Offer HRT to people with vasomotor symptoms associated with menopause. [2015]
Consider menopause-specific cognitive behavioural therapy (CBT) as an option for vasomotor symptoms associated with menopause:
in addition to HRT or
for people for whom HRT is contraindicated or
for those who prefer not to take HRT. [2024]
Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone. [2015]
For a short explanation of why the committee made the 2024 recommendation on CBT and how it might affect practice, see the rationale and impact section on CBT for vasomotor symptoms.
Full details of the evidence and the committee's discussion are in evidence review A: cognitive behavioural therapy.
Offer vaginal oestrogen to people with genitourinary symptoms associated with menopause (including those using systemic HRT) and review regularly as per the recommendations on reviews in this guideline. [2024]
When discussing the option of vaginal oestrogen, explain that:
serious adverse effects are very rare
their treatment should be reviewed in line with recommendations 1.9.2 and 1.9.3 in the section on reviewing treatment
symptoms often return when vaginal oestrogen is stopped but treatment can be restarted if necessary
vaginal oestrogen is absorbed locally – a minimal amount is absorbed into the bloodstream (when compared with systemic HRT), but this is unlikely to have a significant effect throughout the body. [2024]
When someone chooses vaginal oestrogen, make a shared decision with the person about whether to use an oestrogen cream, gel, tablet, pessary or ring. [2024]
Advise people with genitourinary symptoms associated with menopause that vaginal oestrogen can be used on its own or in combination with non-hormonal moisturisers or lubricants. [2024]
For people with genitourinary symptoms in whom vaginal oestrogen preparations are contraindicated, or for people who would prefer not to use vaginal oestrogen, consider non-hormonal vaginal moisturisers or lubricants. [2024]
Consider vaginal prasterone for genitourinary symptoms if vaginal oestrogen, or non-hormonal moisturisers or lubricants have been ineffective or are not tolerated. [2024]
Consider ospemifene as an oral treatment for genitourinary symptoms, if the use of locally applied treatments is impractical, for example, because of disability. [2024]
For the use of vaginal oestrogen in people with genitourinary symptoms and an overactive bladder, see the section on choosing medicines for an overactive bladder, in NICE's guideline on managing urinary incontinence and pelvic organ prolapse in women. [2024]
For the use of vaginal oestrogen in people with genitourinary symptoms and recurrent urinary tract infections, see the recommendations on oestrogen in NICE's guideline on recurrent urinary tract infection (UTI) and the patient decision aid on reducing the chance of recurrent UTI in postmenopausal women. [2024]
For anyone who has been given any treatment for genitourinary symptoms associated with menopause, see the recommendations on reviewing treatment.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on genitourinary symptoms associated with menopause in people with no personal history of breast cancer.
Full details of the evidence and the committee's discussion are in evidence review B1: managing genitourinary symptoms (network meta-analyses).
Offer non-hormonal moisturisers or lubricants to people with a personal history of breast cancer and genitourinary symptoms associated with menopause. [2024]
Consider vaginal oestrogen for people with a personal history of breast cancer and genitourinary symptoms that have continued despite trying non-hormonal treatments (see also recommendation 1.5.15 for people receiving adjuvant aromatase inhibitor treatment for breast cancer). Vaginal oestrogen may be used in combination with a non-hormonal moisturiser or a lubricant.
In November 2024, this was an off-label use of vaginal oestrogen. See NICE's information on prescribing medicines. [2024]
For people currently having aromatase inhibitors as adjuvant treatment for breast cancer, work with a breast cancer specialist to identify treatment options for genitourinary symptoms that have continued despite trying non-hormonal treatments.
When assessing the safety of vaginal oestrogens for someone in relation to breast cancer recurrence, take into account all of the following:
the person's general risk factors for breast cancer recurrence (see recommendations 1.7.7 and 1.7.8 in NICE's guideline on early and locally advanced breast cancer for the definitions of medium or high risk and of low risk of recurrence)
it is unknown whether vaginal oestrogen affects the risks of breast cancer recurrence
vaginal oestrogen is absorbed locally, and some of it is absorbed into the bloodstream but compared with oestrogen from systemic HRT, the amount is minimal. [2024]
For people with a personal history of oestrogen receptor negative breast cancer, recognise that any oestrogen systemically absorbed from taking vaginal oestrogen is unlikely to increase the risk of breast cancer recurrence, and so it is likely to be safe. [2024]
For people with a personal history of oestrogen receptor positive breast cancer, recognise that:
it is unknown whether any oestrogen systemically absorbed from taking vaginal oestrogen could increase the risk of breast cancer recurrence and
adjuvants that block oestrogen receptors in cancer cells (for example, tamoxifen) would reduce any such potential impact. [2024]
For anyone who has been given any treatment for genitourinary symptoms associated with menopause, see the recommendations on reviewing treatment.
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on genitourinary symptoms associated with menopause in people with a personal history of breast cancer.
Full details of the evidence and the committee's decision are in evidence review B2: managing genitourinary symptoms (breast cancer recurrence).
Do not offer vaginal laser treatment for genitourinary symptoms associated with menopause unless as part of a randomised controlled trial (see also NICE's interventional procedures guidance on transvaginal laser therapy for urogenital atrophy). [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on vaginal laser treatment.
Full details of the evidence and the committee's discussion are in evidence review B2: managing genitourinary symptoms (breast cancer recurrence).
Consider HRT to alleviate depressive symptoms (not meeting the criteria for a diagnosis of depression) with onset around the same time as other symptoms associated with menopause. [2015, amended 2024]
Consider CBT as an option for people who have depressive symptoms (not meeting the criteria for a diagnosis of depression) in association with vasomotor symptoms:
in addition to other management options or
for people for whom other options are contraindicated or
for those who prefer not to try other options. [2024]
For people experiencing menopause who are suspected to have or have been diagnosed with depression, follow the recommendations in this guideline alongside the recommendations in NICE's guideline on treating and managing depression in adults to achieve an optimal management plan. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on management options for depressive symptoms or depression in people with menopause-associated symptoms.
Full details of the evidence and the committee's discussion are in evidence review A: cognitive behavioural therapy.
Consider menopause-specific CBT as an option for people who have sleep problems (such as night-time awakening) in association with vasomotor symptoms:
in addition to other management options (including HRT) or
for people for whom other options are contraindicated or
for people who prefer not to try other options. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on CBT for sleep problems associated with menopause.
Full details of the evidence and the committee's discussion are in evidence review A: cognitive behavioural therapy.
Consider testosterone supplementation for people with low sexual desire associated with menopause if HRT alone is not effective. [2015]
In this guideline, medical history covers both personal history and family history (for example, of breast cancer).
Consider referring people to a healthcare professional with expertise in menopause if:
they have symptoms associated with menopause and contraindications to HRT or
there is uncertainty about the most suitable management options for their symptoms. [2015]
Consider HRT for menopause-associated symptoms in people with type 2 diabetes after taking comorbidities into account and seeking specialist advice if needed. [2015]
Consider transdermal rather than oral HRT for people with menopause-associated symptoms who are at increased risk of venous thromboembolism (VTE), including those with a body mass index (BMI) over 30 kg/m2. [2015]
Consider referring people with menopause-associated symptoms who are at high risk of VTE (for example, those with a strong family history of VTE or a hereditary thrombophilia) to a haematologist for assessment before considering HRT. [2015]
For people with a personal history of coronary heart disease or stroke, ensure that combined or oestrogen-only HRT is discussed with and offered, if appropriate, by a healthcare professional with expertise in menopause. [2024]
In November 2024, use of combined or oestrogen-only HRT in people with active or recent arterial thromboembolic disease was off-label. See NICE's information on prescribing medicines.
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on taking coronary heart disease or stroke into account before offering treatment.
Full details of the evidence and the committee's discussion are in evidence review C: cardiovascular disease and stroke.
Offer people with menopause-associated symptoms and who have a personal history, or are at high risk, of breast cancer:
information on all management options available to them
referral to a healthcare professional with expertise in menopause. [2015, amended 2024]
For advice on the treatment of menopause-associated symptoms in people with a personal history of breast cancer or at high risk of breast cancer, see the section on menopause symptoms in NICE's guideline on early and locally advanced breast cancer and the section on risk reduction and treatment strategies in NICE's guideline on familial breast cancer. [2015]
Also see the section on complementary therapy and unregulated preparations in this guideline.
Offer people who are likely to experience menopause as a result of medical or surgical treatment the opportunity to discuss fertility, both before and after they have their treatment, with a healthcare professional with expertise in fertility. [2015, amended 2024]
Offer people who are likely to experience menopause as a result of medical or surgical treatment the opportunity to discuss menopause, both before and after they have their treatment, with a healthcare professional with expertise in menopause. [2015, amended 2024]
Ensure that trans men or non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past and have symptoms associated with menopause can discuss these with a healthcare professional with expertise in menopause. [2024]
Consider menopause-specific CBT for vasomotor symptoms, difficulties with sleep or depressive symptoms associated with menopause for trans men and non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past. CBT could be used:
in addition to other management options or
for people for whom other options are contraindicated or
for those who prefer not to try other options. [2024]
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on managing menopause in people who have taken gender-affirming hormone therapy in the past.
Full details of the evidence and the committee's discussion are in evidence review C: cardiovascular disease and stroke.
The benefits and risks of hormone replacement therapy (HRT) described in this guideline only cover the use of HRT within the licensed dosages.
Making decisions using NICE guidelines has information about prescribing medicines.
See the recommendation for people in early menopause (ages 40 to 44), for information on the effect of either taking or not taking HRT in early menopause on specific health outcomes.
When discussing HRT as a treatment option for menopause-associated symptoms, explain that, overall, taking either combined HRT or oestrogen-only HRT is unlikely to affect life expectancy. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on effect of HRT on life expectancy in people aged 45 or over.
Full details of the evidence and the committee's discussion are in evidence review H: all-cause mortality.
This recommendation is for people with a uterus (see recommendation 1.8.1 on what type of HRT to offer).
When talking about combined HRT as a treatment option:
discuss different combined HRT options to identify the one that best balances benefits and risks for the person
share information from table 1: effect of combined HRT versus no HRT on specific health outcomes
refer to the discussion aid on HRT and the likelihood of some medical conditions to provide information on the extent of benefits and risks associated with HRT. [2024]
See also the:
recommendations on discussing benefits and risks of HRT, including the need to tailor the treatment to the person's age, personal circumstances and potential risk factors and
| – | Baseline risk | How does taking combined hormone replacement therapy (HRT) impact the risks related to this outcome? | Does the way combined HRT is taken affect these risks? | Does the type of hormone affect these risks? |
|---|---|---|---|---|
| All-cause mortality (life expectancy) |
– |
Overall, life expectancy is unlikely to change with the use of combined HRT. [2024] |
– |
– |
| Cancer: breast (Information in this table applies to people with no personal history of breast cancer) |
Breast cancer risk varies depending on a person's modifiable and non-modifiable risk factors. [2024] |
Breast cancer risk increases with combined HRT and the increase:
There is a very small increase in risk of death from breast cancer with combined HRT. Use the discussion aid on HRT for the number of breast cancer cases per 1,000 people taking combined HRT over a 5- or 10- year period. [2024] |
Breast cancer risk with sequential combined HRT is:
|
There is insufficient evidence to establish whether the increase in risk of breast cancer is different with preparations containing micronised progesterone or dydrogesterone from what it is with preparations containing other progestogens. [2024] |
| Cancer: endometrial (Information in this table applies to people with no personal history of endometrial cancer) |
– |
– |
Endometrial cancer risk decreases with continuous combined HRT (use the discussion aid on HRT for the number of endometrial cancer cases per 1,000 people taking combined HRT over a 5-year period). [2024] Endometrial cancer risk may slightly increase with sequential combined HRT, and the increase may be greater with:
|
– |
| Cancer: ovarian (Information in this table applies to people with no personal history of ovarian cancer) |
The baseline population risk of ovarian cancer in women aged under 60 is very low (use the discussion aid on HRT for the number of ovarian cancer cases per 1,000 people over a 5-year period). [2024] |
In people with ovaries, there is a very slight increase in ovarian cancer risk with combined HRT (use the discussion aid on HRT for the number of ovarian cancer cases per 1,000 people over a 5-year and a 10-year period). [2024] |
– |
– |
| Coronary heart disease (Information in this table applies to people with no personal history of coronary heart disease) |
– |
Coronary heart disease risk does not increase with combined HRT (use the discussion aid on HRT for the number of coronary heart disease cases per 1,000 people over a 5-year period.) [2024] Mortality from cardiovascular disease does not increase with combined HRT. [2024] |
– |
– |
| Dementia |
– |
Dementia risk might increase with combined HRT if it is started at 65 or over (use the discussion aid on HRT for the number of dementia cases per 1,000 people over a 4-year period). [2024] |
– |
– |
| Muscle mass and strength |
– |
There is limited evidence suggesting that HRT may improve muscle mass and strength. [2015] |
– |
– |
| Osteoporosis |
The baseline population risk of fragility fracture:
(Use the discussion aid on HRT for the incidence of fragility fractures in women not taking HRT.) [2015] |
Fragility fracture risk is decreased while taking HRT and this benefit:
(Use the discussion aid on HRT for the incidence of fragility fractures in women taking HRT.) [2015] |
– |
– |
| Stroke (Information in this table applies to people with no personal history of stroke) |
The baseline population risk of stroke in women aged under 60 is very low. [2024] |
– |
Stroke risk is unlikely to increase with the use of combined HRT that includes transdermal oestrogen (see the discussion aid on HRT, for the number of stroke cases per 1,000 people over a 5-year period). [2024] Stroke risk increases with combined HRT containing oral oestrogen and the increase:
(See the discussion aid on HRT, for the number of stroke cases per 1,000 people over a 5-year period.) [2024] |
– |
| Type 2 diabetes |
– |
The risk of developing type 2 diabetes does not increase with HRT. [2015] Generally, no adverse effect on blood glucose control is reported when taking HRT. [2015] |
The risk is not affected whether HRT is taken orally or transdermally. [2015] |
– |
| Venous thromboembolism (VTE) |
– |
VTE risk is not increased with transdermal HRT. [2015] |
VTE risk is increased with oral HRT. [2015] VTE risk is greater with oral than transdermal HRT. [2015] |
– |
Table 1 lists the differences in specific health outcomes between people who are taking or have taken combined HRT, and those who have never had HRT.
The statements from 2015 in tables 1 and 2 do not distinguish between combined and oestrogen-only HRT. These statements have been included in both tables to better support discussions.
A downloadable version of this table is also available.
For a short explanation of why the committee made the 2024 recommendations and how they might affect practice, see the rationale and impact section on effect of combined HRT on specific health outcomes in people aged 45 or over.
Full details of the evidence and the committee's discussion are in:
This recommendation is for people who have had a total hysterectomy (see recommendation 1.8.1 on what type of HRT to offer).
When talking about oestrogen-only HRT as a treatment option:
discuss different oestrogen-only HRT options to identify the one that best balances benefits and risks for the person
share information from table 2: effect of oestrogen-only HRT versus no HRT on specific health outcomes
refer to the discussion aid on HRT and the likelihood of some medical conditions to provide information on the extent of benefits and risks associated with HRT. [2024]
See also the:
recommendation on discussing benefits and risks of HRT, including the need to tailor the treatment to the person's age, personal circumstances and potential risk factors and
| – | Baseline risk | How does taking oestrogen-only hormone replacement therapy (HRT) impact the risks related to this outcome? | Does the way oestrogen-only HRT is taken affect these risks? | Does the type of hormone taken affect these risks? |
|---|---|---|---|---|
| All-cause mortality (life expectancy) |
– |
Overall, life expectancy is unlikely to change with the use of oestrogen-only HRT. [2024] |
– |
– |
| Cancer: breast (Information in this table applies to people with no personal history of breast cancer) |
Breast cancer risk varies depending on a person's modifiable and non-modifiable risk factors. [2024] |
There is very little or no increase in breast cancer risk with oestrogen-only HRT. There is little or no increase in the risk of breast cancer mortality with oestrogen-only HRT. Use the discussion aid on HRT for the number of breast cancer cases per 1,000 people taking oestrogen-only HRT over a 5- or 10-year period. [2024] |
– |
Breast cancer risk is similar with oestradiol and with conjugated equine oestrogen. [2024] |
| Cancer: endometrial (Information in this table applies to people with no personal history of endometrial cancer) |
– |
In people with a uterus, endometrial cancer risk increases with oestrogen-only HRT (use the discussion aid on HRT for the number of endometrial cancer cases per 1,000 people taking oestrogen-only HRT over a 5-year period). [2024] See also recommendation 1.8.1 on which type of HRT to offer depending on whether people have a uterus or not in the section on starting HRT. [2024] |
In people with a uterus, endometrial cancer risk increases with both oral and transdermal oestrogen-only HRT. [2024] |
– |
| Cancer: ovarian (Information in this table applies to people with no personal history of ovarian cancer) |
The baseline population risk of ovarian cancer in women aged under 60 is very low. (Use the discussion aid on HRT for the number of ovarian cancer cases per 1,000 people over a 5-year period). [2024] |
In people with ovaries, ovarian cancer risk increases very slightly after 5 years of using oestrogen-only HRT and this risk increases with duration of use (use the discussion aid on HRT for the number of ovarian cancer cases per 1,000 people over a 5-year and a 10-year period). [2024] |
Ovarian cancer risk increases with both transdermal and oral oestrogen-only HRT. [2024] |
– |
| Coronary heart disease (Information in this table applies to people with no personal history of coronary heart disease) |
– |
Coronary heart disease risk does not increase with oestrogen-only HRT (use the discussion aid on HRT for the number of coronary heart disease cases per 1,000 people over a 5-year period). [2024] Mortality from cardiovascular disease does not increase with oestrogen-only HRT. [2024] |
– |
– |
| Dementia |
– |
Dementia risk is unlikely to increase with oestrogen-only HRT (see the discussion aid on HRT for the number of dementia cases per 1,000 people over a 5-year period). [2024] |
– |
– |
| Muscle mass and strength |
– |
There is limited evidence suggesting that HRT may improve muscle mass and strength. [2015] |
– |
– |
| Osteoporosis |
The baseline population risk of fragility fracture:
(Use the discussion aid on HRT for the incidence of fragility fractures in women.) [2015] |
Fragility fracture risk is decreased while taking HRT and this benefit:
(Use the discussion aid on HRT for the incidence of fragility fractures in women.) [2015] |
– |
– |
| Stroke (Information in this table applies to people with no personal history of stroke) |
The baseline population risk of stroke in women aged under 60 is very low. [2024] |
– |
Stroke risk increases with oral oestrogen-only HRT and the increase:
(See the discussion aid on HRT, for the number of stroke cases per 1,000 people over a 5-year period.) [2024] Stroke risk is unlikely to increase with transdermal oestrogen-only HRT (see the discussion aid on HRT, for the number of stroke cases per 1,000 people over a 5-year period). [2024] |
– |
| Type 2 diabetes |
– |
The risk of developing type 2 diabetes does not increase with HRT. [2015] Generally, no adverse effect on blood glucose control is reported when taking HRT. [2015] |
The risk is not affected whether HRT is taken orally or transdermally. [2015] |
– |
| Venous thromboembolism (VTE) |
– |
VTE risk is not increased with transdermal HRT. [2015] |
VTE risk is increased with oral HRT. [2015] VTE risk is greater with oral than transdermal HRT. [2015] |
– |
Table 2 lists the differences in specific health outcomes between people who are taking or have taken oestrogen-only HRT, and those who have never had HRT.
The statements from 2015 in tables 1 and 2 do not distinguish between combined and oestrogen-only HRT. These statements have been included in both tables to better support discussions.
A downloadable version of this table is also available.
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on effect of oestrogen-only HRT on specific health outcomes in people aged 45 or over.
Full details of the evidence and the committee's discussion are in:
Do not offer combined or oestrogen-only HRT for primary or secondary prevention of cardiovascular disease. For guidance on ways to reduce the risk of cardiovascular disease (for example, lifestyle changes), refer to NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on cardiovascular disease prevention.
Full details of the evidence and the committee's discussion are in evidence review C: cardiovascular disease and stroke.
Do not offer combined or oestrogen-only HRT for the purpose of dementia prevention. For dementia prevention, see NICE's guideline on dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on dementia prevention.
Full details of the evidence and the committee's discussion are in evidence review C: cardiovascular disease and stroke.
When discussing HRT as a treatment option, explain to people experiencing early menopause that, for them, the benefits and risks of either taking or not taking HRT are likely to lie between those for people with premature ovarian insufficiency and those for people aged 45 or over. [2024]
See also the recommendations on discussing benefits and risks in the section on HRT and managing symptoms associated with menopause for people aged 40 and over, including the need to tailor the treatment to the person's age, personal circumstances and potential risk factors.
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on effects of HRT in early menopause on specific health outcomes.
Full details of the evidence and the committee's discussion are in evidence review I: early menopause.
Take into account the person's clinical history (for example, previous medical or surgical treatment) and family history when diagnosing premature ovarian insufficiency. [2015]
Diagnose premature ovarian insufficiency in women, trans men and non-binary people registered female at birth who are under 40 based on:
menopause-associated symptoms, including no or infrequent periods (taking into account whether the person has had a hysterectomy) and
elevated follicle stimulating hormone (FSH) levels on 2 blood samples taken 4 to 6 weeks apart. [2015]
Do not diagnose premature ovarian insufficiency on the basis of a single blood test. [2015]
Do not routinely use anti-Müllerian hormone testing to diagnose premature ovarian insufficiency. [2015]
If there is doubt about the diagnosis of premature ovarian insufficiency, refer the person to a specialist with expertise in menopause or reproductive medicine. [2015]
Offer sex steroid replacement with a choice of hormone replacement therapy (HRT) or a combined hormonal contraceptive to people with premature ovarian insufficiency, unless contraindicated (for example, in people with hormone-sensitive cancer). [2015]
Explain to people with premature ovarian insufficiency:
the importance of starting hormonal treatment either with HRT or a combined hormonal contraceptive and continuing treatment until at least the age of natural menopause (unless contraindicated)
that the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age and is very low in people under the age of 40
that HRT may have a beneficial effect on blood pressure when compared with a combined oral contraceptive
that both HRT and combined oral contraceptives offer bone protection
that HRT is not a contraceptive. [2015]
Give people with premature ovarian insufficiency and contraindications to hormonal treatments advice, including on bone and cardiovascular health, and on symptom management. [2015]
Consider referring people with premature ovarian insufficiency to healthcare professionals with the relevant experience to help them manage all aspects of physical and psychosocial health related to their condition. [2015]
For people who wish to take hormone replacement therapy (HRT) for symptoms associated with menopause:
offer combined HRT to people with a uterus
offer oestrogen-only HRT to people who have had a total hysterectomy.
Also see recommendation 1.8.2. [2024]
For people with a condition that may be affected by HRT, consider seeking advice on the choice of HRT from a healthcare professional with specialist knowledge of that condition. [2024]
If a person chooses to take HRT, use the lowest effective dosage. [2024]
Explain to people with a uterus that vaginal bleeding is a common side effect of systemic HRT within the first 3 months of treatment, and they will be asked about this during their 3-month review. Advise them to seek medical help promptly if they experience vaginal bleeding after 3 months. [2015]
Offer people who are stopping HRT a choice of gradually reducing or immediately stopping treatment. [2015]
Explain to people that:
gradually reducing HRT may limit recurrence of symptoms in the short term
gradually reducing or immediately stopping HRT makes no difference to their symptoms in the longer term. [2015]
Stop systemic HRT in people who are diagnosed with breast cancer in line with the recommendations on menopause symptoms in NICE's guideline on early and locally advanced breast cancer. [2024]
For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on starting and stopping HRT for anyone.
Full details of the evidence and the committee's discussion are in:
Discuss with people the importance of keeping up to date with nationally recommended health screening. [2015]
Review each treatment for symptoms associated with menopause:
at 3 months to assess efficacy and tolerability
annually thereafter, unless there are clinical indications for an earlier review (such as treatment ineffectiveness, side effects or adverse events). [2015]
Refer people to a healthcare professional with expertise in menopause if treatments do not improve their menopause-associated symptoms or they have ongoing side effects. [2015]
This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.
Hormone replacement therapy (HRT) with oestrogen and progestogen.
HRT in which oestrogen and progestogen are taken together, daily.
For the purposes of this guideline, depressive symptoms are any symptoms included in the ICD-11 and DSM-5 criteria for the diagnosis of depression, as reproduced in NICE's guideline on managing and treating depression in adults, but the extent, duration and number of which does not lead to a diagnosis of:
depression, as defined by ICD-11 or DSM-5 or
chronic depressive symptoms, as defined in NICE's guideline on managing and treating depression in adults.
Genitourinary symptoms associated with menopause include vulvovaginal dryness, pain with sex, vulvovaginal discomfort or irritation, and discomfort or pain when urinating.
Healthcare professionals with specialist knowledge, skills and training who can (in collaboration with the relevant specialists) manage, or advise colleagues in managing, complex menopause-related needs and risk factors affecting decision making, including:
complex medical problems that potentially affect use of treatments for menopause associated symptoms
menopause associated symptoms for those at elevated risk of breast or ovarian cancer, or with a personal history of hormone dependent cancer.
Their training should be recognised by a professional body such as the British Menopause Society, the Faculty of Sexual and Reproductive Healthcare or the Royal College of Obstetricians and Gynaecologists.
Sometimes also referred to as combined cyclical HRT. A form of HRT in which oestrogen is taken every day, and the progestogen is taken for usually half of the month.
HRT in which the hormones are absorbed into the bloodstream and have an effect throughout the body. As part of systemic HRT:
oestrogen can be taken orally, or transdermally, as a patch, gel or spray that delivers the hormone through the skin
progestogen can be taken orally, transdermally as a patch, or be delivered through an intrauterine system.