Introduction
For UK clinicians managing the menopause, two key guidelines are instrumental: the National Institute for Health and Care Excellence (NICE) guideline NG23 (last updated December 2019, with a focused update on HRT in November 2023) and the Royal College of Obstetricians and Gynaecologists (RCOG) Basis of Menopause Care and associated documents (2022, with ongoing updates). While both aim to standardise and improve care, they serve slightly different purposes. NICE provides a comprehensive, evidence-based framework for the NHS in England, Wales, and Northern Ireland. The RCOG documents offer practical, clinician-focused advice, often delving into nuanced clinical scenarios and serving the UK-wide membership. This comparison highlights the synergies and key differences to aid in practical clinical decision-making.
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Diagnosis and Assessment
NICE NG23
- Diagnosis: Diagnosis in women aged over 45 is made clinically based on vasomotor symptoms (VMS) and change in menstrual pattern. NICE advises that follicle-stimulating hormone (FSH) testing is not routinely necessary to confirm diagnosis in this age group.
- Assessment: A comprehensive assessment should include:
- Symptoms, their impact on quality of life, and patient priorities.
- Contraindications to Hormone Replacement Therapy (HRT).
- Cardiovascular and bone health risk factors.
- Lifestyle advice as a core component.
- Key Point: Focuses on a holistic, symptom-led approach without reliance on biochemical testing for most women.
RCOG
- Diagnosis: Aligns with NICE, stating that FSH measurement is not required for women over 45 with typical menopausal symptoms.
- Assessment: Provides a highly practical and detailed framework for the consultation. Emphasises:
- Use of validated symptom questionnaires (e.g., Greene Climacteric Scale).
- A structured approach to discussing benefits/risks of HRT, including detailed counselling on breast cancer risk.
- Specific guidance on assessing women with complex medical histories or premature ovarian insufficiency (POI).
- Key Point: Offers more granular, step-by-step tools for the clinician-patient conversation, particularly around risk communication.
Practical Takeaway: Both guidelines strongly discourage routine FSH testing in women over 45. RCOG provides more explicit consultation tools, while NICE sets the broader standard of care.
Treatment: Hormone Replacement Therapy (HRT)
NICE NG23
- First-line for VMS: HRT is recommended as the most effective treatment for vasomotor symptoms.
- Regimen: For women with a uterus, estrogen plus progestogen (sequential or continuous combined) must be used to prevent endometrial hyperplasia. Estrogen-only HRT is for women without a uterus.
- Durations: No arbitrary limit on duration of use. Treatment should be individualised, with benefits and risks reviewed annually.
- Formulations: Discusses all types (oral, transdermal, etc.) but does not strongly prioritise one over another, except noting transdermal estrogen may be preferable for women at increased risk of venous thromboembolism (VTE).
RCOG
- First-line for VMS: Fully aligns with NICE on HRT's efficacy.
- Regimen & Duration: Also aligns on regimen and individualised duration.
- Key Difference - Formulation Preference: The RCOG, particularly in its patient-facing materials and expert consensus, more strongly advocates for the use of body-identical HRT (micronised progesterone and estradiol) where appropriate. It positions this as a preferred option due to the evidence base for its safety profile, particularly regarding breast cancer risk compared to some synthetic progestogens.
- Practical Prescribing: Provides very specific advice on starting doses, titration, and managing side-effects.
Practical Takeaway: While both endorse HRT, RCOG offers more explicit, practical prescribing support and shows a stronger preference for body-identical regimens, especially micronised progesterone, in its communications.
Special Situations
Premature Ovarian Insufficiency (POI)
- NICE: Recommends HRT at least until the average age of natural menopause (around 51) for bone and cardiovascular protection. Diagnosis in women under 40 requires two elevated FSH measurements (>30 IU/L).
- RCOG: Provides extensive, dedicated guidance on POI. Strongly emphasises the higher doses of HRT often required to control symptoms and achieve physiological hormone levels in younger women. Stresses the importance of adequate estrogen for long-term health.
Contraindications and High-Risk Patients
- Breast Cancer: Both state HRT is generally contraindicated in women with a current or past history of breast cancer. NICE mentions that discussion with an oncologist is needed for exceptional cases, while RCOG explores non-hormonal options in more depth.
- VTE Risk: Both recommend transdermal estrogen as the safer option. RCOG gives more detailed management algorithms for women with a personal or family history of VTE.
Practical Takeaway: RCOG guidance is often more detailed and prescriptive in complex clinical scenarios like POI and managing patients with significant co-morbidities.
Practical Clinical Flow
A synthesis of both guidelines for a typical patient aged 45-55:
- Consultation: Take a full history (symptoms, cycle pattern, PMH, family history, contraindications). Use a symptom score if helpful (RCOG tool).
- Diagnosis: Confirm perimenopause/menopause clinically. Do not order FSH.
- Discussion: Offer comprehensive lifestyle advice. Discuss HRT as first-line effective treatment for VMS. Use RCOG-style risk-benefit charts to explain absolute risks (e.g., breast cancer).
- Prescribing: For a woman with a uterus, consider a body-identical estradiol preparation (patch/gel) with micronised progesterone (RCOG preference), or other suitable HRT. Start with standard dose.
- Follow-up: Review at 3 months for efficacy and side-effects, then annually. Titrate dose as needed. Continue as long as the benefit outweighs the risk for the individual.
Frequently Asked Questions (FAQs) for Clinicians
1. Which guideline should I follow if they conflict?
Direct conflicts are rare. NICE sets the national standard for the NHS. RCOG provides practical, often more detailed, interpretation. In most cases, they are complementary. For NHS practice, NICE is the foundational document, but RCOG's nuanced advice is highly valuable for complex cases.
2. What is the key difference in their approach to HRT and breast cancer risk?
Both cite the same evidence, but RCOG places greater emphasis on the differential risk of progestogens. It more actively promotes the use of micronised progesterone (e.g., Utrogestan) over synthetic progestogens (e.g., medroxyprogesterone acetate, norethisterone) due to a potentially more favourable breast cancer risk profile.
3. A patient requests a "natural" progesterone. What is the guidance?
Clarify terminology. "Body-identical" or "micronised" progesterone (Utrogestan) is a regulated, evidence-based HRT component. "Natural" progesterone creams are unregulated and not recommended by either body. RCOG strongly supports the use of regulated body-identical micronised progesterone.
4. How long can a woman stay on HRT?
Both guidelines agree: there is no mandatory stopping age or duration. Treatment should be individualised, with annual reviews weighing ongoing benefits (symptom control, bone protection) against potential risks.
5. A 48-year-old with irregular periods and symptoms requests an FSH test. How to respond?
Both NICE and RCOG advise that this is not necessary. Explain that the diagnosis can be made confidently based on her age and symptoms. An FSH test can be misleading due to fluctuating levels in perimenopause and may delay treatment.
Source Links
- NICE Guideline NG23: Menopause - [Full Guideline] (NICE NG23)
- NICE Update: Hormone Replacement Therapy (November 2023) - [Update] (NICE NG23 evidence (update PDF))
- RCOG: Basis of Menopause Care (2022) - [Report] (RCOG menopause care (guidance))
- RCOG & BSGE: Management of Premature Ovarian Insufficiency (2016) - [Green-top Guideline] (RCOG Green-top Guideline No. 10)