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Prescribing HRT Simplified

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Which group does your female patient belong to?

 

No Uterus
(ie had a hysterectomy) 

Uterus intact
with a monthly bleed
Uterus intact AND 
NO periods for 2 yrs if <50yrs OR
NO periods for 1 year if >50 yrs OR
54 years and over
(if mirena coil inserted in the last 4 years then your patient fits this category as uterus is protected) (if mirena coil inserted in the last 4 years then your patient fits category of "no uterus" as already recieving progesterone) (if mirena coil inserted in the last 4 years then your patient fits category of "no uterus" as already recieving progesterone)
Prescribe oestrogen only Prescribe oestrogen throughout
and progestogen in the second half of cycle
(cyclical / sequential)
Prescribe oestrogen
and progesterone throughout
(continuous)

Oral

  • Ellest Solo MX – 40mcg / 80mcg daily
  • Elleste solo - 1mg / 2mg daily
  • Premarin - 300/625/1.25mcg daily

Patch

  • Evorel 25/50/75/100mcg twice weekly
  • Estradot 25/37.5/50/775/100mcg twice weekly

Gel

  • Oestrogel 1-4 doses daily (starting dose 2)

Oral

  • Elleste Duet - 1mg/2mg
  • Femoston - 1mg / 2mg

Patch

  • Evorel Sequi – twice weekly
  • evorel patch combined with utrogestan 100mg x2 capsules at night for 12-14 days

Gel

  • Oestrogel 2 pumps daily  combined with utrogestan 100mg x2 capsules at night for 12-14 days
Oral
  • Kliovance - 1mg daily
    Kliofem - 2mg daily

Patch

  • Evorel Conti
  • Evorel patch combined with Utrogestan 100mg nightly

Gel

  • Oestrogel  2 pumps daily combined with Utrogestan 100mg nightly

  These are firstline treatents - for alternatives scroll down

Oestrogen choices

  • For patients with no uterus
 Formulation  Brand, strength & dose Pros Cons
 Oral
  • Elleste solo
    (oestradiol)
    1mg & 2mg daily
  • Premarin
    (conjugated oestrogens)
    a mixture of oestrogen hormones
  • Patients may find this easier to take especially if taking other tablets
  • Oral is not recommended as first line
  • VTE risk
  • Increases sex hormone binding globulin (SHBG) so reduces free androgen index (lowers libido even more)
  • Less reliable absorption
  • More contraindications (for example obesity, diabetes, gallbladder disease, migraine and so on)

 

Patches

  • Evorel 25 / 50 / 75 / 100mcg patches
    twice a week
  • Estradot 25 / 50 / 75 / 100mcg patches
    twice a week (smaller in size)
  • Elleste 40 / 80mcg patches twice a week
  • Usually stick well and easy to use
  • Can swim, shower, bath, swim with them on
  • Constant level given so can be better in women with migraines
  • Can use more than one which is useful for women with early menopause / primary ovarian insufficiency (POI)
  • Some women do not like to have something stuck to their skin
  • Can lead to local irritation
  • Some women find they do not stick on well or they crinkle (therefore reduced absorption)
  • Some women find they have high absorption in hot climates
  • Plaster mark on bottom – can be removed with baby oil and dry flannel!
Gel
  • Oestrogel 2-4 pumps a day
    (young women often higher doses)
  • Sandrena sachets 0.5-1mg daily
  • Easy to alter dose so women have more control
  • Usually absorb really easily
  • Can be used with patches to ‘top up’
  • Women with cyclical symptoms (including PMS) can use more on the days with worse symptoms. 
  • Young women needing higher doses need to use large quantities
  • Harder to remember as needed once or twice a day
  • Sachets can be hard to open

Progesterone choices

  • Prescribed in addition to oestrogen
  • Protects the lining of the womb and controls bleeding
  • For patients with an intact uterus with or without monthly bleeds 
 Formulation  Brand, strength & dose Pros Cons

Oral

Micronised progesterone (Utrogestan)

  • Continuos: 100mg capsule each evening
    (licensed for days 1-25 but easier to take every night)
  • Cyclical: 2 x 100mg capsules each evening for 2 out of 4 weeks  
    (licensed for days 15-26 but easier to take for 2 weeks)

Norethisterone (Micronor HRT) (unlicensed)

  • Continuous: 5mg daily
  • Cyclical: 5mg twice daily for 2 out of 4 weeks
  • Fewer side effects so better tolerated
  • Can improve cardiovascular risk / lipids
  • Neutral effect on BP / may reduce BP
  • No VTE risk
  • No breast cancer risk for first 5 years of taking it (in women over 51 years old)
  • Studies have shown some positive effect on bone strength
  • Can have more breakthrough bleeding for first 3-6/12
  • Can cause some sedation – take at night time
  • Needs to be taken on empty stomach (eating food increases absorption)
  • Not a contraceptive
Vaginal

Oral tablet can be given vaginally (unlicensed)

  • Continuous: Utrogestan tablet given on alternate nights
  • Cyclical: Utrogestan tabet given one every night for 12-14 days each month 
  • For patients who cannot tolerate oral
  • Unlicensed
Intra-uterine system  Levonorgestrel (Mirena Coil) 
  • Contraceptive
  • Treats menorrhagia
  • Less risk of bleeding
  • Once in-situ, periods may be reduced by >95% by 6 months, and approximately 20% of users will be completely amenorrheic. 
  • Needs changing every 4 years (vs license for contraceptive 5 years) 
  • Cheapest for NHS

 

  • Systemic side effects in some women (especially first 3-6/12); endometrial atrophy, disturbance of ovulation and the development of hostile cervical mucous
  • Spotting can occur in first 3-6/12
  • Not every woman’s choice
  • Not always available in primary care

 Sequential / Cyclical combined HRT choices

  • Oestrgen throughout & Progesterone for two weeks of the month 
  • For patients with an intact uterus & monthly bleed
  Firstline Alternatives
Oral
  • Elleste Duet
    (oestradiol, norethisterone)
  • Prempak C
    (conjugated oestrogens, norgestrel)
  • Femoston 1/10, 2/10, 2/20
    (oestradiol, didrogesterone)
  • Adgyn Combi (oestradiol, norethisterone)
  • Climagest (oestradiol, norethisterone)
  • Cyclo-Progynova (oestradiol, levonorgestrel)
  • Nuvelle (oestradiol, levonorgestrel)
  • Nuvelle TS (oestradiol, levonorgestrel)
  • Premique (conjugated oestrogens, medroxyprogesterone acetate)
  • Premique Cycle (conjugated oestrogens, medroxyprogesterone acetate)
  • Trisequence (oestradiol, norethisterone)
  • Trisequens Forte (oestradiol, norethisterone)
Patch
  • Evorel Sequi
    (oestradiol, norethindrone acetate)
  • Femseven Sequi
    (oestradiol, levonorgestrel)
  • Estracombi (oestradiol, norethindrone acetate)
  • Estrapak (oestradiol, norethindrone acetate)
  • Evorel-Pak (oestradiol, norethindrone acetate)
  • Fempak (oestradiol, didrogesterone)
Gel
  • Oestrogel 2-4 pumps a day
    & 2 x Utrogestan 100mg capsules each evening for 2 out of 4 weeks
 

 

 

Continuous HRT choices

  • For patients with an intact uterus & no monthly bleed
  Firstline Alternatives
Oral
  • Elleste Duet Conti
    (oestradiol, norethindrone acetate)
  • Kliofem
    (oestradiol, norethisterone)
  • Femoston Conti
    (oestradiol, dydrogesterone)
  • Climesse (oestradiol, norethindrone acetate)
  • Kliovance (oestradiol, norethindrone acetate)
  • Nuvelle Continuous (oestradiol, norethindrone)
  • Tibolone (see below)
Patch
  • Evorel Conti
    (oestradiol, norethindrone acetate)
  • Use gel
Gels
  • Oestrogel 2-4 pumps a day
    & Utrogestan 100mg capsule each evening as continuous 
 

Tibolone

Pharmacology Pros Cons
  • a synthetic steroid with oestrogenic, progestogenic and androgenic activity.
  • As such, it is a type of continuous combined HRT and so is a no bleed preparation.
  • Because of its androgenic activity, it has been shown to have a positive effect on libido.
  • Tibolone has been shown to be as/or more effective than oestradiol in controlling menopausal symptoms.
  • Although 85% of Tibolone users are amenorrhoeic, there is an 11% chance of irregular bleeding, so this may require gynaecological investigation
  • Prescribing of Tibolone should take into account the risks of other forms of HRT, such as a possible increase in breast cancer
  • Tibolone may enhance the effect of anticoagulants such as warfarin

 

 

Keep it simple
by prescribing oestrogel only
or in combination with utrogestan capsules

  • Woman has no uterus

    • Oestrogel 2-4 pumps a day

  • Woman has a uterus but and is menstruating

    • Oestrogel 2-4 pumps a day & 2 x 100mg capsules each evening for 2 out of 4 weeks cyclical

  • Woman has a uterus intact and NO periods for 2 yrs if <50yrs old, 1 year if >50 yrs old or women is 54+

    • Oestrogel 2-4 pumps a day & 100mg capsule each evening as continuous

 

Panay N. Body identical hormone replacement. Post Reprod Health 2014; 20(2): 69–72.

https://www.gwh.nhs.uk/media/163808/wiltshire_hrt_guidance_2014.pdf

 

 

Reviewed By: Laura Marshall-Andrews
Reviewed Date: 2020-03-04

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