A 52-year-old perimenopausal woman with intact uterus has moderate-severe vasomotor symptoms significantly affecting quality of life. She has no contraindications to hormone therapy. According to the NICE 2023 menopause guidelines and the evidence base, which regimen is most appropriate as first-line HRT?

• A Continuous combined estrogen + progestogen (CCT) using transdermal estradiol (patch/gel) plus oral micronised progesterone (Utrogestan) — lower VTE risk than oral estrogen, endometrial protection with most favourable safety profile ✓
• B Oral conjugated equine estrogen 0.625 mg alone — progestogen unnecessary until uterus is removed
• C Oral 17-beta estradiol + medroxyprogesterone acetate — most evidence-based combination based on WHI data
• D Tibolone 2.5 mg daily — first-line as it avoids all estrogen-related VTE risk while providing complete symptom relief

Explanation

NICE 2023 and RCOG/BMS guidelines recommend that for women with a uterus, combined estrogen plus progestogen is mandatory (progestogen protects against endometrial hyperplasia/carcinoma). Transdermal estradiol avoids first-pass hepatic metabolism, does NOT increase VTE risk (unlike oral estrogen), and does not increase stroke risk. Oral micronised progesterone (body-identical progesterone, Utrogestan) has the most favourable safety profile: no increased breast cancer signal versus synthetic progestogens in large studies (CGHFBC 2019 data disputed for micronised P). Oral CEE + MPA (WHI formulation) is associated with increased VTE, stroke, and breast cancer risk and is NOT recommended as first-line. Tibolone is a second-line option.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.