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6.4.1 Female sex hormones

6.4.1 Female sex hormones

6.4.1 Female sex hormones Oestrogens and HRT 
Guidance is given below on the type of product required in different situations.  The choice of actual preparation (tablet, patch, 
gel) to remain with the prescriber bearing in mind patient preference and the cost differences between the preparations.
Note: HRT should only be used for osteoporosis prevention in patients where other therapies are contra-indicated, not tolerated,
           or there is a lack of response. This should ideally be under the direction of a specialist.
Women with uterus
Sequential preparations for patients with an  intact uterus &   perimenopausal i.e. have not yet had 1 year amenorrhoea.
GREEN       1st line Elleste Duet 1mg, 2mg    (Estradiol / norethisterone combination) 
GREEN       2nd line Femoston 1/10, 2/10     (Estradiol / dydrogesterone combination)
Continuous combined preparations for period free HRT, should only to be used in patients who are amenorrhoeic for 1 year
or over 54 years if currently on sequential preparation.
GREEN      1st line Elleste-Duet Conti   (Estradiol/ norethisterone continuous 'no bleed' combination) 
GREEN      2nd line Femoston-Conti     (Estradiol/ dydrogesterone continuous 'no bleed' combination)  
GREEN      3rd line Premique                 (Conj. oestrogens/ medroxyprogesterone continuous 'no bleed' combination)  
BLACK       0.45mg conjugated oestrogens & Bazedoxifene (Duavive®)
HRT should be trialled for 4 months and reviewed. If progesterone side effects are reported consider switching to Femoston 
products. If oestrogen side effects are reported switch to Prempak-C/ Premique. If side effects of both are severe, consider
transdermal patches (Evorel Sequi or Evorel Conti).
HRT patches should be reserved for use in patients with diabetes, liver disease or severe side effects.
GREEN      Evorel Sequi 50,and 50/170 micrograms  in 24 hours   (Estradiol/ norethisterone sequential combination) 
GREEN      Evorel Conti 50/170 micrograms in 24 hours                  (Estradiol/ norethisterone continuous 'no bleed' combination)     
Women without uterus   
Unopposed oestrogen is used for patients with hysterectomy, however in endometriosis, endometrial foci may remain and the use of combination preparations should be considered. 
GREEN      1st line Elleste Solo 1mg, 2mg     (Estradiol)     
GREEN      2nd line Premarin 0.625, 1.25      (Conjugated oestrogens)
HRT patches should be reserved for use in patients with diabetes, liver disease or severe side effects. 
GREEN      Evorel 25, 50, 75, 100 (micrograms in 24 hours)    (Estradiol)     
Where patches are not tolerated but symptoms of menopause require treatment, estradiol gel is an option.  
GREEN     Estradiol gel (Sandrena), 500mcg/sachet & 1mg/sachet
Tibolone increases the risk of breast cancer recurrence in women with a history of breast cancer. Tibolone should not be used in
women with known or suspected breast cancer, or in those with a history of breast cancer. It should be used for loss of libido only.
GREEN      Tibolone tablets 2.5mg Progestogens and progesterone receptor modulators
GREEN      Medroxyprogesterone tablets 5mg,10mg
GREEN      Norethisterone tablets 5mg 
GREEN      Progesterone pessaries 200mg, 400mg 
MHRA 18th March 2020 - UPDATE
ESMYA [Ulipristal acetate]- License suspended to protect public health while a safety review is conducted following a further 

case of liver injury requiring transplant

[Indications: > Intermittent treatment of moderate to severe symptoms of uterine fibroids in adult women of reproductive age
                     > Pre-surgical treatment of moderate to sever symptoms of  uterine fibroids in adult women of reproductive age]
BLACK         Ulipristal acetate tablets 5mg (Esmya®) - SEE MHRA DRUG SAFETY UPDATE

All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the  
public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service. 
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