Related resources:
Menopause and Hormone Replacement Therapy for detailed information on:
- Menopause symptom management and prescribing guidance
- Resources including how to manage stock availability issues
- HRT choice flow charts for Transdermal and Oral therapies
- Risks and benefits, and prescribing options
- Premature ovarian insufficiency
- Testosterone for low sexual desire in menopausal patients where optimised HRT alone is not effective (off-label use) resources and prescribing information
- Unexplained / unscheduled vaginal bleeding
- Supporting people with menopausal symptoms after breast cancer
See the HRT Quick Reference Table to access formulary choices for HRT and local estrogen at a glance
Somerset local estrogen detailed information for information on vaginal atrophy and Formulary Chapter 7.7 – Vaginal and vulval conditions for formulary preparations for local estrogen
Reproductive Health for information on reproductive health, including endometriosis
Medicines in pregnancy, children and lactation for information on prescribing in pregnancy and lactation, including breastfeeding and menopause
Gender Identity for information on gender dysphoria and guidance for clinicians supporting patients
Formulary Chapter 6.8.2 – Male Sex Hormone responsive conditions for testosterone preparations on formulary
Formulary Chapter 8.4 – Hormone responsive malignancy for information on chemoprevention and malignancy
Contraception for information on contraception, including combined oral contraception which may be an option as HRT for premature ovarian insufficiency.
- See Formulary Chapter 7.3 – Contraception for formulary choices.
- HRT does not provide contraceptive cover. Spontaneous pregnancy after 50 years of age is uncommon, however if patients do not wish to become pregnant, suitable contraception should be planned and in place until menopause is complete. This is particularly important for people taking regular medications not suitable in pregnancy, known teratogenic medication or medications which pose a risk to a foetus. Follow guidance including licenced information, Pregnancy Prevention Programme requirements and specialist resources including BUMPS / UKTIS (log in for full monographs on the UKTIS site) and guidance available on the Medicines used in pregnancy webpage and the Medication Safety page for updates on valproate and other teratogenic medicines.
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Calcium regulating drugs, Bone resorption inhibitors: Selective oestrogen receptor modulator | Raloxifene | 60mg tablet: £4.07 | Primary prevention of osteoporotic fragility fractures in postmenopausal women: Raloxifene is classified by NHS Somerset as NOT RECOMMENDED for the primary prevention of osteoporotic fragility fractures in postmenopausal women (Off-label) as per the Traffic light guidance and NICE TA160. Secondary prevention of osteoporotic fragility fractures in postmenopausal women: Third line option for secondary prevention of osteoporotic fragility fractures in postmenopausal women. In line with NICE TA161. Consider for chemoprevention in postmenopausal women at moderate to high risk of breast cancer and have severe osteoporosis - depending on clinical circumstances (off-label.) In line with CG164. The recommended dose is 60mg once daily. |
| See Chapter 6.2 – Bone metabolism disorders for more information on osteoporosis | |||
| See Chapter 8.4 Hormone responsive malignancy for more information on chemoprevention | |||
| Tibolone is non-formulary - Increased risk of stroke in older women should be taken into account in prescribing decisions. See MHRA Drug Safety Update (December 2014) for Tibolone: benefit-risk balance. | |||
| Estradiol with drospireone as Angeliq® is classified as NOT RECOMMENDED as per Traffic light guidance. | |||
| Progesterone | |||
| Threatened miscarriage | Micronised Progesterone (vaginal delivery) | 200mg progesterone pessaries: £8.95 (15) 400mg progesterone pessaries: £12.96 (15) 200mg micronised progesterone vaginal capsule: £21.00 (21) | For threatened miscarriage as per the Traffic light guidance and NICE NG126 Offer vaginal micronised progesterone 400 mg twice daily to people with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage. (Off label) If a fetal heartbeat is confirmed, continue progesterone until 16 completed weeks of pregnancy. Acute trusts to provide initial supply to avoid delay in starting (4 weeks supply, or if the patient is >12 weeks pregnant, then enough to last up until 16 weeks). If a 4 week supply doesn’t take the patient up to 16 weeks, then primary care to prescribe remaining course. NB ensure appropriate folic acid is being taken and consider risk of pre-eclampsia see Medicines used in pregnancy for detailed information |
| Progestogens and Endometrial Protection Unopposed estrogen replacement is associated with a significant increase in the risk of endometrial hyperplasia that is both dose and duration dependent with exposure. A progestogen is required for 12–14 days in a sequential / cyclical regimen or daily in a continuous combined regimen to minimise the risk of endometrial hyperplasia and endometrial cancer associated with unopposed estrogen in non-hysterectomised people, or after a hysterectomy in people with a history of endometriosis as recommended by guidelines (continuous combined therapy is recommended with endometriosis). See Reproductive Health for more information on endometriosis and related topics. |
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| Micronised progesterone (also known as body identical, or natural. Chemically identical to human progesterone) | as Gepretix® | 100mg micronised progesterone capsule: £4.62 (30) | First line for endometrial protection adjunct to oestrogen replacement therapy. The recommended dose is 200 mg daily at bedtime, for twelve days in the last half of each therapeutic cycle (beginning on Day 15 of the cycle and ending on Day 26). Withdrawal bleeding may occur in the following week. Alternatively, 100 mg can be given at bedtime from Day 1 to Day 25 of each therapeutic cycle, withdrawal bleeding being less with this treatment schedule. |
| as Generic Second line | 100mg micronised progesterone capsule: £6.60 (30) | As above | |
| Levonorgestrel (a progestogen) | as Mirena® | 20micrograms/24hours intrauterine device: £88 (1) | T-shaped plastic frame. Mirena used for protection from endometrial hyperplasia during oestrogen replacement therapy, should be removed no later than 4 years after insertion. When used for endometrial protection, Mirena also provides the added benefit of contraceptive cover. Mirena licence for effectiveness differs for contraception (8 years) and idiopathic menorrhagia (5 years) See Chapter 7.3 - Contraception for details. |
| Unopposed Estrogens | |||
| Hormone Replacement Therapy for estrogen replacement or deficiency symptoms in perimenopause, post-menopause, after hysterectomy, or as indicated. Adjunctive progestogen is needed to protect the endometrium of an intact uterus or if hysterectomised with endometriosis within guidelines. |
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| Transdermal Unopposed Oestrogen | |||
| Estradiol Patch | as Evorel® | 25mcg/24hour: £4.35 (8) 50mcg/24hour: £4.35 (8), £13.04 (24) 75mcg/24hour: £4.35 (8) 100mcg/24hour: £4.35 (8) | |
| as Estraderm MX® | 25mcg/24hour: £5.50 (8), £16.46 (24) 50mcg/24hour: £5.51 (8), £16.46 (24) 75mcg/24hour: £6.42 (8), £19.27 (24) 100mcg/24hour: £6.66 (8), £19.99 (24) | ||
| as Estradot® | 25mcg/24hour: £7.38 (8) 37.5mcg/24hour: £7.39 (8) 50mcg/24hour: £7.41 (8) 75mcg/24hour: £8.62 (8) 100mcg/24hour: £8.95 (8) | ||
| as Progynova TS® | 50mcg/24hour: £8.90 (12) 100mcg/24hour: £20.70 (12) | ||
| Estradiol Transdermal Gel | as Oestrogel® | 0.06% gel: £6.17 (80g pump-pack) | |
| as Sandrena® | 500mcg gel sachets: £5.08 (28) 1mg gel sachets: £5.85 (28), £17.57 (91) | ||
| Estradiol Transdermal Spray | as Lenzetto® | 1.53mg/dose transdermal spray: £6.90 (56 dose), £20.70 (168 dose) | |
| Oral Unopposed Oestrogen | |||
| Estradiol | as Elleste Solo® | 1mg tablets: £5.06 (84) 2mg tablets: £5.06 (84) | |
| as Zumenon® | 1mg tablets: £6.89 (84) 2mg tablets: £6.89 (84) | ||
| Estradiol valerate | as Progynova® | 1mg tablets: £7.30 (84) 2mg tablets: £7.30 (84) | |
| Conjugated estrogens | as Premarin® | 300mcg tablets: £24.02 (84) 625mcg tablets: £26.87 (84) 1.25mg tablets: £52.56 (84) | |
| Combined Hormone Replacement Therapy - Oestrogen and Progestogen For guided information on choosing the right HRT with your patient including suitability and contraindications, as well as options for combining a separate unopposed oestrogen and progestogen, detailed flow charts can be found for Transdermal and Oral choices |
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| Combined Continuous Oestrogen and Progestogen - No planned withdrawal bleed | |||
| Transdermal | |||
| Estradiol and Norethisterone | as Evorel Conti® | 50mcg/170mcg/24hour patch: £14.56 (8), £43.68 (24) | |
| Estradiol and Levonorgestrel | as FemSeven Conti® | 50mcg/7mcg/24hour patch: £15.48 (4), £44.12 (12) | |
| Oral | |||
| Estradiol and Progesterone | as Bijuve® | 1mg/100mg capsules: £8.14 (28) | |
| Estradiol and Dydrogesterone | as Femoston Conti® | 500mcg/2.5mg tablets: £24.43 (84) 1mg/5mg tablets: £24.43 (84) | |
| Estradiol and Norethisterone | as Kliofem® | 2mg/1mg tablets: £11.43 (84) | |
| as Elleste Duet Conti® | 2mg/1mg tablets: £17.02 (84) | ||
| as Kliovance® | 1mg/500mcg tablets: £13.20 (84) | ||
| Sequential/ Cyclical Combined Oestrogen and Progestogen - Withdrawal bleed expected | |||
| Transdermal | |||
| Estradiol and Norethisterone | as Evorel Sequi® | 50mcg/170mcg/24hour patches: £14.56 (8) | |
| Oral | |||
| Estradiol and Norethisterone | as Elleste Duet® | 1mg/1mg tablets: £9.20 (84) 2mg/1mg tablets: £9.20 (84) | |
| Estradiol and Dydrogesterone | as Femoston® | 1mg/10mg tablets: £16.16 (84) 2mg/10mg tablets: £16.16 (84) | |