Menopause and HRT Guidance UK 2026: NICE Recommends Fezolinetant and Updates NG23

Two pieces of UK menopause guidance changed in 2026. NICE recommended fezolinetant (Veoza) as a non-hormonal option for moderate to severe vasomotor symptoms when HRT is unsuitable — technology appraisal TA1143, published 31 March 2026, with around 500,000 people estimated to be eligible. And NICE updated NG23, the menopause guideline, on 15 April 2026 with revised advice on unscheduled bleeding while taking systemic HRT. HRT remains first-line throughout.

This post is a plain-English summary for busy clinicians. We summarise; we do not replace NICE, and nothing here substitutes for clinical judgement on individual patients.

The headline: a non-hormonal option for vasomotor symptoms

The substantive development is fezolinetant. It is the first NK3 (neurokinin-3) receptor antagonist NICE has recommended for menopause, and it gives UK clinicians a genuinely non-hormonal route for the patients who need one.

The detail that matters in clinic:

• What it is. Fezolinetant (Veoza, Astellas) — a 45mg tablet, once daily. It blocks the brain pathway that drives hot flushes and night sweats, rather than acting on hormones.
• Who it is for. Moderate to severe vasomotor symptoms in people for whom HRT is unsuitable — those who cannot take it, or choose not to. NICE estimates around 500,000 eligible.
• Funding. Where it is the most suitable option for an eligible patient, the NHS in England must fund it within 90 days of final publication.

HRT remains first-line

This is the line NICE has been careful to hold, and it is worth repeating. Fezolinetant does not displace HRT. NICE states that HRT remains the first-line treatment for menopausal symptoms, and positions fezolinetant as the option for people who are unable or unwilling to use it.

For most patients with vasomotor symptoms and no contraindication, the first conversation is still about HRT. Fezolinetant widens the second conversation — the one that previously offered fewer evidence-backed pharmacological choices.

The safety point that will shape prescribing

Fezolinetant has been associated with hepatotoxicity. NICE advises liver function tests before starting and periodically during treatment. In practice this is the operational detail that distinguishes it from a simple swap-in: it carries a monitoring schedule, and that schedule needs to be set up at initiation. The BNF entry for fezolinetant is the authoritative source for the monitoring interval and cautions.

The NG23 update (15 April 2026)

Separately from the fezolinetant appraisal, NICE updated the NG23 menopause guideline on 15 April 2026. This was a targeted amendment, not a rewrite. It revised the advice — within the section on starting HRT — on when to seek medical help for unscheduled vaginal bleeding while taking systemic HRT.

The practical point: the safety-netting wording you give a patient starting systemic HRT has changed. If you use a template or a patient information leaflet for HRT initiation, it is worth checking it against the current NG23 wording so the bleeding advice matches.

What this means for UK practice

For GPs and menopause clinics, the 2026 picture is: HRT first, as before; fezolinetant as a recommended non-hormonal option for moderate to severe vasomotor symptoms when HRT is unsuitable, with LFT monitoring built in; and a refreshed safety-netting line for unscheduled bleeding on systemic HRT.

The highest-yield action is small: update your HRT-initiation safety-netting to the current NG23 wording, and add fezolinetant — with its monitoring requirement — to your local pathway for patients who cannot use HRT. Local formulary and ICB or Health Board positions should be checked before prescribing.

A note on what this post is — and is not

This is a guideline summary for awareness. It is not a substitute for the NICE guidance itself, the BNF, or local prescribing policy. Where there is doubt, NICE TA1143 and NICE NG23, plus the BNF entry for fezolinetant, should be consulted. Clinical decisions remain the responsibility of the prescribing clinician.

The Monday Clinical Brief publishes weekly summaries of the most important new papers and guideline updates across 31 UK medical specialties — including the kind of guideline change covered here. We do not replace the source documents. We surface them, summarise them, and link to them, so practice-changing material does not get missed in a busy clinical week. For the wider picture on staying current, see our pillar guide on how to keep up with the medical literature.

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