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6.4.1a Women who have not had a hysterectomy

HRT shortages – if products are unavailable see SPS and BMS websites for current availability and alternative products.

Sequential combined (oral)

ChoiceDrug

1st choices

Elleste-Duet® 1mg, 2mg tablets (estradiol and norethisterone)

or

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

Sequential combined (transdermal)

ChoiceDrug
1st choice

Evorel® 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])

Continuous combined (oral)

ChoiceDrug

Formulary choices

Bijuve® 1mg/100mg capsules (estradiol 1 mg and progesterone 100mg)
or
Femoston® - conti 0.5mg/2.5mg tablets; 1mg/5mg tablets (estradiol and dydrogesterone)
or

Indivina® 1mg/2.5mg tablets;1mg/5mg tablets; 2mg/5mg tablets (estradiol and medroxyprogesterone acetate)

Note: only licensed when LMP occurred over 3 years previously

or
Kliofem® tablets (estradiol 2mg and norethisterone 1mg)
or
Kliovance® tablets (estradiol 1mg and norethisterone 500micrograms)

Continuous combined (transdermal)

ChoiceDrug
1st choice

Evorel® Conti patches:

(estradiol 50micrograms/24hours and norethisterone 170micrograms/24hours [matrix patch])

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, are likely to benefit from the higher dose of oestrogen for bone protection even if the lower dose is adequate for symptom prevention.
  • Women who commence sequential combined HRT should expect a monthly bleed, although a small percentage of women won’t have any bleeding. Women who commence continuous combined HRT may experience some irregular light bleeding for 4-6 months.
  • Refer to a gynaecology or menopause service if:
    • Heavy, prolonged bleeds with HRT, or
    • Lighter bleeding which continues for >6 months after commencing continuous combined HRT
  • 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® intrauterine system as the progestogen component of HRT

In  Northern Ireland, micronised progesterone (Utrogestan® 100mg oral capsules) is accepted for adjunctive use with oestrogen as HRT in line with SMC2529. It provides an additional treatment choice for women requiring combined HRT but unsuitable for or intolerant of standard combination preparations listed in the NI Formulary.

    • The licensed dose is 200mg at night for 12 days (Day 15-26 of cycle) or 100mg at bedtime from Day 1-25 of cycle.
    • Alternatively, women may be advised to take Utrogestan® 200mg at night for the first 12 days of each calendar month (if irregular/infrequent cycles) or 100mg on a continuous basis. This dosing regimen differs slightly from licensed doses but is endorsed by the British Menopause Society as it may be more straightforward to take in this way.