What NHS guideline NG23 actually says
The controlling document for menopause care in the UK is NHS guideline NG23: Menopause: diagnosis and management. Updated November 2024. The headline positions are:
- HRT is recommended first-line for vasomotor symptoms (hot flushes, night sweats), low mood arising in menopause, and for the prevention of osteoporosis in women under 60.
- Body-identical (estradiol + micronised progesterone) is the standard formulation.
- Diagnosis in women over 45 is on symptoms alone — FSH blood tests are explicitly NOT required.
- The benefits of HRT generally outweigh the risks for most women under 60 or within 10 years of menopause.
A GP refusing on "your bloods are normal" or "you're not in menopause yet" without engaging with NG23 is going against the guideline.
Diagnosis without blood tests
NG23 paragraph 1.2 is unambiguous: in women aged over 45 with menopausal symptoms, diagnose without laboratory tests. FSH levels fluctuate in perimenopause and a "normal" result does not rule it out. The diagnostic test is your symptom pattern — irregular periods, hot flushes, sleep disruption, mood changes, joint pain, brain fog, vaginal dryness, low libido.
If you are under 40, suspected premature ovarian insufficiency does need FSH testing — that is a specific exception in NG23.
What HRT the NHS will prescribe
- Estradiol patches (e.g. Evorel, Estradot). Twice-weekly skin patch. Bypasses the liver — lower clot risk than oral.
- Estradiol gel (e.g. Oestrogel, Sandrena). Daily skin gel.
- Estradiol spray (Lenzetto). Daily underarm spray.
- Oral estradiol (e.g. Elleste Solo). Tablet. Slightly higher clot risk than transdermal.
- Micronised progesterone (Utrogestan). Capsule, body-identical, required if you have a uterus.
- Combined patches (e.g. Evorel Conti, FemSeven Conti).
- Mirena coil as the progesterone component — convenient for many women.
- Vaginal estrogen (Vagifem, Estriol cream, Estring). For local symptoms. Long-term use is safe under NG23, including in many women who cannot take systemic HRT.
What it costs in England
England is the only UK nation that still charges NHS prescription fees. The standard charge is £9.90 per item (2025/26). Most HRT regimens are 2–3 items, which gets expensive fast.
The HRT prepayment certificate (HRT PPC) caps the cost at £19.80 a year for unlimited HRT items. Buy it once, prescribed HRT then costs nothing extra for 12 months. It only covers HRT — other medication still attracts the £9.90 charge unless covered by a standard PPC.
HRT is free at the point of use for everyone in Wales, Scotland and Northern Ireland.
Testosterone for women
Testosterone is unlicensed for use in women in the UK, but NHS guideline NG23 supports its use specifically for low libido that persists despite optimised HRT. The usual NHS preparation is Testogel (a male product, used at one-tenth the male dose) — prescribed off-label.
Many NHS GPs will not initiate testosterone for women because it is off-label — they will refer to a menopause specialist for initiation, then take over prescribing under shared care. That referral is your right under NG23.
If your GP refuses to prescribe
- Ask for the refusal in writing, with the clinical reasoning and the guideline they are relying on.
- Quote NG23 directly: "NHS guideline NG23 recommends HRT first-line for symptomatic perimenopausal and menopausal women, and explicitly does not require FSH testing for diagnosis in women over 45."
- Ask for a same-practice second opinion. You have the right to ask to see a different GP.
- Ask for referral to a menopause specialist or the local Women's Health Hub.
- If the pattern continues, a formal letter setting out the guideline, the symptoms, and the requested outcome is the most effective lever. Finally Seen writes that letter.
Getting an NHS menopause clinic referral
NHS menopause clinics exist in most areas, but referral routes vary. Increasingly, the first step is the local Women's Health Hub. Where local clinic waits are long, Right to Choose lets you pick any NHS-funded provider in England — including specialist menopause services with shorter waits. Your GP must process the referral; the choice of provider is yours.
Frequently asked questions
›Is HRT free on the NHS?
HRT itself is prescribed, not free — the standard NHS prescription charge applies per item (currently £9.90 per item in England, free in Wales, Scotland and Northern Ireland). The HRT prepayment certificate caps your cost at £19.80 a year for unlimited HRT prescriptions in England. HRT is free at the point of use in the rest of the UK.
›Do I need blood tests before my GP will prescribe HRT?
Usually no. NHS guideline NG23 explicitly says routine FSH testing is NOT required to diagnose perimenopause or menopause in women over 45 — diagnosis is on symptoms alone. A GP refusing to prescribe without bloods in a woman over 45 is going against the guideline.
›What if my GP refuses to prescribe HRT?
Ask for the refusal in writing, with their clinical reasoning and the guideline they are relying on. NHS guideline NG23 is the controlling document and recommends HRT first-line for most symptomatic women. You can also ask for a second opinion within the practice or request referral to an NHS menopause clinic.
›Can I get body-identical HRT on the NHS?
Yes. Estradiol patches, gels and sprays, and micronised progesterone (Utrogestan) are all body-identical and all available on the NHS. Compounded 'bioidentical' HRT from private clinics is a different thing — that is not NHS-prescribable and not recommended by NHS guideline NG23.
›What about testosterone for women on the NHS?
Testosterone is unlicensed for women in the UK, but NHS guideline NG23 supports its use for low libido in menopause where HRT alone is not enough. Many NHS GPs will not initiate it; an NHS menopause clinic can — referral is your right.
›How do I get a referral to an NHS menopause clinic?
Ask your GP for a referral. Some areas now have Women's Health Hubs as the first-line referral. Right to Choose lets you pick any NHS-funded provider in England — relevant where local waits are long.