Policy

Hormone Replacement Therapy Prescribing Policy

Who may prescribe hormone replacement therapy, on what basis, with what endometrial protection, and with what follow-up

For Women's Health & Menopause ClinicRef BS-WOM-POL-003See a sample (PDF) →
£44.99
One-off purchase · no VAT · instant download
  • Instant download after checkout
  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This policy is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Policy statement
  • 4. Definitions
  • 5. Who may prescribe
  • 6. Before the first prescription
  • 7. GP information sharing and remote prescribing safeguards
  • 8. Benefits and risks that must be discussed
  • 9. Patients needing specialist input or additional care
  • 10. Choosing the oestrogen
  • 11. Endometrial protection
  • 12. Tibolone and vaginal oestrogen
  • 13. Bleeding on HRT
  • 14. Follow-up, continuation and stopping
  • 15. Supply, shortages and substitution
  • 16. Adverse reactions, incidents and emergencies
  • 17. Roles and responsibilities
  • 18. Training and competence
  • 19. Records, monitoring and audit
  • 20. Related documents
  • 21. Version control and review
  • 22. Disclaimer

CQC fundamental standard

Regulation 9 (Person-centred care)
This document is written to evidence that standard. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 17 (Good governance), Regulation 18 (Staffing) and Regulation 20 (Duty of candour).
  • Human Medicines Regulations 2012, including regulation 226A (supply in accordance with a serious shortage protocol) and regulation 284 (advertising of prescription only medicines to the public).
  • Equality Act 2010.
  • UK General Data Protection Regulation and Data Protection Act 2018.
  • National Institute for Health and Care Excellence (NICE) guideline NG23, Menopause: identification and management (as last updated).
  • National Institute for Health and Care Excellence (NICE) guideline NG12, Suspected cancer: recognition and referral (as last updated).
  • British Menopause Society consensus statements and Tools for Clinicians, including Progestogens and endometrial protection (reviewed February 2026).
  • Management of unscheduled bleeding on hormone replacement therapy (HRT): joint guideline of the British Menopause Society, Royal College of Obstetricians and Gynaecologists and partner organisations (2024).
  • General Medical Council (GMC), Good practice in proposing, prescribing, providing and managing medicines and devices, including the sections on remote prescribing and on medicines requiring additional safeguards.
  • GMC, Remote consultations guidance and decision flowchart.
  • Nursing and Midwifery Council, The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates; General Pharmaceutical Council, Standards for pharmacy professionals; Royal Pharmaceutical Society, A Competency Framework for All Prescribers.
  • Care Quality Commission (CQC) assessment framework: the five key questions (safe, effective, caring, responsive and well-led) and the quality statements of the single assessment framework, and the sector-specific framework for primary care and community services when it replaces them.
  • Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update, Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping (August 2019), and the Yellow Card scheme.
  • College of Sexual and Reproductive Healthcare (CoSRH, formerly the Faculty of Sexual and Reproductive Healthcare) guidance, Contraception for Women Aged over 40 Years (as amended).
  • Records Management Code of Practice (2023).

Who it applies to

All prescribing clinicians (whether registered with the General Medical Council, the Nursing and Midwifery Council or the General Pharmaceutical Council), the Registered Manager, the Nominated Individual, the Clinical Lead, administrative and patient-support staff, and self-employed, sessional and locum clinicians working for [Organisation Name]

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Amenorrhoea
The absence of periods.
Aromatase inhibitor
A breast cancer medicine that lowers oestrogen levels in the body.
Body mass index (BMI)
A measure of weight relative to height, calculated as weight in kilograms divided by height in metres squared (kg/m2).
BRCA
Genes which, when altered, greatly increase the risk of breast and ovarian cancer.
British Menopause Society (BMS)
The UK professional society that provides education and guidance to healthcare professionals on menopause care.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
College of Sexual and Reproductive Healthcare (CoSRH)
The UK professional body for sexual and reproductive healthcare, formerly known by another name, which publishes national contraception guidance.
Continuous combined regimen
HRT in which oestrogen and progestogen are both taken every day, aiming for no bleeding.
Data Protection Act 2018
The UK law that sits alongside the UK General Data Protection Regulation and governs the use of personal data.
Duty of candour
The legal duty to be open and honest with a patient when something goes wrong with their care that causes, or could cause, harm.
Endometrial hyperplasia
Abnormal thickening of the lining of the womb, which can progress to cancer.
Endometrial protection
Using a progestogen to stop oestrogen from over-stimulating the lining of the womb.
Equality Act 2010
The law that protects people from discrimination because of protected characteristics such as sex, gender reassignment, age and disability.
General Medical Council (GMC)
The body that registers and regulates doctors in the UK.
General Pharmaceutical Council (GPhC)
The body that registers and regulates pharmacists and pharmacy technicians in Great Britain.
General practitioner (GP)
A family doctor who usually holds a patient's main medical record.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that CQC-registered providers must meet.
Hormone replacement therapy (HRT)
Medicines that replace the hormones, mainly oestrogen, that fall during the menopause.
Human Medicines Regulations 2012
The main UK law on the licensing, supply, prescribing and advertising of medicines.
Levonorgestrel intrauterine system (LNG-IUS)
A small device placed in the womb that releases a progestogen called levonorgestrel; the 52 mg version can protect the womb lining during HRT.
Medicines and Healthcare products Regulatory Agency (MHRA)
The UK government agency that regulates medicines and medical devices and runs the Yellow Card scheme.
Micronised progesterone
A licensed form of progesterone that is chemically identical to the hormone the body makes.
National Institute for Health and Care Excellence (NICE)
The body that produces national evidence-based guidance on health and care in England.
NICE NG12
The NICE guideline Suspected cancer: recognition and referral.
NICE NG23
The NICE guideline Menopause: identification and management.
Nursing and Midwifery Council (NMC)
The body that registers and regulates nurses, midwives and nursing associates in the UK.
Oestradiol
The main natural form of oestrogen, used in body-identical HRT.
Off-label use
Using a licensed medicine in a way not covered by its licence, such as a different dose or duration.
Premature ovarian insufficiency (POI)
Loss of normal ovarian function before the age of 40.
Progestogen
Natural progesterone or a synthetic hormone that acts like it, used in HRT to protect the womb lining.
Records Management Code of Practice (2023)
National guidance on how long health and care records should be kept and how they should be managed.
Sequential combined regimen
HRT with daily oestrogen and a progestogen for part of each month, usually producing a monthly bleed.
Serious shortage protocol (SSP)
A government-issued protocol allowing a pharmacist to supply an alternative to a medicine that is in serious shortage without contacting the prescriber.
Summary of Product Characteristics
The official document describing a licensed medicine's approved uses, doses and warnings.
Tibolone
A synthetic hormone medicine with oestrogen-like, progestogen-like and androgen-like effects, used for menopausal symptoms after periods have stopped.
Transdermal
Absorbed through the skin, for example by a patch, gel or spray.
Transient ischaemic attack (TIA)
A temporary interruption of blood supply to part of the brain, sometimes called a mini-stroke, needing urgent assessment.
Transvaginal ultrasound
An internal ultrasound scan used to measure the thickness of the womb lining.
UK General Data Protection Regulation
The UK's main data protection law governing how personal information is collected and used.
Venous thromboembolism (VTE)
A blood clot in a vein, such as a deep vein thrombosis in the leg or a pulmonary embolism in the lung.
Yellow Card scheme
The MHRA system for reporting suspected side effects of medicines.

How it works

  1. Buy securely with Stripe - instant, no VAT, no account needed.
  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

Related documents

PolicyWomen's Health Scope of Service Policy£44.99
PolicyMenopause Assessment & Diagnosis Policy£44.99
PolicyTestosterone Prescribing in Women Policy£44.99
PolicyUnlicensed & Off-Label Medicines Policy£44.99

Need the whole set?

Buy the full Women's Health & Menopause Clinic pack and save versus buying documents individually.

View the Women's Health & Menopause Clinic pack →