Primary Care Guidelines
Claim This Podcastby Juan Fernando Florido Santana
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<p>A podcast intended for healthcare professionals wanting to keep up to date relevant information about clinical practice guidelines</p>
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Publishing Since
2/6/2022
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Recent Episodes
July 19, 2026
Podcast - NICE News - June 2026
<p><span>The video version of this podcast can be found here: </span></p><p>· <a href="https://youtu.be/i9b7QqtmcAs" rel="nofollow">https://youtu.be/i9b7QqtmcAs</a></p><p><span>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.</span></p><p><span>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.</span></p><p><span>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. </span></p><p><span> </span></p><p><span>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. </span></p><p><span> </span></p><p><span>Disclaimer:</span></p><p><span>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.</span></p><p><span> 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.</span></p><p> </p><p><span>Intro / outro music: </span><span>Track: Halfway Through — Broke In Summer [Audio Library Release] </span></p><ul><li><span>Music provided by Audio Library Plus </span></li><li><span>Watch: </span><a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a><span> </span></li><li><span>Free Download / Stream: </span><a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a><span> </span></li></ul><p><span> </span></p><p><span>There is a podcast version of this and other videos that you can access here:</span></p><p><span> </span></p><p><span>Primary Care guidelines podcast: </span></p><p><span> </span></p><p><span>· </span><span>Redcircle: </span>https://redcircle.com/shows/primary-care-guidelines</p><p><span>· </span><span>Spotify: </span><span>https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK</span></p><p><span>· </span><span>Apple podcasts: </span>https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148</p><p><br></p><p><span> There is a YouTube version of this and other videos that you can access here: </span></p><ul><li><span>The Practical GP YouTube Channel: </span></li></ul><p><a href="https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk" rel="nofollow">https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk</a></p><p><br></p><p><span> The Full NICE News bulletin for June 2026 can be found here:</span></p><p> </p><p>· https://www.nice.org.uk/guidance/published?from=2026-06-01&to=2026-06-30</p><p><br></p><p>The new Technology appraisal guidance [TA694] Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia can be found here:</p><p>· https://www.nice.org.uk/guidance/ta694</p><p>The updated NICE guideline on Ectopic pregnancy and miscarriage: diagnosis and initial management [NG126] can be found here:</p><p>· https://www.nice.org.uk/guidance/ng126</p><p> </p><p>The updated NICE guideline on Postnatal care [NG194] can be found here:</p><p>· https://www.nice.org.uk/guidance/ng194</p><p> </p><p>The new updated NICE guideline on Multiple sclerosis in adults: management [NG220] can be found here:</p><p>· https://www.nice.org.uk/guidance/ng220</p><p> </p><p><strong>Transcript</strong></p><p>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.</p><p>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. </p><p>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.</p><p>Right, let’s jump into it.</p><p>And let’s start with the new guidance on bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia.</p><p>But first, what is bempedoic acid?</p><p>Bempedoic acid is a relatively new oral, non-statin lipid-lowering drug used to reduce LDL cholesterol.</p><p>It works in the liver by inhibiting cholesterol production earlier in the pathway than statins.</p><p>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.</p><p>The result is reduced cholesterol synthesis in the liver and increased clearance of LDL cholesterol from the blood.</p><p>Bempedoic acid is usually given with ezetimibe because the two drugs work in complementary ways.</p><p>Bempedoic acid reduces cholesterol production in the liver, while ezetimibe reduces cholesterol absorption from the intestine.</p><p>Together, they lower LDL cholesterol more than either drug alone, and they provide an all-oral option for people who cannot tolerate statins.</p><p>Now let’s look at the NICE guidance.</p><p>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.</p><p>The evidence shows LDL cholesterol reduction, with cardiovascular outcome evidence.</p><p>In practical terms, this is not a replacement for statins as first-line lipid-lowering treatment.</p><p>NICE describes the usual pathway as statins first, with ezetimibe added if LDL cholesterol is not lowered enough.</p><p>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.</p><p>However, a useful practical point is that bempedoic acid is an oral treatment, whereas alirocumab and evolocumab are given by subcutaneous injection.</p><p>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.</p><p>Let’s now move to the updated guideline on ectopic pregnancy and miscarriage.</p><p>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.</p><p>However, from twelve weeks and zero days to twelve weeks and six days, anti-D remains relevant for RhD-negative pregnant people.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>A negative test will mean the pregnancy has miscarried.</p><p>Let’s now touch on the updated guideline on postnatal care.</p><p>For GP practice, the June 2026 update itself probably changes very little.</p><p>NICE has added a recommendation to offer vitamin K prophylaxis for babies, linking to the intrapartum care guideline.</p><p>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.</p><p>And finally, the updated guideline on multiple sclerosis.</p><p>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.</p><p>But this does not affect us in primary care.</p><p>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.</p><p>However, we should not routinely suspect MS from fatigue, dizziness, or vague sensory symptoms alone.</p><p>We should then refer suspected MS cases to neurology, and secondary care will make the diagnosis following specific criteria.</p><p>So that is it, a review of the NICE updates relevant to primary care.</p><p>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.</p><p>Thank you for listening and goodbye.</p>
July 5, 2026
Podcast - NICE 2026 Menopause Part 3 HRT risks explained
<p>The video version of this podcast can be found here: </p><p>· <a href="https://youtu.be/lgHKxBVz6kE" rel="nofollow">https://youtu.be/lgHKxBVz6kE</a></p><p>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.</p><p>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.</p><p>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.</p><p>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. </p><p> </p><p>Disclaimer:</p><p>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.</p><p> 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.</p><p> </p><p>Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] </p><ul><li>Music provided by Audio Library Plus </li><li>Watch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a> </li><li>Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a> </li></ul><p> </p><p> </p><p>There is a podcast version of this and other videos that you can access here:</p><p> </p><p>Primary Care guidelines podcast: </p><p> </p><p>· Redcircle: https://redcircle.com/shows/primary-care-guidelines</p><p>· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK</p><p>· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148</p><p><br></p><p> There is a YouTube version of this and other videos that you can access here: </p><ul><li>The Practical GP YouTube Channel: </li></ul><p><a href="https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk" rel="nofollow">https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk</a></p><p> </p><p>The NICE clinical guideline on Menopause: identification and management</p><p>[NG23] can be found here:</p><p> </p><p>· <a href="https://www.nice.org.uk/guidance/NG23" rel="nofollow">https://www.nice.org.uk/guidance/NG23</a></p><p> </p><p>The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:</p><p> </p><p>· <a href="https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901" rel="nofollow">https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901</a></p><p> </p><p>The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:</p><p> </p><p>· <a href="https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf" rel="nofollow">https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf</a></p><p> </p><p> </p><p>The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:</p><p>· <a href="https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/" rel="nofollow">https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/</a></p><p> </p><p><strong>Transcript</strong></p><p>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.</p><p>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.</p><p>Today we will focus on HRT risks and benefits in people aged 45 and over.</p><p>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.</p><p>Right, let’s jump into it.</p><p>So let’s start by looking at the effects of HRT on specific health outcomes.</p><p>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.</p><p>Let’s first look at the effects that are similar with combined and oestrogen-only HRT.</p><p>For people aged 45 or over, we will explain that neither combined HRT or oestrogen-only HRT is likely to affect life expectancy.</p><p>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.</p><p>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.</p><p>Neither combined HRT or oestrogen-only HRT increases the risk of developing type 2 diabetes and it has no adverse effect on blood glucose.</p><p>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.</p><p>And now let’s review the specific effects of combined HRT, which is given to people with a uterus.</p><p>And we will start looking at the Breast cancer risk first, which varies depending on the person’s risk factors.</p><p>With combined HRT, breast cancer risk increases, and this increase rises with duration of use.</p><p>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.</p><p>NICE says there is a very small increase in the risk of death from breast cancer too.</p><p>The type of combined HRT also matters.</p><p>Breast cancer risk is lower with sequential combined HRT than with continuous combined HRT, but it is still higher than without HRT.</p><p>There is not enough evidence that any specific progestogen carries a higher risk of breast cancer.</p><p>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.</p><p>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.</p><p>For dementia, the risk might increase if it is started at the age of 65 or over.</p><p>For stroke, we should explain that the baseline population risk in women under 60 is very low.</p><p>Stroke risk is unlikely to increase with combined HRT that includes transdermal oestrogen, but it increases with combined HRT containing oral oestrogen.</p><p>This increase rises with higher oestrogen dose and longer duration of treatment, for example if used for more than 5 years.</p><p>The risk is also higher when HRT is started at a later age, and may be higher in Black people.</p><p>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.</p><p>Let’s now move to oestrogen only HRT, remembering that this is the option recommended for people who have had a total hysterectomy.</p><p>Starting with breast cancer, the discussion is different from combined HRT.</p><p>Oestrogen-only HRT causes very little or no increase in breast cancer risk or breast cancer mortality.</p><p>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.</p><p>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.</p><p>For dementia, NICE says that the risk is unlikely to increase.</p><p>For stroke, the route of oestrogen matters.</p><p>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.</p><p>However, stroke risk is unlikely to increase with transdermal oestrogen-only HRT.</p><p>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.</p><p>So that is it, a review of a section of the NICE guideline on the menopause.</p><p>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.</p><p>Thank you for listening and goodbye.</p>
June 21, 2026
Podcast - NICE 2026 Menopause Part 2 Symptoms and treatments
<p>The video version of this podcast can be found here:</p><p>· <a href="https://youtu.be/2zTvO-QuDNE" rel="nofollow">https://youtu.be/2zTvO-QuDNE</a></p><p>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.</p><p>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.</p><p>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.</p><p>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. </p><p> </p><p>Disclaimer:</p><p>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.</p><p>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.</p><p> </p><p>Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] </p><ul><li>Music provided by Audio Library Plus </li><li>Watch: <a href="https://www.youtube.com/watch?t=0s&v=aBGk6aJM3IU" rel="nofollow">https://youtu.be/aBGk6aJM3IU</a> </li><li>Free Download / Stream: <a href="https://www.youtube.com/redirect?event=video_description&q=https%3A%2F%2Falplus.io%2Fhalfway-through&redir_token=QUFFLUhqbVNpZlBNM0lCeDIxQzRkU29qUnJGQy15WEtTQXxBQ3Jtc0tuUUFSMkZwSEVuaHdUTWlYV21fZmpjWS1WRXI3R0hZU056MkpmRFpKdXdGYm1La3BlazhUemZ5SkVMTFdaWWRvSG9Ucy1neWpudTJ0MUIxNnl2NmhvR0lmdzduWXEwUUg0alduYkRNdjlWWTNsMnhzaw&v=aBGk6aJM3IU" rel="nofollow">https://alplus.io/halfway-through</a> </li></ul><p> </p><p> </p><p>There is a podcast version of this and other videos that you can access here:</p><p> </p><p>Primary Care guidelines podcast:</p><p> </p><p>· Redcircle: https://redcircle.com/shows/primary-care-guidelines</p><p>· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK</p><p>· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148</p><p><br></p><p>There is a YouTube version of this and other videos that you can access here: </p><ul><li>The Practical GP YouTube Channel: </li></ul><p><a href="https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk" rel="nofollow">https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk</a></p><p> </p><p>The NICE clinical guideline on Menopause: identification and management</p><p>[NG23] can be found here:</p><p> </p><p>· <a href="https://www.nice.org.uk/guidance/NG23" rel="nofollow">https://www.nice.org.uk/guidance/NG23</a></p><p> </p><p>The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:</p><p> </p><p>· <a href="https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf" rel="nofollow">https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf</a></p><p> </p><p>The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:</p><p>· <a href="https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/" rel="nofollow">https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/</a></p><p> </p><p><strong>Transcript</strong></p><p>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.</p><p>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.</p><p>Today we will focus on symptom management and treatment risks.</p><p>In the last episode we covered diagnosis, and treatment choices and in future episodes we will cover the other sections of the guideline.</p><p>Right, let’s jump into it.</p><p>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.</p><p>Let’s look at the various possible symptoms one by one.</p><p>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.</p><p>Fezolinetant is also recommended as an option when HRT is unsuitable.</p><p>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.</p><p>NICE says we should not routinely offer SSRIs, SNRIs, or clonidine as first-line treatment for vasomotor symptoms alone.</p><p>Now let’s look at genitourinary symptoms.</p><p>For people with no history of breast cancer, we should offer vaginal oestrogen, including in people who are already using systemic HRT.</p><p>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.</p><p>Vaginal oestrogen is absorbed locally and a minimal amount is absorbed systemically, which is unlikely to have a significant effect throughout the body.</p><p>Types of vaginal oestrogen include creams, gels, vaginal tablets, pessaries, or rings. They can be used alone, or with non-hormonal moisturisers or lubricants.</p><p>If vaginal oestrogen is contraindicated, or the person prefers not to use it, we should then just consider non-hormonal vaginal moisturisers or lubricants.</p><p>If vaginal oestrogen, moisturisers, or lubricants have not worked, NICE says we should consider vaginal prasterone or oral ospemifene.</p><p>These medicines are not started routinely in primary care, and their use will depend on local formulary and prescribing guidance.</p><p>For people with genitourinary symptoms and overactive bladder, or recurrent urinary tract infections, NICE signposts their specific guidance in those areas.</p><p>For people with a personal history of breast cancer and genitourinary symptoms, we should initially only offer non-hormonal moisturisers or lubricants.</p><p>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.</p><p>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.</p><p>For people with oestrogen receptor-negative breast cancer, vaginal oestrogen is unlikely to increase the risk recurrence.</p><p>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.</p><p>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.</p><p>CBT can also be considered for depressive symptoms which are associated with vasomotor symptoms.</p><p>However, if someone has depression, we should also follow the NICE guideline on depression.</p><p>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.</p><p>For low sexual desire associated with menopause, NICE says we can consider testosterone supplementation if HRT alone is not effective.</p><p>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.</p><p>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.</p><p>For people with type 2 diabetes, we can consider HRT after taking comorbidities into account and specialist advice can be sought if needed.</p><p>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.</p><p>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.</p><p>For people with a personal history of coronary heart disease or stroke, HRT should only be offered by a menopause specialist.</p><p>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.</p><p>There is separate specific guidance for people at high familial risk of ovarian cancer, so we will not cover it here.</p><p>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.</p><p>Trans men and those who have taken gender-affirming hormone therapy in the past, should also be referred to a menopause specialist.</p><p>So that is it, a review of a section of the NICE guideline on the menopause.</p><p>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.</p><p>Thank you for listening and goodbye.</p>
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