This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
The updated NICE technology appraisal on 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites [TA1045] can be found here:
The updated NICE technology appraisal on 12 SQ-Bet SLIT for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen in people 5 years and over [TA1087] can be found here:
· https://www.nice.org.uk/guidance/ta1087
The updated NICE guideline on Acne vulgaris: management [NG198] can be found here:
· https://www.nice.org.uk/guidance/ng198
The new updated NICE guideline on Heavy menstrual bleeding: assessment and management [NG88] can be found here:
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2026, focusing on what is relevant in Primary Care only.
This month, we have only two areas to cover: updated guidance allergic rhinitis and conjunctivitis, and an update on acne vulgaris.
Right, let’s jump into it.
There are two updates on allergic rhinitis that are very similar, so let’s take them together.They both involve sublingual immunotherapy for allergic rhinitis, and both updates expand the eligible population to include younger children.
The first one is Acarizax, for house dust mite allergic rhinitis.
It was recommended for people aged 12 to 65 and it now also includes children aged 5 to 11 years.
The second is Itulazax, for allergic rhinitis or conjunctivitis caused by tree pollen from the birch group.It was recommended for adults and it now includes people aged 5 years and over.
In both cases, the symptoms need to be moderate to severe, the diagnosis needs to be supported by a positive sensitisation test, such as skin prick testing or specific IgE, and symptoms must persist despite symptom-relieving treatment.
So, what are these treatments?
As we said Acarizax is for house dust mite allergic rhinitis, while Itulazax is for birch-related tree pollen allergic rhinitis or conjunctivitis.
Both are sublingual immunotherapy tablets.
Acarizax contains house dust mite allergen extract and Itulazax contains birch pollen allergen extract.
Both are placed under the tongue and work by gradually desensitising the immune system to the relevant allergen.
So these are not just another antihistamine or nasal spray.
They are allergen immunotherapy treatments, aiming to modify the immune response itself rather than simply providing temporary symptom relief.
In usual care, allergic rhinitis, with or without conjunctivitis, is treated first with standard medicines, such as antihistamines and intranasal corticosteroids.
These immunotherapy treatments come later, when symptoms remain moderate to severe and persistent despite standard treatment.
It is worth saying that Acarizax is not recommended for allergic asthma, even when house dust mite allergy may be triggering it.
Having asthma does not necessarily prevent someone from receiving Acarizax for rhinitis, but the NICE recommendation is not for asthma treatment itself.
Itulazax is for tree pollen allergy from the birch group, and it can be given for allergic rhinitis, conjunctivitis, or both.
Although these may not be treatments that GPs routinely prescribe, they are useful to know about because we will see children and adults with persistent allergic rhinitis despite antihistamines and nasal steroids, and , in those cases, these options may be relevant for specialist referral or discussion.
Let’s now look at the updated NICE guideline on acne vulgaris.
This update is quite focused and NICE has amended references to polycystic ovarian syndrome, because this condition is now called polyendocrine metabolic ovarian syndrome, or PMOS. This name change was agreed by global consensus and reflects that this is a whole-body metabolic and hormonal condition, not a disease defined by ovarian cysts.
Additionally the recommendation on triamcinolone injections has been withdrawn, but this is relevant to specialist care.
For us in primary care, the main acne management is otherwise unchanged so let’s give it a very quick overview.
For drug treatment, NICE recommends a 12-week course of one first-line treatment option, depending on severity and patient preference.
For many patients, we can use a fixed-combination topical treatment, such as adapalene with benzoyl peroxide, or tretinoin with clindamycin.
Adapalene with benzoyl peroxide has the advantage that it does not contain an antibiotic, but for mild to moderate acne, we can also consider benzoyl peroxide with clindamycin.
For moderate to severe acne, we should usually use a topical treatment together with an oral antibiotic, either lymecycline or doxycycline.
If the person cannot use lymecycline or doxycycline, we can consider trimethoprim or an oral macrolide, such as erythromycin.
Topical benzoyl peroxide alone can also be considered if the other options are contraindicated, or if the person wants to avoid topical retinoids or antibiotics.
We should not use topical antibiotic monotherapy, oral antibiotic monotherapy, or a combination of topical and oral antibiotics, because of the risk of antimicrobial resistance.
We should also explain that treatment can take 6 to 8 weeks before improvement become noticeable.
Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning pregnancy, so effective contraception or an alternative treatment is needed for people of childbearing age.
If hormonal contraception is wanted, we should consider the combined oral contraceptive pill in preference to the progestogen-only pill.
We should then review first-line treatment at 12 weeks.
If the treatment includes an oral antibiotic and the acne has cleared, we should consider stopping the antibiotic but continuing the topical treatment.
If the acne has improved but has not completely cleared, we should consider continuing the oral antibiotic with the topical treatment for up to 12 more weeks.
We should only continue antibiotic-containing treatment for more than 6 months in exceptional circumstances, with review every 3 months, and we should stop the antibiotic as soon as possible.
We should refer if there is diagnostic uncertainty, acne conglobata, or nodulo-cystic acne. We should also consider referral if acne is not responding to treatment, or if acne is causing scarring, persistent pigmentary change, or significant psychological distress.
For PMOS and acne, we should use a first-line acne treatment option first.
If that is not effective, we should consider adding co-cyprindiol or an alternative combined oral contraceptive pill.
For people using co-cyprindiol, we should review at 6 months and discuss continuation or alternative options.
We should consider specialist referral if acne and PMOS are associated with hyperandrogenism, or if there is severe acne resistant to standard treatment.
So that is it, a review of the NICE updates relevant to primary care.
We have come to the end of this episode.
Remember that this is not medical advice, but only my summary and interpretation of the guidelines.
You must always use your clinical judgement.
Thank you for listening and goodbye.
Podcast - 2026 Menopause Part 5 HRT Made Practical
Sunday, August 30, 2026 • Duration 09:04
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE News - July 2026
Sunday, August 16, 2026 • Duration 10:28
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in July 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE 2026 Menopause Part 4 Premature menopause and HRT review
Sunday, August 2, 2026 • Duration 07:37
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE News - June 2026
Sunday, July 19, 2026 • Duration 06:41
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in May 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE 2026 Menopause Part 3 HRT risks explained
Sunday, July 5, 2026 • Duration 07:15
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE 2026 Menopause Part 2 Symptoms and treatments
Sunday, June 21, 2026 • Duration 07:16
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE News – May 2026
Wednesday, June 10, 2026 • Duration 04:40
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in May 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE 2026 Menopause Part 1 Diagnosis and choices
Wednesday, June 3, 2026 • Duration 07:42
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Podcast - NICE 2026 Hypertension Part 4 Stepwise Treatment
Wednesday, May 27, 2026 • Duration 07:28
The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we’re doing a practical review of menopause, focusing on what is relevant in primary care only.
We’ve recently covered the NICE guideline, so today we’ll keep things practical.
We’ll look at key definitions, common prescribing pitfalls, HRT regimens, contraception while using HRT, and how to advise someone who wants to delay a period for a holiday.
Right, let’s jump into it.
Let’s start with some definitions first.
Systemic HRT means HRT that is absorbed into the bloodstream and has effects throughout the body. The oestrogen can be oral, or transdermal.
The progestogen can be oral, transdermal, or provided through a levonorgestrel intrauterine system.
This is different from vaginal oestrogen, which is used locally for genitourinary symptoms. It is absorbed locally, with only a minimal amount absorbed into the bloodstream, so it is unlikely to have a significant systemic effect.
Vaginal oestrogen can be used alone or with systemic HRT.
Let’s look at the types of HRT, starting with combined HRT.
Combined HRT means HRT with both oestrogen and progestogen.
We use this in people with a uterus because unopposed systemic oestrogen increases the risk of endometrial hyperplasia and endometrial cancer.
Combined HRT can be continuous or sequential.
Continuous combined HRT means oestrogen and progestogen are taken together every day. The aim is no regular withdrawal bleed and it can be used when the person is postmenopausal, meaning at least 12 months since their last period or from around age 54 if the bleeding pattern is unclear..
Continuous combined HRT is not usually suitable during perimenopause or within 12 months of the last menstrual period, because it can cause irregular bleeding. In these cases, we would use sequential combined HRT, also called cyclical HRT.
This means oestrogen is taken every day, and progestogen is usually taken for part of the month, usually giving a predictable monthly bleed.
Another option for combined HRT is to prescribe an oestrogen-only preparation with a separate progestogen, for example, micronised progesterone which is usually given as Utrogestan in the UK.
Common regimens are Utrogestan 200 mg at night for 12 days per 28-day cycle, usually days 15 to 26, for sequential combined HRT or, for a continuous combined HRT, 100 mg at night from days 1 to 25 of each 28-day cycle.
Another progestogen option for endometrial protection is a 52 mg levonorgestrel intrauterine system, such as Mirena, which should be changed every 5 years when used for this purpose.
Let’s now look at oestrogen-only HRT.
This means oestrogen is given without progestogen and it is usually used in people who have had a total hysterectomy.
But we should mindful of possible pitfalls.
For example, after subtotal hysterectomy, some endometrial tissue may remain in the cervical stump. In that situation, progestogen may be still needed.
Another important pitfall is a history of previous widespread endometriosis. This is because even after hysterectomy, residual endometriosis deposits can remain, so combined HRT may be advised here too. In these two cases, we should consider specialist advice before prescribing unopposed oestrogen.
Oestrogen-only HRT can be oral or transdermal. Transdermal is often the first choice because it has a more favourable venous thromboembolism and stroke risk profile than oral oestrogen.
The general principle is to use the lowest effective dose that controls symptoms.
If symptoms are not controlled after a reasonable trial, or side effects occur, we can adjust the dose, change the route, or change the progestogen.
In practice, we should allow around 3 months after starting or changing HRT before judging the full effect, unless there are significant issues.
When starting HRT, we should explain the expected bleeding pattern. With sequential combined HRT, a regular withdrawal bleed is expected. With continuous combined HRT, the aim is no bleeding, but irregular bleeding can occur initially.
Now let’s talk about contraception.
The main message is simple: HRT is not contraception.
If pregnancy is possible and not wanted, contraception still needs to be discussed.
Non-hormonal contraception can obviously be used alongside HRT.
A 52 mg levonorgestrel intrauterine system or Mirena, can be particularly useful because it can provide both contraception and endometrial protection when used with systemic oestrogen.
Although Mirena is licensed for up to 8 years for contraception, for endometrial protection as part of HRT it is only effective for up to 5 years.
If a Mirena intrauterine device is not possible, we need to remember that not all progestogen-only contraceptives can be used for endometrial protection with oestrogen-only HRT. For example, the progestogen-only pill, progestogen-only implant, and depot medroxyprogesterone acetate cannot be used for this.
However, they can normally be used as contraception alongside HRT.
On the other hand, combined hormonal contraception should not be used in combination with HRT.
In eligible women under 50, combined hormonal contraception can be used as an alternative to HRT for symptom relief and bone protection, but not together with HRT.
If a woman reaches 50 while using combined hormonal contraception, they are usually switched to a progestogen-only method, and then we should reconsider HRT options.
And let’s finish with a practical question that often comes up: how to delay a predictable HRT withdrawal bleed for a holiday.
In UK practice, we could treat this as a short-term HRT schedule adjustment, rather than routine period delay tablets.
Here we would usually extend the progestogen-containing phase until after the holiday. That is because the bleed usually happens when the progestogen phase stops.
So, for someone using transdermal or oral sequential combined HRT, if the holiday falls when they are due to bleed, the practical option is usually to continue the progestogen containing patches or tablets through the holiday.
After the holiday, they switch back to the oestrogen-only patches or tablets and should expect a withdrawal bleed.
We should not extend the oestrogen-only phase to delay bleeding, because that increases time on unopposed oestrogen.
And we should not casually add high dose oral norethisterone on top of sequential combined HRT, because the patient may already be receiving progestogen in the combined phase, and extra norethisterone may add side effects and risk.
If the patient uses separate daily oestrogen with cyclical progestogen, they simply continue the progestogen until after the holiday.
Then they stop the progestogen, expect a withdrawal bleed, and return to the usual monthly schedule.
This is an off-licence schedule adjustment, and we should explain that spotting can still happen, and they should seek review for heavy, persistent, or unusual bleeding.
So that is it, a practical review of menopause.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in July 2026, focusing on what is relevant in Primary Care only.
This month, we have three areas to cover: updated guidance on low back pain and sciatica, updated guidance on heavy menstrual bleeding, and a brand-new guideline on osteoporosis risk assessment.
Right, let’s jump into it.
Let’s start with osteoporosis risk assessment.
NICE says to assess fragility fracture risk in all people aged 50 and over, and in women who have experienced menopause, if they have had a previous fragility fracture or currently use, or frequently use, systemic glucocorticoids.
It also says to consider assessment in all men aged 75 and over, all women aged 65 and over, and younger people with risk factors.
These include 2 or more falls in the last year, hip fracture in a first-degree relative, BMI below 18.5, smoking, alcohol intake over 14 units per week, or other risk factors such as, for example, endocrine or gastrointestinal conditions, multiple myeloma, Parkinson’s disease, immobility, COPD, autoimmune disease, and CKD stage 4 or 5.
For people under 50, the threshold is higher: we should assess risk after a previous hip or vertebral fragility fracture, 2 or more major osteoporotic fractures, or another major risk factor.
For people aged 40 to 90, we should use FRAX or QFracture to estimate 10-year major osteoporotic fracture risk. For people aged 30 to 39, we should use QFracture.
For people over 90, we should remember that FRAX assumes age 90, while QFracture calculates risk up to age 100.
We should seek specialist advice for people under 30 or with rare bone diseases.
We should offer DXA to people aged 30 and over with a previous hip or vertebral fragility fracture, a single major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures.
We should also consider DXA when the 10-year major osteoporotic fracture risk is 10% or more.
When starting treatment, we should usually do a baseline DXA unless it is not tolerated or feasible.
If DXA is delayed, we should consider fast-tracking within 6 weeks if anabolic treatment is likely, or starting antiresorptive treatment if anabolic treatment is unlikely.
NICE also discusses DXA-based vertebral fracture assessment, or VFA.
What is VFA exactly? VFA is an extra spine image done using the DXA scanner to look for vertebral fragility fractures.
We should consider VFA in men aged 70 and over and women aged 60 and over.
In younger people, we should consider VFA during DXA if there has been a previous major osteoporotic fracture, signs or symptoms of vertebral fracture, systemic glucocorticoid use, or exceptionally low bone mineral density for age.
For treatment decisions, we should consider FRAX or QFracture risk scores, DXA results if available, previous fragility fractures, and risk factors.
For people aged 50 and over, and women who have experienced menopause, we should consider treatment after a previous hip or vertebral fragility fracture, or high-dose systemic glucocorticoids.
We should also consider treatment with a T-score of minus 2.5 or less, or minus 1.5 or less if there is previous fragility fracture, systemic glucocorticoid use, or other risk factors.
Treatment can also be considered without DXA if the person meets assessment criteria but DXA is not tolerated or feasible, for example in frail older people.
If someone declines treatment, we should advise when and how to re-access the service if they change their mind or circumstances change.
If 10-year risk is below 10%, we should reassess if circumstances change, or at 5 years.
If 10-year risk is 10% or more, or DXA was done but treatment criteria were not met, we should do the same, but consider repeat DXA within 2 to 3 years if they were close to treatment criteria.
Now let’s move to low back pain and sciatica.
In this update NICE has withdrawn the recommendations on psychological therapy and combined physical and psychological programmes for low back pain or sciatica.
The rest of the primary care approach is largely unchanged.
We should think about alternative diagnoses, including red flags, cancer, infection, trauma, and inflammatory disease.
Management may involve exercise programmes, with or without manual therapy.
We should not routinely offer imaging. If referring, we should explain that imaging may still not be needed and that imaging should only be considered by a specialist if it is likely to change management.
For self-management, we should encourage normal activities and consider group exercise programmes for suitable patients.
Manual therapy, including manipulation, mobilisation, or massage, can be considered only as part of a package that includes exercise.
For medicines, NICE says not to offer gabapentinoids, other antiepileptics, oral corticosteroids, benzodiazepines, or opioids for low back pain and sciatica.
If prescribing NSAIDs, we should consider gastrointestinal, liver and cardio-renal toxicity, age, and other risk factors and use the lowest effective dose for the shortest possible time.
Weak opioids, with or without paracetamol, can be considered for acute low back pain only if NSAIDs are contraindicated, not tolerated, or ineffective.
But NICE says not to offer paracetamol alone for low back pain.
It also says not to routinely offer opioids for acute low back pain, and not to offer opioids for chronic low back pain.
Finally, let’s look at heavy menstrual bleeding.
The update is about serum ferritin testing.
Previously, NICE advised not to routinely test serum ferritin in women with heavy menstrual bleeding. That recommendation has now been removed because of the risk of iron deficiency.
Heavy menstrual bleeding can have a major impact on quality of life, and management should focus on this rather than blood loss alone.
If there are no related symptoms, NICE says we can consider pharmacological treatment without physical examination.
However, we should offer examination if there is intermenstrual bleeding, pelvic pain, pressure symptoms, or if considering a levonorgestrel-releasing intrauterine system.
We should a full blood count and use clinical judgement on ferritin.
We should consider coagulation testing if heavy bleeding has been present since periods started and there is a personal or family history suggesting a coagulation disorder.
We should not do female hormone or thyroid testing unless clinically indicated.
We can start pharmacological treatment without investigating if history or examination suggests low risk of uterine or histological abnormality.
If cancer is suspected, we should follow the NICE suspected cancer pathway.
If investigations are needed, we should use history and examination to decide between hysteroscopy and ultrasound as the first line investigation.
We should offer outpatient hysteroscopy if the history suggests submucosal or endometrial pathology, for example if there is persistent intermenstrual bleeding or risk factors for endometrial pathology.
However we should offer pelvic ultrasound if the uterus is palpable abdominally, a pelvic mass is suspected, or examination is inconclusive or difficult.
For suspected adenomyosis, with significant period pain or a bulky, tender uterus, we should offer transvaginal ultrasound in preference to transabdominal ultrasound or MRI.
For no identified pathology, fibroids under 3 cm without cavity distortion, or suspected adenomyosis, we should consider a levonorgestrel-releasing intrauterine system first.
If this is declined or unsuitable, we should consider tranexamic acid, NSAIDs, combined hormonal contraception, or cyclical oral progestogens.
Progestogen-only contraception may suppress menstruation, which may also help.
We should refer if treatment is unsuccessful, pharmacological treatment is declined, symptoms are severe, there are submucosal fibroids, or fibroids are 3 cm or more.
While investigations or definitive treatment are being organised, tranexamic acid and NSAIDs can still be offered.
So that is it, a review of the NICE updates relevant to primary care.
We have come to the end of this episode.
Remember that this is not medical advice, but only my summary and interpretation of the guidelines.
You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.
Today we will focus on early menopause, and premature ovarian insufficiency.
In the previous three episodes, we covered diagnosis, symptom management and HRT risks and benefits in people aged 45 and over.
Right, let’s jump into it.
In terms of disease prevention, NICE says we should not offer combined or oestrogen-only HRT for the primary or secondary prevention of cardiovascular disease or for the purpose of dementia prevention.
For cardiovascular risk reduction, and dementia prevention we should follow the relevant NICE guidelines on those subjects.
Now let’s look at premature ovarian insufficiency, which applies to people under 40.
Premature ovarian insufficiency is diagnosed in people under 40 based on symptoms, including no or infrequent periods and elevated FSH levels on 2 blood samples taken 4 to 6 weeks apart. We should not diagnose premature ovarian insufficiency based on a single blood test.
If there is doubt about the diagnosis, we should seek specialist advice.
For premature ovarian insufficiency, NICE says we should offer sex steroid replacement, unless it is contraindicated. This can be either HRT or a combined hormonal contraceptive.
We should explain the importance of hormonal treatment until at least the age of natural menopause, unless there is a contraindication.
We should advise that both HRT and combined oral contraceptives offer bone protection and that HRT may have a beneficial effect on blood pressure compared with a combined oral contraceptive.
On the other hand,HRT is not contraception, so contraception still needs to be discussed if pregnancy is possible and not wanted.
We should also explain that the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age, and is very low in people under 40.
If hormonal treatment cannot be taken, we should still give advice on bone health, cardiovascular health, and symptom management and consider specialist referral if necessary.
Let’s now look at early menopause, which is defined as menopause between the ages of 40 and 44.
Here the benefits and risks of taking or not taking HRT are likely to sit between those for premature ovarian insufficiency and those for people aged 45 or over.
In premature ovarian insufficiency, that is, before 40, the potential benefit of HRT is usually greater, because we are not only thinking about the risks of HRT but also the risks of not taking it, particularly in respect of bone health. As we know, HRT helps reduce fragility fracture risk.
In early menopause, between 40 and 44, the same issue still applies, but to a lesser extent, so the balance of risks and benefits sits between premature ovarian insufficiency and menopause at 45 or over.
In simple terms, the younger the person is at menopause, the more important it is to consider the health effects of not taking HRT. As always, the discussion should be tailored to the person’s age, circumstances, and individual risk factors.
Now let’s look at starting and stopping HRT.
Firstly, if the person has a medical condition that may be affected by HRT, we should consider seeking specialist advice before starting it.
For symptoms control, we should offer combined HRT to people with a uterus and oestrogen-only HRT to people who have had a total hysterectomy and use the lowest effective dose.
For people with a uterus, we should explain that vaginal bleeding is a common side effect during the first 6 months of taking systemic HRT, or within 3 months of changing the dose or preparation.
They should also be advised to seek medical help promptly if unscheduled vaginal bleeding happens beyond these timeframes.
There is limited evidence for unscheduled bleeding while on HRT, and NICE signposts the British Menopause Society guidance on unscheduled bleeding on HRT.
Let’s have a look at what they say:
The British Menopause Society guidance say that we should first assess the patient fully, including, amongst other things, the bleeding pattern, adherence, examination, BMI, and individual risk factors for endometrial cancer.
Major risk factors include a BMI of 40 or more and some hereditary conditions. Minor risk factors include a BMI between 30 and 39, diabetes, and polycystic ovarian syndrome.
In people at low risk, if bleeding occurs within 6 months of starting HRT, or within 3 months of changing it, we will adjust the progestogen or HRT preparation, for 6 months in total, before arranging further investigations.
If unscheduled bleeding continues in low-risk women, after six months of adjustments, we could request an urgent transvaginal ultrasound. We should also do this if bleeding first occurs more than 6 months after starting HRT, or more than 3 months after changing treatment, and also if bleeding is heavy, prolonged, or if there are 2 minor risk factors.
An urgent suspected cancer referral is recommended if there is 1 major risk factor or 3 minor risk factors for endometrial cancer, regardless of bleeding pattern or timing.
Now let’s go back to the NICE guideline and look at stopping HRT.
NICE says we should offer a choice between gradually reducing treatment or stopping it immediately. Gradually reducing it may decrease recurrence of symptoms in the short term but it makes no difference in the long term.
Finally, systemic HRT should be stopped in people diagnosed with breast cancer.
What should we cover during an HRT review?
We should encourage nationally recommended health screening and, at 3 months, we should review the effect of HRT on menopausal symptoms.
After that, treatment should be reviewed annually, unless there is a clinical reason to review sooner, such as poor response or side effects. If HRT is not effective or tolerated, we should seek specialist advice.
So that is it, a review of a section of the NICE guideline on the menopause.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
The new Technology appraisal guidance [TA694] Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia can be found here:
· https://www.nice.org.uk/guidance/ta694
The updated NICE guideline on Ectopic pregnancy and miscarriage: diagnosis and initial management [NG126] can be found here:
· https://www.nice.org.uk/guidance/ng126
The updated NICE guideline on Postnatal care [NG194] can be found here:
· https://www.nice.org.uk/guidance/ng194
The new updated NICE guideline on Multiple sclerosis in adults: management [NG220] can be found here:
· https://www.nice.org.uk/guidance/ng220
Transcript
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in June 2026, focusing on what is relevant in Primary Care only.
This month, the main update is the guidance on bempedoic acid with ezetimibe, although we will also briefly touch on ectopic pregnancy and miscarriage, postnatal care, and multiple sclerosis.
Right, let’s jump into it.
And let’s start with the new guidance on bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia.
But first, what is bempedoic acid?
Bempedoic acid is a relatively new oral, non-statin lipid-lowering drug used to reduce LDL cholesterol.
It works in the liver by inhibiting cholesterol production earlier in the pathway than statins.
Because it is activated mainly in the liver rather than skeletal muscle, it can be useful when statins are not tolerated, particularly because of muscle symptoms.
The result is reduced cholesterol synthesis in the liver and increased clearance of LDL cholesterol from the blood.
Bempedoic acid is usually given with ezetimibe because the two drugs work in complementary ways.
Bempedoic acid reduces cholesterol production in the liver, while ezetimibe reduces cholesterol absorption from the intestine.
Together, they lower LDL cholesterol more than either drug alone, and they provide an all-oral option for people who cannot tolerate statins.
Now let’s look at the NICE guidance.
In the NICE guideline, bempedoic acid with ezetimibe is an option for adults with primary hypercholesterolaemia or mixed dyslipidaemia only when statins are contraindicated or not tolerated, and ezetimibe alone has not controlled LDL cholesterol well enough.
The evidence shows LDL cholesterol reduction, with cardiovascular outcome evidence.
In practical terms, this is not a replacement for statins as first-line lipid-lowering treatment.
NICE describes the usual pathway as statins first, with ezetimibe added if LDL cholesterol is not lowered enough.
NICE also notes that there was no direct comparison with PCSK9 inhibitors such as alirocumab or evolocumab, and indirect comparison suggested bempedoic acid may be less effective than these options.
However, a useful practical point is that bempedoic acid is an oral treatment, whereas alirocumab and evolocumab are given by subcutaneous injection.
Despite those uncertainties, NICE concluded that bempedoic acid with ezetimibe is a cost-effective option for people with primary hypercholesterolaemia or mixed dyslipidaemia, where statins are contraindicated or not tolerated, and ezetimibe alone does not control LDL cholesterol well enough.
Let’s now move to the updated guideline on ectopic pregnancy and miscarriage.
The main change affects secondary care, but it is useful for us to know that anti-D immunoglobulin prophylaxis is no longer offered for ectopic pregnancy, miscarriage, or threatened miscarriage up to and including eleven weeks and six days’ gestation.
However, from twelve weeks and zero days to twelve weeks and six days, anti-D remains relevant for RhD-negative pregnant people.
And while we are here, we should remember that in any woman of reproductive age with non-specific symptoms, we should consider pregnancy and think about offering a pregnancy test.
We should also refer to early pregnancy assessment services if there is bleeding or pain, and the pregnancy is of 6 weeks or more, or the pregnancy is of uncertain gestation. The urgency will depend on the clinical situation.
If the pregnancy is under 6 weeks, there is bleeding but no pain, and there are no risk factors such as previous ectopic pregnancy, NICE recommends expectant management.
We should advise them to return if bleeding continues or pain develops, to repeat a urine pregnancy test after 7 to 10 days, and to return if it is positive.
A negative test will mean the pregnancy has miscarried.
Let’s now touch on the updated guideline on postnatal care.
For GP practice, the June 2026 update itself probably changes very little.
NICE has added a recommendation to offer vitamin K prophylaxis for babies, linking to the intrapartum care guideline.
For primary care, the main practical message is unchanged: the 6-to-8-week postnatal check remains an opportunity to assess maternal physical and mental health, contraception, pelvic floor and perineal problems, bleeding, safeguarding, feeding, and the baby’s wellbeing and development.
And finally, the updated guideline on multiple sclerosis.
The main change is diagnostic: the guideline now refers to specialist criteria known as the McDonald criteria, and NICE has removed the old statement that MS should not be diagnosed solely on MRI findings.
But this does not affect us in primary care.
For us, the practical message is that we should think of MS when there are focal neurological symptoms evolving over more than 24 hours, lasting days or weeks, often improving afterwards, and not explained by other common diagnoses.
However, we should not routinely suspect MS from fatigue, dizziness, or vague sensory symptoms alone.
We should then refer suspected MS cases to neurology, and secondary care will make the diagnosis following specific criteria.
So that is it, a review of the NICE updates relevant to primary care.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.
Today we will focus on HRT risks and benefits in people aged 45 and over.
In the next episode, we’ll cover early menopause, meaning people aged 40 to 44, and premature ovarian insufficiency, which refers to those aged under 40. In the previous two episodes, we covered diagnosis, treatment choices, and symptom management.
Right, let’s jump into it.
So let’s start by looking at the effects of HRT on specific health outcomes.
When discussing the risk of individual medical conditions, NICE recommends using its HRT discussion aid to explain risks and benefits more clearly. The link to this aid is in the episode description. It presents the information as the number of cases per 1,000 people over a 5- or 10-year period. So, in practice, the message is more nuanced than simply saying that HRT is safe or unsafe.
Let’s first look at the effects that are similar with combined and oestrogen-only HRT.
For people aged 45 or over, we will explain that neither combined HRT or oestrogen-only HRT is likely to affect life expectancy.
Equally, for people without coronary heart disease, the risk of developing it or mortality from it does not increase with either combined HRT or oestrogen-only HRT.
For osteoporosis, fragility fracture risk is reduced while on either combined HRT or oestrogen-only HRT and the benefit is maintained during treatment, but decreases once HRT stops. It may continue for longer in people who take HRT for longer. There is also limited evidence that HRT improves muscle mass and strength.
Neither combined HRT or oestrogen-only HRT increases the risk of developing type 2 diabetes and it has no adverse effect on blood glucose.
And finally, for venous thromboembolism, route matters. The risk is not increased with transdermal HRT, but it is increased with oral HRT, both combined and oestrogen-only.
And now let’s review the specific effects of combined HRT, which is given to people with a uterus.
And we will start looking at the Breast cancer risk first, which varies depending on the person’s risk factors.
With combined HRT, breast cancer risk increases, and this increase rises with duration of use.
In addition, the risk is higher while taking HRT compared to having taken it in the past and, after stopping HRT, the risk goes down, but it can persist for at least 10 years.
NICE says there is a very small increase in the risk of death from breast cancer too.
The type of combined HRT also matters.
Breast cancer risk is lower with sequential combined HRT than with continuous combined HRT, but it is still higher than without HRT.
There is not enough evidence that any specific progestogen carries a higher risk of breast cancer.
Contrary to what happens with breast cancer, for endometrial cancer, continuous combined HRT reduces risk whereas sequential combined HRT may slightly increase it, and this increases with the duration of use, fewer days of progestogen per cycle, or a higher dose of oestrogen.
For ovarian cancer there is a very slight increase in risk with combined HRT, but we should explain that the baseline population risk in women under 60 is very low.
For dementia, the risk might increase if it is started at the age of 65 or over.
For stroke, we should explain that the baseline population risk in women under 60 is very low.
Stroke risk is unlikely to increase with combined HRT that includes transdermal oestrogen, but it increases with combined HRT containing oral oestrogen.
This increase rises with higher oestrogen dose and longer duration of treatment, for example if used for more than 5 years.
The risk is also higher when HRT is started at a later age, and may be higher in Black people.
So, in summary, combined HRT is used in people with a uterus, breast cancer risk is increased and rises with duration of use, continuous combined HRT reduces endometrial cancer risk, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment.
Let’s now move to oestrogen only HRT, remembering that this is the option recommended for people who have had a total hysterectomy.
Starting with breast cancer, the discussion is different from combined HRT.
Oestrogen-only HRT causes very little or no increase in breast cancer risk or breast cancer mortality.
For endometrial cancer, the key point is that oestrogen-only HRT should not be used in people with a uterus precisely because it increases the risk of endometrial malignancy.
Ovarian cancer risk increases very slightly after 5 years of oestrogen-only HRT, and rises with longer use, regardless of the route. However, the baseline risk in women under 60 is very low.
For dementia, NICE says that the risk is unlikely to increase.
For stroke, the route of oestrogen matters.
Stroke risk increases with oral oestrogen-only HRT, and this increase rises with the dose of oestrogen and if started after the age of 60.
However, stroke risk is unlikely to increase with transdermal oestrogen-only HRT.
So, in summary, oestrogen-only HRT is generally used after total hysterectomy, breast cancer risk is very little or not increased, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment.
So that is it, a review of a section of the NICE guideline on the menopause.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.
Today we will focus on symptom management and treatment risks.
In the last episode we covered diagnosis, and treatment choices and in future episodes we will cover the other sections of the guideline.
Right, let’s jump into it.
We will start by covering the management of menopausal symptoms in people aged 40 or over. This is because, for people under 40, we should follow the separate NICE guideline on premature ovarian insufficiency.
Let’s look at the various possible symptoms one by one.
For vasomotor symptoms, such as hot flushes and sweats, NICE says we should offer HRT. Menopause-specific CBT can also be considered and used in addition to or instead of HRT.
Fezolinetant is also recommended as an option when HRT is unsuitable.
Fezolinetant is not HRT. It works through receptor pathways involved in temperature regulation. Although recommended as an option, in practice, it may well be specialist initiated only, depending on local prescribing guidance.
NICE says we should not routinely offer SSRIs, SNRIs, or clonidine as first-line treatment for vasomotor symptoms alone.
Now let’s look at genitourinary symptoms.
For people with no history of breast cancer, we should offer vaginal oestrogen, including in people who are already using systemic HRT.
We should explain that serious adverse effects are very rare and that symptoms often return when vaginal oestrogen is stopped, but treatment can be restarted if necessary.
Vaginal oestrogen is absorbed locally and a minimal amount is absorbed systemically, which is unlikely to have a significant effect throughout the body.
Types of vaginal oestrogen include creams, gels, vaginal tablets, pessaries, or rings. They can be used alone, or with non-hormonal moisturisers or lubricants.
If vaginal oestrogen is contraindicated, or the person prefers not to use it, we should then just consider non-hormonal vaginal moisturisers or lubricants.
If vaginal oestrogen, moisturisers, or lubricants have not worked, NICE says we should consider vaginal prasterone or oral ospemifene.
These medicines are not started routinely in primary care, and their use will depend on local formulary and prescribing guidance.
For people with genitourinary symptoms and overactive bladder, or recurrent urinary tract infections, NICE signposts their specific guidance in those areas.
For people with a personal history of breast cancer and genitourinary symptoms, we should initially only offer non-hormonal moisturisers or lubricants.
If symptoms continue despite this, vaginal oestrogen can be considered and used with a non-hormonal moisturiser or lubricant. However, this is an off-label use so we should seek specialist advice before initiating them, particularly if the patient is taking aromatase inhibitors as adjuvant treatment for breast cancer.
Patients should be made aware that it is unknown whether vaginal oestrogen affects the risk of breast cancer recurrence, given that only a minimal amount is absorbed systemically.
For people with oestrogen receptor-negative breast cancer, vaginal oestrogen is unlikely to increase the risk recurrence.
On the other hand, for people with oestrogen receptor-positive breast cancer, NICE says the risk of recurrence could potentially increase. However, adjuvant treatments, such as tamoxifen, would reduce any such potential impact.
For depressive symptoms associated with menopause, NICE says we can consider HRT if the symptoms do not meet the criteria for depression, and started around the same time as other menopause-associated symptoms.
CBT can also be considered for depressive symptoms which are associated with vasomotor symptoms.
However, if someone has depression, we should also follow the NICE guideline on depression.
For sleep problems, such as night-time awakening associated with vasomotor symptoms, menopause-specific CBT can be considered, either alone of alongside other options, including HRT.
For low sexual desire associated with menopause, NICE says we can consider testosterone supplementation if HRT alone is not effective.
However, in the UK, testosterone use for this indication is off-label, and prescribing depends on local formulary guidance. So, as GPs, we should consider specialist advice, although ongoing prescribing may sometimes continue in primary care.
Before offering treatment for the menopause, we should consider referral if there are contraindications to HRT, or if there is uncertainty about the most suitable option.
For people with type 2 diabetes, we can consider HRT after taking comorbidities into account and specialist advice can be sought if needed.
For people at increased risk of venous thromboembolism, we should consider transdermal rather than oral HRT, and this includes people with a BMI over 30.
For people at high risk of venous thromboembolism, for example those with a strong family history or thrombophilia, we should also refer to a haematologist before starting HRT.
For people with a personal history of coronary heart disease or stroke, HRT should only be offered by a menopause specialist.
For people with a personal history of breast cancer, or a high risk of breast cancer, NICE says we should also refer to a menopause specialist.
There is separate specific guidance for people at high familial risk of ovarian cancer, so we will not cover it here.
For people who are likely to experience menopause because of medical or surgical treatment, NICE says they should be able to discuss fertility with a fertility specialist.
Trans men and those who have taken gender-affirming hormone therapy in the past, should also be referred to a menopause specialist.
So that is it, a review of a section of the NICE guideline on the menopause.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
The new Technology appraisal guidance [TA1152] Semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity can be found here:
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in May 2026, focusing on what is relevant in Primary Care only.
This month, we only have one technology appraisal that is relevant to primary care, which is semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity.
Right, let’s jump into it.
This particular technology appraisal recommends semaglutide for reducing the risk of major adverse cardiovascular events in adults with established cardiovascular disease and overweight or obesity.
The difference is that this is not a general obesity recommendation.
This is about secondary prevention in people who already have established cardiovascular disease and a BMI of at least 27.
NICE defines established cardiovascular disease in this guidance as having at least one of the following: a previous MI, previous ischaemic or haemorrhagic stroke, or symptomatic peripheral arterial disease.
For peripheral arterial disease, NICE specifies intermittent claudication with an ankle brachial index below 0.85 at rest, or previous peripheral arterial revascularisation, or amputation because of atherosclerotic disease.
The recommendation is that semaglutide, up to a maintenance dose of 2.4 mg once weekly, can be used alongside standard routine management in order to reduce the risk of a major adverse cardiovascular event.
In this guidance, a major adverse cardiovascular event means cardiovascular death, non-fatal MI, or non-fatal stroke.
The guidance does not specify which setting semaglutide should be used in and it does not say that it needs to be provided in Primary Care but it does say that, once recommended by NICE, it must be funded in the NHS in England within 90 days of final publication.
NHS England has said semaglutide is expected to become available to eligible people over the next few years, but there is not yet a single national primary care prescribing pathway.
Some local formularies still restrict semaglutide in primary care, although many of these restrictions relate to weight management services rather than this new cardiovascular indication, so we will have to watch the space.
In the rationale, NICE states that lifestyle changes and standard medicines are used to reduce cardiovascular risk. These measures include diet, exercise, reducing alcohol, stopping smoking, and managing weight.
Medicines may include antihypertensives, lipid lowering drugs, antiplatelets, and anticoagulants.
Semaglutide is positioned as another option alongside standard care for secondary prevention given that trial evidence shows that it reduces the risk of a first major adverse cardiovascular event compared with placebo.
We know that people from South Asian, Chinese, other Asian, Middle Eastern, Black African, or African Caribbean ethnic backgrounds may have a higher cardiovascular risk at lower BMI thresholds.
However, NICE did not recommend semaglutide below a BMI of 27 because of licensing reasons and because evidence in that lower BMI group is not available.
In summary, for us primary care, the main message is that semaglutide is a cardiovascular secondary prevention option for people with established cardiovascular disease and a BMI of at least 27.
And semaglutide should be used alongside standard cardiovascular prevention, not instead of it. So, we should still give lifestyle advice and optimise blood pressure and lipids and prescribe antiplatelet or anticoagulant treatment where appropriate.
So that is it, a review of the NICE updates relevant to primary care.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.
Today we will focus on patient information, diagnosis, and treatment choices.
In future episodes we will cover the other sections of the guideline.
Right, let’s jump into it.
Let’s start by saying that the NICE menopause guideline applies to women, trans men, and non-binary people registered female at birth who have menopause-associated symptoms now, or who may experience them in the future.
It does not apply to people having gender-affirming hormone therapy.
Let’s now look at what information should be given to patients. When we assess and manage menopause, we should use shared decision making when discussing symptom management, including the benefits and risks of different options.
We should explain that menopause usually happens in mid-life, but that it can also happen earlier because of surgery, medical treatment, an inherited condition, or an unknown cause.
Menopause symptoms may be mild or severe, and they may last for a short time or a long time. Symptoms may include changes in the menstrual cycle, hot flushes, vaginal dryness, mood symptoms, joint or muscle pain, and sexual difficulties, such as low sexual desire.
NICE says we should discuss contraception with people who have menopause-associated symptoms because menopause symptoms do not necessarily mean that ovulation has stopped. Although fertility declines with age, contraception may still be needed if pregnancy is not wanted.
For people using non-hormonal contraception, the Faculty of Sexual and Reproductive Healthcare advises that contraception can usually be stopped after 2 years of amenorrhoea between the ages of 40 and 50, or after 1 year of amenorrhoea after the age of 50.
However, most women using hormonal contraception during the perimenopause will have altered bleeding patterns or amenorrhoea. As a result, it can be difficult to give accurate advice, so we should check the specific recommendations for each type of hormonal contraceptive in the Faculty of Sexual and Reproductive Healthcare guidance. In general, it advises that contraception can be stopped at age 55, because spontaneous pregnancy after this age is exceptionally rare.
Bone health should be discussed too, explaining the importance of maintaining muscle mass and strength through physical activity.
For people experiencing early menopause, between the ages of 40 and 44, we should offer psychological support if they are distressed by it.
Let’s now look at the diagnosis. In otherwise healthy people aged 45 or over, with menopause-associated symptoms, NICE says we can usually identify perimenopause and menopause without laboratory tests.
Perimenopause can be identified if vasomotor symptoms have recently started, and there are changes in the menstrual cycle.
Menopause can be identified if the person has not had a period for at least 12 months, and they are not using hormonal contraception.
In people who have had a hysterectomy, menopause is identified based on the type and combination of symptoms, for example vasomotor symptoms.
NICE also says that menopause can be harder to identify in people taking hormonal treatments, because, as we mentioned earlier, hormonal contraception can alter bleeding patterns, making it difficult to know the underlying menopausal status.
NICE says we should not use FSH to identify menopause in people using combined oestrogen and progestogen contraception, or high-dose progestogen and The Faculty of Sexual and Reproductive Healthcare explains why: combined hormonal contraception suppresses oestradiol, FSH, and LH, and depot medroxyprogesterone acetate can suppress FSH to some extent, meaning someone could be menopausal but not show the expected rise in FSH.
NICE also says that people from some ethnic minority backgrounds, and people with some lifelong conditions, may experience menopause at a younger age.
NICE does not give a list of specific ethnicities, but in its rationale, it gives Down’s syndrome as an example of a lifelong condition. So, the practical point is to think about menopause earlier in these groups.
NICE says that FSH should only be considered in specific situations.
This includes people aged 40 to 45 with menopause-associated symptoms, including a change in their menstrual cycle.
It also includes people under 40 in whom menopause is suspected, where we also need to think about premature ovarian insufficiency.
When discussing management options with people aged 40 or over, we should discuss the benefits and risks of the various treatment options.
Additionally, when discussing HRT, we should discuss combined HRT compared with oestrogen-only HRT, and explain which type the person would be offered and why.
We should also discuss transdermal HRT compared with oral HRT, the different types of oestrogen and progestogen, and when to give sequential versus continuous combined HRT, and why.
If the person chooses to take HRT, we should discuss the possible duration of treatment from the start and revisit, at every review, the benefits and risks of continuing it.
We should also explain that symptoms may return when HRT is stopped, and discuss the option of restarting treatment if needed.
Cognitive behavioural therapy can also be discussed as a possible management option, including menopause-specific CBT, which may include face-to-face or remote sessions, individual or group sessions, and self-help options, depending on the person’s preferences.
For complementary therapies, we should explain that the safety, quality, and purity of unregulated preparations may be unknown.
There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms, but NICE says we should also explain that their safety is uncertain, preparations may vary, and interactions with other medicines have been reported.
For people with a personal history of breast cancer, or at high risk of breast cancer, we should explain that, although St John’s wort may help relieve vasomotor symptoms, there is uncertainty about the correct dose, how long the effect lasts, and the variation in strength and content between preparations.
We should also warn about potential serious interactions with other medicines, including tamoxifen, anticoagulants, and anticonvulsants.
So that is it, a review of a section of the NICE guideline on the menopause.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
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Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.
In previous episodes we covered the diagnosis, criteria for urgent referral, when to start drug treatment and blood pressure targets.
Today we will focus on antihypertensive drug treatment.
Right, let’s jump into it.
Let’s start with what antihypertensive treatment to choose.
The recommendations in this guideline apply to people with hypertension, with or without type 2 diabetes, but for people with type 1 diabetes or CKD, we should refer to the relevant NICE guideline.
We should also remember that ACE inhibitors and angiotensin receptor blockers should not be used in pregnancy, breastfeeding, or when planning pregnancy, unless absolutely necessary. If used, we must discuss risks and benefits and follow safety guidance.
In general, and if possible, we should choose once daily treatments.
For isolated systolic hypertension, defined as a systolic blood pressure of 160 or higher, we should treat in the same way as people with both raised systolic and diastolic blood pressure.
We should offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension, in line with the general guideline on hypertension.
For women planning pregnancy, who are pregnant, or breastfeeding, we should manage hypertension in line with the specific NICE guideline on hypertension in pregnancy, including guidance during breastfeeding.
When choosing antihypertensive treatment for adults of Black African or African Caribbean family origin, we should consider an angiotensin receptor blocker in preference to an ACE inhibitor. This is because ACE inhibitors may be less effective in this group, partly because low renin hypertension is more common, and they also carry a higher risk of angioedema.
For people with cardiovascular disease, we should first follow the disease specific recommendations in the relevant NICE guideline for their condition. These include:
· acute coronary syndromes,
· acute and chronic heart failure,
· stable angina, and
· type 1 diabetes.
If blood pressure remains uncontrolled despite following these disease specific recommendations, we should then offer the general stepwise approach outlined in the hypertension guideline. Let’s have a look at it.
As step 1 treatment, we should offer an ACE inhibitor or an ARB as step 1 treatment if they have type 2 diabetes, regardless of age or family origin.
We should also offer an ACE inhibitor or an ARB to adults under the age of 55, provided they are not of Black African or African Caribbean family origin.
If an ACE inhibitor is not tolerated, for example because of cough, we should offer an ARB instead. We should not combine an ACE inhibitor with an ARB.
We should offer a calcium channel blocker as step 1 treatment if they are aged 55 or over and do not have type 2 diabetes.
We should also offer a calcium channel blocker to adults of Black African or African Caribbean family origin who do not have type 2 diabetes, regardless of age.
If a calcium channel blocker is not tolerated, for example because of oedema, we should offer a thiazide like diuretic.
Equally, if there is evidence of heart failure, we should offer a thiazide like diuretic and follow the NICE guideline on chronic heart failure.
If starting or changing diuretic treatment, we should prefer a thiazide like diuretic, such as indapamide, over conventional thiazides such as bendroflumethiazide or hydrochlorothiazide.
If blood pressure is stable and well controlled on bendroflumethiazide or hydrochlorothiazide, we should continue the current treatment.
Now let’s move on to step 2 treatment.
Before considering the next step, we should discuss with the person whether they are taking their medication as prescribed.
If blood pressure is not controlled on step 1 treatment with an ACE inhibitor or an ARB, we should offer one of the following in addition:
a calcium channel blocker, or
a thiazide like diuretic.
If blood pressure is not controlled in adults taking step 1 treatment with a calcium channel blocker, we should offer one of the following in addition:
an ACE inhibitor,
an ARB, or
a thiazide like diuretic.
For adults of Black African or African Caribbean family origin without type 2 diabetes, not controlled on step 1 treatment, we should consider an ARB in preference to an ACE inhibitor as the add on treatment.
Now let’s move on to step 3 treatment.
Before considering the next step, we should make sure that optimal tolerated doses are being taken, and we should discuss adherence.
If blood pressure is not controlled on step 2 treatment, we should offer a combination of three drugs, that is:
an ACE inhibitor or an ARB,
plus a calcium channel blocker,
plus a thiazide like diuretic.
And finally, let’s now move on to step 4 treatment.
If blood pressure is not controlled despite optimal tolerated doses of an ACE inhibitor or an angiotensin receptor blocker, plus a calcium channel blocker, plus a thiazide like diuretic, we should regard this as resistant hypertension.
Before considering further treatment, we should confirm the elevated clinic readings using ambulatory or home blood pressure monitoring.
We should assess for postural hypotension.
And we should discuss adherence.
If resistant hypertension is confirmed, we should consider a fourth antihypertensive drug or seek specialist advice.
If considering a fourth drug. we should consider adding low dose spironolactone if the blood potassium is 4.5 millimoles per litre or less, using caution if kidney function is reduced, because of hyperkalaemia.
When starting further diuretic therapy, we should monitor sodium, potassium, and renal function within one month, and repeat as needed.
If potassium is above 4.5, we should consider an alpha blocker or a beta blocker instead.
If blood pressure remains uncontrolled despite four drugs at optimal tolerated doses, we should seek specialist advice.
So that is it, a review of a section of the NICE guideline on hypertension.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
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