1. Why this matters for MRCGP

Menopause is high-yield because AKT commonly tests when not to request follicle-stimulating hormone (FSH), who needs combined rather than oestrogen-only hormone replacement therapy (HRT), and what bleeding needs cancer assessment.

In SCA, it often presents as a patient worried about hot flushes, mood, sleep, sex, fertility, HRT risk, or “brain fog”.

The GP risk is either over investigating normal perimenopause, or missing pregnancy, cancer-type bleeding, premature ovarian insufficiency, unsafe HRT, or the ongoing need for contraception.

Practical use matters because HRT choice, vaginal oestrogen, fezolinetant, testosterone monitoring, contraception and HRT review all have safety rules.

2. GP Bottom Line

• In otherwise healthy people aged 45 or over with typical menopause-associated symptoms, diagnose clinically; do not routinely use FSH.
• Urgency changes with postmenopausal bleeding, postcoital bleeding, intermenstrual bleeding, sudden bleeding change, ovarian-type symptoms, or significant unscheduled bleeding on HRT.
• If systemic HRT is used: uterus = combined HRT; total hysterectomy = oestrogen-only HRT, unless endometriosis changes the plan. In people with a uterus, regimen choice also depends on whether they are perimenopausal or postmenopausal.
• Key trap: HRT is not contraception, and unopposed systemic oestrogen in someone with a uterus increases endometrial cancer risk.

3. 60 Second Exam Snapshot

• Menopause is usually diagnosed after 12 months of amenorrhoea; perimenopause is irregular cycles plus symptoms before that.
• Consider FSH only in selected situations: suspected premature ovarian insufficiency (POI) under 40, menopause-associated symptoms aged 40–45, or people over 50 using progestogen-only contraception when menopausal status is needed for contraception decisions, especially if amenorrhoeic and wanting to stop before 55. Do not use FSH to identify menopause in people using combined hormonal contraception, high-dose progestogen or HRT.
• POI is under 40 with symptoms/no or infrequent periods and elevated FSH on 2 samples 4–6 weeks apart. Unless contraindicated, POI management should include hormonal treatment with HRT or a combined hormonal contraceptive until at least the usual age of menopause, with specialist menopause/reproductive medicine input where diagnosis, cause or management is uncertain. HRT is not contraception and spontaneous pregnancy can still occur.
• Offer HRT for vasomotor symptoms if suitable; consider menopause-specific cognitive behavioural therapy (CBT), especially if HRT is unsuitable or not preferred.
• Vaginal oestrogen is first-line for genitourinary symptoms in people without a personal history of breast cancer, including those already using systemic HRT. If there is a personal history of breast cancer, offer non-hormonal moisturisers or lubricants first; if symptoms persist, consider vaginal oestrogen only with appropriate specialist input, especially if the person is taking an aromatase inhibitor.
• Review treatment after 3 months, then at least annually.
• Fezolinetant is non-hormonal for moderate to severe vasomotor symptoms when HRT is unsuitable, but needs liver function monitoring and clear liver injury safety-netting.

4. Recognition and Diagnosis

• Suspect perimenopause or menopause when there is a change in menstrual pattern plus symptoms such as hot flushes, night sweats, mood change, sleep disturbance, urogenital symptoms or altered sexual function.
• Cycle length may shorten to 2–3 weeks or lengthen to months. Bleeding amount may change, but abnormal bleeding must not be dismissed as “just perimenopause”.
• Assessment should cover symptoms, impact on quality of life, lifestyle, contraception, smear/screening status, family history, previous treatments, current medicines, comorbidities and treatment wishes. Check blood pressure and body mass index (BMI).
• Do not routinely perform pelvic examination unless clinically indicated or needed to exclude another cause.
• Consider alternatives: pregnancy, amenorrhoea causes, heavy menstrual bleeding causes, thyroid disease, anxiety, depression, sleep disorders, drug effects, infection, lichen sclerosus, and gynaecological malignancy where symptoms suggest it.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

• Age 45 or over with typical symptoms: clinical diagnosis.
• Menopause: no period for at least 12 months and not using hormonal contraception.
• Hysterectomy: diagnose from symptom pattern, for example vasomotor symptoms.
• POI: under 40; do not diagnose from one blood test.

Investigation

• Pregnancy test if amenorrhoea could be pregnancy.
• Consider FSH only in selected situations: suspected POI under 40, menopause-associated symptoms aged 40–45, or people over 50 using progestogen-only contraception when menopausal status is needed for contraception decisions. Do not use FSH to identify menopause in people using combined hormonal contraception, high-dose progestogen or HRT.
• Do not routinely use anti-Müllerian hormone for premature ovarian insufficiency.
• Lipids and HbA1c may support cardiovascular risk assessment.

Management

• Offer HRT for vasomotor symptoms if suitable.
• People with a uterus need endometrial protection. In perimenopause, this is usually sequential combined HRT, with oestrogen daily and progestogen for part of the cycle. After menopause, continuous combined HRT uses oestrogen and progestogen daily. Women taking sequential HRT over age 45 should be offered a change to continuous combined HRT after 5 years of use or by age 54, whichever comes first.
• Consider menopause-specific CBT for vasomotor symptoms, sleep problems or depressive symptoms associated with menopause.
• Do not routinely offer selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors or clonidine first-line for vasomotor symptoms alone.

Medicines / safety

• Uterus present: combined oestrogen plus progestogen HRT.
• Total hysterectomy: oestrogen-only HRT.
• Hysterectomy plus endometriosis: combined HRT may be needed.
• Increased venous thromboembolism risk, including BMI over 30 kg/m²: consider transdermal rather than oral HRT.

Follow-up

• Review HRT or non-hormonal treatment at 3 months, then annually, or earlier if ineffective or adverse effects occur. At review, check symptom response, tolerability, adverse effects, bleeding pattern, weight and blood pressure, and re-discuss benefits and risks. Adjust dose, preparation or route if needed.

6. SCA Consultation Essentials

This often appears as: “I think I’m menopausal; do I need a blood test?” or “I want HRT but I’m worried about cancer.”

• Gather: age, cycle pattern, last period, contraception, pregnancy possibility, bleeding pattern, hot flushes, sleep, mood, concentration, urinary symptoms, vaginal dryness, dyspareunia, libido, work impact, medical history, family history and medicines.
• The communication pivot is to normalise the life transition while taking symptoms seriously: explain that symptoms can be mild or severe and may affect work, relationships and wellbeing.
• Be explicit about choices. Do not push HRT or dismiss it. Explain why uterus status changes HRT type, why contraception may still be needed, and when bleeding needs assessment.
• Safety-net specifically: new postmenopausal bleeding, postcoital bleeding, intermenstrual bleeding, heavy or prolonged bleeding on HRT, and HRT stop pending assessment symptoms. Stop HRT pending assessment and seek urgent help for sudden severe chest pain, sudden breathlessness, coughing blood, one-sided calf swelling or severe calf pain, severe new or unusual headache, sudden vision loss, speech disturbance, collapse, new seizure, sudden weakness or numbness, jaundice, or blood pressure above 160/95 mmHg.

7. Red Flags / Escalation / Referral

Refer to a healthcare professional with expertise in menopause if symptoms persist despite treatment, adverse effects continue, treatment choice is uncertain, contraindications or comorbidities complicate care, premature ovarian insufficiency is uncertain, or symptoms occur after past gender-affirming hormone therapy.

Arrange urgent suspected cancer referral if gynaecological cancer is suspected. Bleeding triggers include sudden menstrual-pattern change, intermenstrual bleeding, postcoital bleeding and postmenopausal bleeding.

Unscheduled bleeding on HRT

• Unscheduled bleeding can occur in the first 6 months after starting systemic HRT or within 3 months of changing the dose or preparation.
• If there are no endometrial cancer risk factors and bleeding is within these timeframes, offer progestogen or HRT adjustment for up to 6 months in total.
• Use the BMS risk-factor pathway: urgent suspected cancer referral is needed with one major risk factor, such as BMI ≥40, Lynch/Cowden syndrome, oestrogen only HRT for more than 6 months in someone with a uterus, or tricycling HRT for more than 12 months, or with three minor risk factors, such as BMI 30–39, diabetes, polycystic ovarian syndrome (PCOS)/anovulatory cycles, or shorter unopposed oestrogen or inadequate progestogen exposure.
• Arrange urgent transvaginal ultrasound within 6 weeks for heavy or prolonged bleeding, two minor risk factors, or first bleeding more than 6 months after starting HRT or more than 3 months after changing it.
• Refer on a suspected cancer pathway if endometrium is >4 mm on continuous combined HRT or >7 mm on sequential HRT.

Ovarian type symptoms

• Persistent or frequent ovarian type symptoms, particularly more than 12 times per month, should prompt NICE ovarian cancer assessment rather than being dismissed as menopause or irritable bowel syndrome (IBS). In people aged 40 or over, this includes CA125 testing and ultrasound according to the NICE pathway.
• Refer urgently to a gynaecological cancer service if examination identifies ascites or a pelvic/abdominal mass that is not obviously fibroids, or if ultrasound suggests ovarian cancer. New IBS type symptoms from age 50 should not simply be labelled IBS.
• Stop HRT pending assessment and seek urgent help for sudden severe chest pain, sudden breathlessness, coughing blood, one sided calf swelling or severe calf pain, severe new or unusual headache, sudden vision loss, speech disturbance, collapse, new seizure, sudden weakness or numbness, jaundice, or blood pressure above 160/95 mmHg.

8. What the GP Should Do Today

• Assess symptoms, bleeding, quality of life impact, contraception, pregnancy risk, comorbidities, medicines, family history and screening status.
• Check blood pressure and BMI.
• Investigate only where indicated: pregnancy test, selected FSH, cardiovascular risk bloods, or cancer pathway tests/referral if symptoms fit.
• Discuss options: lifestyle measures, HRT, CBT, vaginal oestrogen, moisturisers/lubricants, and non-hormonal options where appropriate.
• Prescribe safely: choose combined or oestrogen only HRT according to uterus/endometriosis status; consider transdermal route in higher venous thromboembolism or cardiovascular risk.
• Contraception: explain HRT is not contraception; review method and age related stopping rules.
  • HRT is not contraception. If not using hormonal contraception, contraception is usually needed for 2 years after the last menstrual period if this occurs between 40 and 50, and for 1 year after the last menstrual period if over 50. In general, contraception can stop at age 55.
  • Combined hormonal contraception (CHC) should be stopped for contraception at age 50 and changed to a safer method. In over 50 progestogen-only contraception users with amenorrhoea who want to stop before 55, FSH can guide stopping: if FSH is >30 IU/L, continue contraception for one more year.
  • A 52 mg levonorgestrel intrauterine device (LNG-IUD) inserted at age 45 or over can remain for contraception until 55, but if used for HRT endometrial protection it must be changed every 5 years.
• Review HRT at 3 months, then at least annually, or earlier if ineffective or adverse effects occur. At review, check symptom response, tolerability, adverse effects, bleeding pattern, weight and blood pressure, and re-discuss benefits and risks. Adjust dose, preparation or route if needed.

9. Practical Use in GP: How to Apply This Topic

Before use

• Confirm whether symptoms fit menopause, perimenopause or premature ovarian insufficiency.
• Check for pregnancy possibility and abnormal bleeding.
• Check uterus status, endometriosis history, breast cancer/venous thromboembolism/cardiovascular disease history, liver disease, migraine, diabetes, thyroid disease and current medicines.

Starting / advising

• Systemic HRT: use the lowest effective dose and review regularly.
• People with a uterus need endometrial protection. In perimenopause, combined HRT is usually sequential; after menopause, it is usually continuous combined. Women taking sequential HRT over age 45 should be offered a change to continuous combined HRT after 5 years of use or by age 54, whichever comes first.
• Vaginal oestrogen is first-line for genitourinary symptoms in people without a personal history of breast cancer, including those already using systemic HRT. Cream, gel, tablet, pessary or ring can be chosen with the patient. If there is a personal history of breast cancer, offer non-hormonal moisturisers or lubricants first; if symptoms persist, consider vaginal oestrogen only with appropriate specialist input, especially if the person is taking an aromatase inhibitor.
• Moisturisers and lubricants: moisturisers at least twice weekly; lubricants at sexual activity; oil-based lubricants can weaken condoms.
• A 52 mg LNG-IUD can provide endometrial protection with oestrogen HRT for 5 years.
• HRT is not contraception. (See stopping rules in Section 8).

Monitoring

• Review HRT at 3 months, then at least annually; check response, tolerability, adverse effects, bleeding, weight, blood pressure and ongoing benefit-risk balance.
• Fezolinetant: check ALT, AST, ALP and bilirubin before treatment, monthly for 3 months, then periodically.
• For low sexual desire associated with menopause, consider testosterone only if HRT alone is not effective (after discussing with specialist) and other causes have been excluded. Explain that this is off-label, evidence is limited, long-term safety data are limited, and adverse effects can include excess hair growth, acne and weight gain. Prescribe in line with local guidance (specialist initiated). Check baseline testosterone, recheck 3–6 weeks after starting, then every 6–12 months.

Do not

• Use HRT as contraception.
• Use oestrogen-only systemic HRT in someone with a uterus.
• Use HRT to prevent cardiovascular disease or dementia.
• Do not recommend unregulated or compounded bioidentical hormone preparations; their efficacy and safety are unknown. This is separate from regulated HRT preparations.

10. Medicines, Investigations and Intervention Safety

Systemic HRT

• Combined HRT means oestrogen plus progestogen. Continuous combined HRT uses both daily; sequential combined HRT uses oestrogen daily and progestogen for part of the cycle. Progestogen protects the endometrium from unopposed oestrogen.
• People with a uterus need endometrial protection. (See rules above).
• Do not prescribe systemic HRT in current/past/suspected breast cancer, oestrogen-dependent cancer, undiagnosed vaginal bleeding, untreated endometrial hyperplasia, previous idiopathic or current venous thromboembolism, active/recent arterial thromboembolic disease, acute/active liver disease, pregnancy or thrombophilic disorder.
• Breast-cancer risk discussion should be individualised rather than oversimplified; distinguish systemic HRT from low dose vaginal oestrogen and discuss personal risk factors, HRT type and duration.
• In people taking levothyroxine, monitor thyroid stimulating hormone (TSH) after starting oral HRT, for example at 6–12 weeks, because the levothyroxine dose may need adjustment.

Vaginal oestrogen

• Vaginal oestrogen is first-line for genitourinary symptoms in people without a personal history of breast cancer.
• Local absorption is minimal. Serious adverse effects are very rare. A progestogen is not needed for endometrial protection with low dose vaginal oestrogen. Symptoms often return when it is stopped.
• If there is a personal history of breast cancer, offer non-hormonal moisturisers or lubricants first.

Fezolinetant

• Fezolinetant is a non-hormonal neurokinin-3 receptor antagonist for moderate to severe vasomotor symptoms when HRT is unsuitable.
• Check ALT, AST, ALP and bilirubin before treatment, monthly for 3 months, then periodically.
• Avoid in known or higher-risk liver disease, moderate to severe hepatic impairment, and estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m².
• Do not start if ALT, AST or total bilirubin is ≥2× upper limit of normal (ULN).
• Stop if transaminases exceed 5× ULN, or are ≥3× ULN with bilirubin >2× ULN or liver-injury symptoms.
• Advise urgent help for fatigue, itching, jaundice, dark urine, pale stools, nausea, vomiting, reduced appetite or abdominal pain.
• Perimenopausal people of childbearing potential should use effective non-hormonal contraception during treatment.

Testosterone

• For low sexual desire associated with menopause, consider testosterone only if HRT alone is not effective and other causes have been excluded (initiated by specialist). Explain that this is off-label.
• Prescribe in line with local guidance. Check baseline testosterone, recheck 3–6 weeks after starting, then every 6–12 months.

Contraception

• HRT is not contraception.
• If not using hormonal contraception, contraception is usually needed for 2 years after the last menstrual period if this occurs between 40 and 50, and for 1 year after the last menstrual period if over 50.
• In general, contraception can stop at age 55.
• CHC should be stopped for contraception at age 50 and changed to a safer method.
• In over 50 progestogen-only contraception users with amenorrhoea who want to stop before 55, FSH can guide stopping: if FSH is >30 IU/L, continue contraception for one more year.
• A 52 mg LNG-IUD inserted at age 45 or over can remain for contraception until 55, but if used for HRT endometrial protection it must be changed every 5 years.

11. How to Explain It to the Patient

“The pattern of your symptoms and periods often tells us more than a blood test at this age.”

“HRT can help symptoms, but the safest type depends on whether you still have a womb and on your own risk factors.”

“If you still have a womb, oestrogen needs to be balanced with a progestogen to protect the womb lining.”

“HRT does not work as contraception, so we need to check whether you still need contraception.”

“Vaginal oestrogen works mainly where it is applied, and only a minimal amount is absorbed into the bloodstream.”

“If you have had breast cancer, we usually start with non-hormonal vaginal moisturisers or lubricants, and involve specialist advice if vaginal oestrogen is being considered.”

“Some bleeding can happen in the first few months after starting or changing HRT, but bleeding after the expected adjustment period, bleeding after sex, or bleeding after menopause needs checking rather than assuming it is hormonal.”

12. When the Plan Changes

If the person is under 40 with menopause symptoms and no or infrequent periods:

• Why this changes the plan: premature ovarian insufficiency is possible.
• What the GP does now: check FSH on 2 samples 4–6 weeks apart and do not diagnose from one blood test. Refer or seek specialist menopause/reproductive medicine advice if diagnosis, cause or management is uncertain. Unless contraindicated, discuss hormonal treatment with HRT or a combined hormonal contraceptive until at least the usual age of menopause. Explain that HRT is not contraception and spontaneous pregnancy can still occur.

If the person has a uterus and wants systemic HRT:

• Why this changes the plan: oestrogen alone increases endometrial cancer risk.
• What the GP does now: offer combined HRT or ensure adequate progestogen protection. In perimenopause this is usually sequential combined HRT; after menopause it is usually continuous combined HRT.

If there is personal history of breast cancer or high breast cancer risk:

• Why this changes the plan: systemic HRT is not routine and options need specialist input.
• What the GP does now: offer information, non-hormonal options and referral to menopause expertise. For genitourinary symptoms, use non-hormonal moisturisers or lubricants first; consider vaginal oestrogen only if symptoms persist and with appropriate specialist input, especially with aromatase inhibitor use.

If HRT bleeding is heavy, prolonged, late-onset or risk-factor positive:

• Why this changes the plan: endometrial cancer risk must be assessed.
• What the GP does now: arrange urgent ultrasound or suspected cancer referral according to risk and timing.

If venous thromboembolism risk is increased:

• Why this changes the plan: oral HRT carries higher venous thromboembolism risk than transdermal HRT.
• What the GP does now: consider transdermal HRT and seek specialist/haematology advice if high risk.

If the person takes levothyroxine and starts oral HRT:

• Why this changes the plan: oral HRT may affect thyroid replacement requirements.
• What the GP does now: monitor TSH after starting oral HRT, for example at 6–12 weeks, because the levothyroxine dose may need adjustment.

13. Common AKT / SCA Traps

• Requesting FSH for a typical symptomatic person aged 45 or over.
• Using FSH to identify menopause in someone using combined hormonal contraception, high-dose progestogen or HRT.
• Forgetting that FSH in over 50 progestogen-only contraception users is mainly a contraception stopping decision, especially if amenorrhoeic and wanting to stop before 55.
• Calling one raised FSH “premature ovarian insufficiency”.
• Under managing POI by missing specialist input, hormonal treatment until at least the usual age of menopause, or the fact that HRT is not contraception.
• Forgetting pregnancy as a cause of amenorrhoea.
• Giving oestrogen-only systemic HRT to someone with a uterus.
• Assuming HRT provides contraception.
• Missing bleeding that needs cancer assessment.
• Not reviewing HRT after 3 months and annually, including symptoms, tolerability, adverse effects, bleeding, weight, blood pressure and benefit-risk balance.
• Prescribing fezolinetant without liver function monitoring, start/stop thresholds, liver disease cautions or non-hormonal contraception advice where relevant.

14. Common Exam Angles

• Angle: 48 year old with hot flushes and irregular periods asking for blood tests.
  • Hidden challenge: FSH is not routinely needed.
  • What the candidate must not miss: contraception and abnormal bleeding screen.
• Angle: 52 year old with a uterus requesting HRT.
  • Hidden challenge: oestrogen alone is unsafe for the endometrium.
  • What the candidate must not miss: combined HRT or adequate progestogen, with continuous combined HRT usually used after menopause.
• Angle: Postmenopausal patient with vaginal dryness and recurrent urinary symptoms.
  • Hidden challenge: local treatment may be enough.
  • What the candidate must not miss: vaginal oestrogen, moisturisers/lubricants, breast cancer history caveat, and review.
• Angle: New bleeding after HRT.
  • Hidden challenge: timing and endometrial cancer risk factors decide urgency.
  • What the candidate must not miss: expected early bleeding window, risk-factor pathway, urgent ultrasound or suspected cancer referral thresholds.

15. 90 Second Audio Summary Script

Menopause is usually a clinical diagnosis. In a healthy person aged 45 or over with typical symptoms, do not reach for FSH. Think symptoms, cycle change, impact on life, contraception, comorbidities and bleeding pattern.

Use FSH only in selected situations: suspected POI under 40, symptoms aged 40–45, or over 50 progestogen-only contraception users when menopausal status is needed for contraception decisions, especially if amenorrhoeic and wanting to stop before 55. Do not use FSH to identify menopause in people using combined hormonal contraception, high-dose progestogen or HRT.

The big AKT rule is uterus status. If systemic HRT is used and the person has a uterus, they need combined HRT. In perimenopause this is usually sequential; after menopause it is usually continuous combined. If they have had a total hysterectomy, oestrogen-only HRT is usually used, unless endometriosis changes the plan.

Genitourinary symptoms are common and often under discussed. Low dose vaginal oestrogen is first line in people without a personal history of breast cancer, can be used with systemic HRT, and works mainly locally. If there is a personal history of breast cancer, start with non-hormonal moisturisers or lubricants and use specialist input if vaginal oestrogen is being considered.

Do not forget contraception: HRT is not contraception. If not using hormonal contraception, contraception is usually needed for 2 years after the last period if it occurs between 40 and 50, and for 1 year if it occurs over 50. Contraception can usually stop at 55, and combined hormonal contraception should be changed at 50 for contraceptive use.

Bleeding is the danger area. Postmenopausal bleeding, postcoital bleeding, intermenstrual bleeding, sudden bleeding change, or concerning bleeding on HRT needs assessment and sometimes urgent referral.

Review treatment after 3 months, then annually, and keep the consultation practical: symptoms, safety, patient priorities, and what should prompt urgent help.

References

• British Menopause Society (BMS) (2022) Menopause practice standards. Marlow: British Menopause Society. Available at: https://thebms.org.uk/wp-content/uploads/2022/07/BMS-Menopause-Practice-Standards-JULY2022-01D.pdf (Accessed: 27 April 2026).
• Collaborative Group on Hormonal Factors in Breast Cancer (2019) ‘Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence’, The Lancet, 394(10204), pp. 1159–1168. doi:10.1016/S0140-6736(19)31709-X.
• Faculty of Sexual and Reproductive Healthcare (FSRH) (2025a) FSRH Guideline: Contraception for women aged over 40 years. August 2017, amended May 2025. London: FSRH. Available at: https://www.fsrh.org/standards-and-guidance/documents/fsrhguidance-contraception-for-women-aged-over-40-years-2017/ (Accessed: 27 April 2026).
• Faculty of Sexual and Reproductive Healthcare (FSRH) (2025b) FSRH Guideline: Intrauterine contraception. March 2023, amended January 2025. London: FSRH. Available at: https://www.cosrh.org/Public/Public/Standards-and-Guidance/Intrauterine-Contraception.aspx (Accessed: 27 April 2026).
• Hamoda, H. (2022) ‘British Menopause Society tools for clinicians: Progestogens and endometrial protection’, Post Reproductive Health, 28(1), pp. 40–46. doi:10.1177/20533691211058030.
• Joint Formulary Committee (2026a) ‘Estradiol’, British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/drugs/estradiol/ (Accessed: 27 April 2026).
• Joint Formulary Committee (2026b) ‘Fezolinetant’, British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/drugs/fezolinetant/ (Accessed: 27 April 2026).
• Joint Formulary Committee (2026c) ‘Hormone replacement therapy’, British National Formulary: Interactions. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/interactions/hormone-replacement-therapy/ (Accessed: 27 April 2026).
• Joint Formulary Committee (2026d) ‘Progesterone’, British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/drugs/progesterone/ (Accessed: 27 April 2026).
• Joint Formulary Committee (2026e) ‘Sex hormones’, British National Formulary: Treatment summaries. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/treatment-summaries/sex-hormones/ (Accessed: 27 April 2026).
• Manley, K., Hillard, T., Clark, J., Kumar, G., Morrison, J., Hamoda, H., Barber, K., Holloway, D., Middleton, B., Oyston, M., Pickering, M., Sassarini, J. and Williams, N. (2024) ‘Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time’, Post Reproductive Health, 30(2), pp. 95–116. doi:10.1177/20533691241254413.
• Medicines and Healthcare products Regulatory Agency (MHRA) (2019) Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping. Drug Safety Update. Available at: https://www.gov.uk/drug-safety-update/hormone-replacement-therapy-hrt-further-information-on-the-known-increased-risk-of-breast-cancer-with-hrt-and-its-persistence-after-stopping (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (MHRA) (2025) Fezolinetant▼ (Veoza): risk of liver injury; new recommendations to minimise risk. Drug Safety Update. Available at: https://www.gov.uk/drug-safety-update/fezolinetantv-veoza-risk-of-liver-injury-new-recommendations-to-minimise-risk (Accessed: 27 April 2026).
• National Health Service (NHS) (2022a) Menopause. NHS.UK. Available at: https://www.nhs.uk/conditions/menopause/ (Accessed: 27 April 2026).
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• National Institute for Health and Care Excellence (NICE) (2024) Urinary tract infection (recurrent): antimicrobial prescribing. NICE guideline NG112. London: NICE. Available at: https://www.nice.org.uk/guidance/ng112 (Accessed: 27 April 2026).
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• National Institute for Health and Care Excellence (NICE) (2026b) Suspected cancer: recognition and referral. NICE guideline NG12. London: NICE. Available at: https://www.nice.org.uk/guidance/ng12 (Accessed: 27 April 2026).
• National Institute for Health and Care Excellence (NICE) (2026c) Fezolinetant for treating moderate to severe vasomotor symptoms associated with menopause. Technology appraisal guidance TA1143. London: NICE. Available at: https://www.nice.org.uk/guidance/ta1143 (Accessed: 27 April 2026).
• North American Menopause Society (NAMS) (2022) ‘The 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7), pp. 767–794. doi:10.1097/GME.0000000000002028.
• Panay, N. (2022) ‘British Menopause Society Tool for clinicians: Testosterone replacement in menopause’, Post Reproductive Health, 28(3), pp. 158–160. doi:10.1177/20533691221104266.
• Panay, N. et al. (2024) ‘Evidence-based guideline: premature ovarian insufficiency’, Human Reproduction Open, 2024(4), hoae065. doi:10.1093/hropen/hoae065.
• Royal College of General Practitioners (RCGP) (2025) Gynaecology and breast health. RCGP Curriculum Topic Guide. London: RCGP. Available at: https://www.rcgp.org.uk/mrcgp-exams/gp-curriculum/gynaecology-and-breast-health (Accessed: 27 April 2026).
• Santoro, N., Roeca, C., Peters, B.A. and Neal-Perry, G. (2021) ‘The menopause transition: signs, symptoms, and management options’, Journal of Clinical Endocrinology and Metabolism, 106(1), pp. 1–15. doi:10.1210/clinem/dgaa764.
• Stuenkel, C.A., Davis, S.R., Gompel, A., Lumsden, M.A., Murad, M.H., Pinkerton, J.V. and Santen, R.J. (2015) ‘Treatment of symptoms of the menopause: an Endocrine Society clinical practice guideline’, Journal of Clinical Endocrinology and Metabolism, 100(11), pp. 3975–4011. doi:10.1210/jc.2015-2236.

Important Disclaimer

This MedDigest MRCGP Topic Essentials is an independent educational and revision resource, created to support exam preparation only. It is not a clinical guideline, prescribing resource, or a substitute for your own professional judgment.

This content is designed to highlight exam-relevant clinical principles, management pathways, and consultation approaches in a concise format. Any example explanations, consultation wording, scenario angles, or summary scripts are illustrative and should not be used as stand-alone clinical advice.

This resource has not been produced, reviewed, or endorsed by NICE, the Royal College of General Practitioners, or any other official organisation.

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