NICE has updated its menopause guidance to give clearer advice about vaginal bleeding while taking systemic hormone replacement therapy, or HRT.
The Menopause: identification and management guideline was updated on 15 April 2026. The main change concerns unscheduled bleeding in women using systemic HRT, including tablets, patches, gels and sprays.
NICE now provides specific time frames for bleeding after starting or changing HRT, such as within the first six months or three months, to guide when women should seek medical advice.
Since 2015, NICE has recommended that healthy women aged 45 and over with menopause symptoms can usually be assessed without routine hormone blood tests, highlighting its continued importance.
Why does this matter for women?
Menopause does not always arrive with a clear-cut test result.
During perimenopause, hormone levels can rise and fall considerably. This means a single blood test may not accurately reflect what is happening in the body.
For women aged 45 and over who have typical menopause symptoms, NICE recommends that clinicians usually rely on a woman’s age, symptoms and menstrual history rather than routinely measuring hormone levels, which can help women feel more confident in their diagnosis.
For example, perimenopause may be identified when hot flushes or night sweats begin alongside changes in the menstrual cycle.
Menopause can generally be identified when a woman has not had a period for at least 12 months and is not using hormonal contraception.
This does not mean blood tests are never useful. Testing may still be appropriate if symptoms could have another cause, or when menopause is suspected in younger women.
The 2026 update is particularly relevant for women who are taking HRT and experience unexpected bleeding.
What does the evidence say?
NICE advises against routinely using several hormone-related tests to diagnose menopause or perimenopause in otherwise healthy women aged 45 and over.
These include tests for oestradiol, anti-Müllerian hormone and inhibin, as well as tests looking at ovarian volume or follicle numbers.
Follicle-stimulating hormone, commonly known as FSH, has a more limited role.
NICE says FSH testing may be considered in women aged 40 to 45 who have menopause symptoms and changes to their menstrual cycle. It may also be considered when menopause is suspected in someone under 40.
The message is therefore not that women over 45 should never have blood tests. Rather, routine hormone testing is often unlikely to add useful information when age, symptoms and menstrual history already point towards perimenopause or menopause.
What has changed about bleeding on HRT?
For women with a uterus who are taking systemic HRT, NICE says vaginal bleeding is common during the first six months after starting treatment.
Bleeding can also occur within three months of changing the dose or type of HRT.
If unscheduled bleeding continues or begins outside these time frames, NICE advises seeking medical help promptly, reassuring women that their concerns are valid and important.
This does not mean that bleeding within the first six months should automatically be ignored. Individual circumstances still matter, including the type of HRT being used, the pattern of bleeding, a woman’s age and any other risk factors.
What do we still not know?
There is more uncertainty around unscheduled bleeding during HRT than there is around symptom-based menopause diagnosis.
When NICE reviewed the evidence, it found no relevant studies that could reliably show how accurately different patterns of bleeding in women using HRT predict endometrial cancer, which is cancer of the lining of the womb.
That means there are still unanswered questions about exactly which bleeding patterns should trigger investigation in every situation.
NICE therefore points healthcare professionals towards additional British Menopause Society guidance and has recognised the need for further research.
Hormonal contraception can also make menopause harder to identify because it may change or stop menstrual bleeding. This means some women will need a more individualised assessment, emphasizing that each woman’s experience is unique and deserves tailored care.
This does not mean every woman over 45 with menopause symptoms needs no investigation; individual assessment remains essential for appropriate care.
Nor should unexpected bleeding automatically be dismissed as a normal part of taking HRT.
Our take
There is something useful in the wider message behind the NICE guidance: women do not necessarily need a hormone result on a laboratory report before their menopause symptoms can be recognised and taken seriously.
For many otherwise healthy women aged 45 and over, a thoughtful conversation about symptoms, menstrual changes and medical history can provide more useful information than repeatedly checking fluctuating hormone levels.
But this is not a new development in 2026. NICE has supported symptom-based diagnosis in this age group for more than a decade.
What has changed is the advice around unscheduled bleeding during systemic HRT.
Some bleeding can happen while the body adjusts to starting HRT or after a change in treatment. NICE now makes the time frames clearer, while also advising women to seek medical help if bleeding occurs outside them.
The practical message is one of balance.
Menopause care should not depend on unnecessary testing, but neither should symptoms or unexpected bleeding be dismissed.
If you are concerned about bleeding while taking HRT, or your symptoms do not fit the usual pattern, an individual assessment with a healthcare professional is appropriate.
Sources
Source: National Institute for Health and Care Excellence (NICE), Menopause: identification and management (NG23), updated 15 April 2026.
Original guidance: NICE, Menopause: identification and management: Recommendations.
Additional sources: NICE, Quality statement 1: Diagnosing perimenopause and menopause; NICE guidance on suspected cancer recognition and referral; British Menopause Society guidance on managing unscheduled bleeding while using HRT.
