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Home Formulary 6.0 Endocrine 6.4 Sex hormones 6.4.1.1 Hormone replacement therapy (HRT) for menopausal symptoms 6.4.1.1a Women who have not had a hysterectomy

6.4.1.1a Women who have not had a hysterectomy

Sequential combined (oral)

ChoiceDrugDosage
1st choiceElleste-Duet® 1mg, 2mg tablets (estradiol and norethisterone)

Dose:
Elleste-Duet® 1mg tablets – menopausal symptoms, 1 white tablet daily for 16 days starting on day 1 of menstruation (or at any time if cycles have ceased or are infrequent), then 1 green tablet daily for 12 days; subsequent courses are repeated without interval

Elleste-Duet® 2mg tablets – menopausal symptoms and osteoporosis prophylaxis (see section 6.6), 1 orange tablet daily for 16 days, starting on day 1 of menstruation (or at any time if cycles have ceased or are infrequent) then 1 grey tablet daily for 12 days; subsequent courses are repeated without interval

Or
Femoston® 1/10, 2/10 tablets (estradiol and dydrogesterone)

Dose:
Femoston® 1/10 tablets – menopausal symptoms and osteoporosis prophylaxis (see section 6.6), in women with a uterus, 1 white tablet daily for 14 days, starting within 5 days of onset of menstruation (or any time if cycles have ceased or are infrequent) then 1 grey tablet daily for 14 days; subsequent courses repeated without interval

Femoston® 2/10 tablets - menopausal symptoms and osteoporosis prophylaxis (see section 6.6), in women with a uterus, 1 red tablet daily for 14 days, starting within 5 days of onset of menstruation (or any time if cycles have ceased or are infrequent) then 1 yellow tablet daily for 14 days; subsequent courses repeated without interval;

Where therapy required for menopausal symptoms alone, Femoston® 1/10 given initially and Femoston® 2/10 substituted if symptoms not controlled

Sequential combined (transdermal)

ChoiceDrugDosage
1st choiceEvorel® Sequi patches: combination pack of 4 Evorel® 50 patches (estradiol 50micrograms/24hours) and 4 Evorel® Conti patches (estradiol 50micrograms/24hours) and norethisterone acetate 170micrograms/24hours

Dose:
Menopausal symptoms and osteoporosis prophylaxis (see section 6.6), in women with a uterus, 1 Evorel® 50 patch to be applied twice weekly for 2 weeks, starting within 5 days of onset of menstruation (or at any time if cycles have ceased or are infrequent), followed by 1 Evorel® Conti patch twice weekly for 2 weeks; subsequent courses are repeated without interval

2nd choiceFemSeven Sequi® patches: providing estradiol 50micrograms per 24 hours (phase 1); estradiol 50micrograms and levonorgestrel 10micrograms per 24 hours (phase 2)

Dose:
Menopausal symptoms in women with a uterus, one Phase 1 patch applied once a week for 2 weeks followed by one Phase 2 patch once a week for 2 weeks; subsequent courses are repeated without interval

Continuous combined (oral)

ChoiceDrugDosage
1st choiceKliovance® tablets (estradiol 1mg and norethisterone 500micrograms)

Dose: Menopausal symptoms in women with a uterus whose last menstrual period occurred over 12 months previously, Osteoporosis prophylaxis in women with a uterus (see section 6.6),

1 tablet daily continuously, to be started at end of scheduled bleed if changing from cyclical HRT

or
Kliofem® tablets
(estradiol 2mg and norethisterone 1mg)

Dose: Menopausal symptoms in women with a uterus whose last menstrual period occurred over 12 months previously , Osteoporosis prophylaxis in women with a uterus (see section 6.6),

1 tablet daily continuously, to be started at end of scheduled bleed if changing from cyclical HRT

2nd choiceBijuve® 1mg/100mg capsules (estradiol 1 mg, progesterone 100mg)Dose:
Menopausal symptoms in women with a uterus whose last menstrual period occurred over 12 months previously, 1 capsule daily continuously, dose to be taken in the evening with food, if changing from continuous sequential or cyclical HRT, start treatment the day after finishing the 28-day cycle. Treatment may start immediately after surgical menopause or if changing from another continuous combined HRT
or
Femoston® - conti 0.5mg/2.5mg tablets; 1mg/5mg tablets (estradiol and dydrogesterone)

Dose: Femoston®-conti 0.5mg/2.5mg tablets: Menopausal symptoms in women with a uterus whose last menstrual period occurred over 12 months previously, 1 tablet daily continuously, if changing from cyclical HRT begin treatment the day after finishing oestrogen plus progestogen phase.

Femoston®-conti 1 mg/5 mg tablets: Menopausal symptoms and osteoporosis prophylaxis (see section 6.6) in women with a uterus whose last menstrual period occurred over 12 months previously, 1 tablet daily continuously (if changing from cyclical HRT begin treatment the day after finishing oestrogen plus progestogen phase)

Continuous combined (transdermal)

ChoiceDrugDosage
1st choiceEvorel® Conti patches (estradiol 50micrograms/24hours and norethisterone 170micrograms/24hours (matrix patch))

Dose:
Menopausal symptoms and osteoporosis prophylaxis (see section 6.6), in women with a uterus, 1 patch to be applied twice weekly continuously

Prescribing Notes

  • HRT preparations should be brand prescribed to aid product identification
  • It is recommended that the lowest dose of HRT based on relieving menopausal symptoms should be prescribed
  • Women with an early menopause (<45 years), especially if surgically induced, require the higher dose of oestrogen to control their vasomotor symptoms and for bone protection
  • Women with irregular or heavy bleeding with HRT which persists for more than 3 months should be referred to a gynaecology or menopause service
  • Amenorrhoea with HRT is not a risk for endometrial cancer and does not require investigation
  • Progestogenic side effects (women typically describe symptoms similar to PMS) may resolve within a few months. For persistent or troublesome symptoms consider:
    • Changing the progestogen type, e.g. to a less androgenic one such as dydrogesterone
    • Changing the route of delivery e.g. oral to transdermal
    • 3 monthly bleed preparation (Tridestra®)
    • Using a Mirena® IUS as the progestogen component of HRT

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