If you are having problems getting your usual HRT due to supply issues then print this list off to show to your doctor. I did it & he was very very grateful (just a little helping hand for them
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HRT preparations: for PerimenopausePlease note: Patients should consult a health professional to decide on the appropriate treatment option to be prescribed.
PERI-MENOPAUSAL SEQUENTIAL COMBINED THERAPY
Used in women with an intact uterus (womb) who are not yet postmenopausal, i.e. have some periods due to continuing ovarian function. Products contain daily estrogen and cyclical progestogen.
Progestogens which can be used cyclically are of 3 main types:
Testosterone derived - Norgestrel, Norethisterone acetate and Levonorgestrel.
Less testosterone related - Medroxyprogesterone acetate(MPA).
Least testosterone related - Dydrogesterone and Micronised progesterone (Utrogestan).
Side effects are often experienced during the progestogen phase of treatment and can be reduced by using a product containing a different type or route of progestogen.
TABLET
a. Low dose - recommended starting dose.
CLIMAGEST 1mg Estradiol valerate 1mg
Norethisterone 1mg for 12 days/28
£6.61
ELLESTE DUET 1mg Estradiol 1mg
Norethisterone 1mg for 12 days/28 £3.07
FEMOSTON 1/10* Estradiol 1mg
Dydrogesterone 10mg for 14 days/28
£5.39
NOVOFEM* Estradiol 1mg
Norethisterone 1mg for 12 days/28
£3.81
b. Medium dose -
CLIMAGEST 2mg Estradiol valerate 2mg
Norethisterone 1mg for 12 days/28
£6.61
CLINORETTE 2mg Estradiol 2mg
Norethisterone 1mg for 12 days/28 £3.08
CYCLO-PROGYNOVA 2mg* Estradiol valerate 2mg
Norgestrel 0.5mg for 10 days/21, followed by 7 tablet-free days. £3.11
ELLESTE DUET 2mg* Estradiol 2mg
Norethisterone 1mg for 12 days/28. £3.07
FEMOSTON 2/10* Estradiol 2mg
Dydrogesterone 10mg for 14 days/28
£5.39
TRISEQUENS* Estradiol 2mg/1mg
Norethisterone 1mg for 10 days/28
£3.70
All the above cause a monthly bleed in 85% of patients.
Long cycle treatment - useful in perimenopausal patients who are having infrequent periods, but may not be sufficiently post menopausal to offer continuous combined therapy to, and will confer a bleed every 3 months. Available is:
TRIDESTRA* Estradiol valerate 2mg
Medroxyprogesterone 20mgs for 14 days/3 month pack.
£6.83
TRANSDERMAL
Medium Dose
EVOREL SEQUI* M 2 x Weekly Transdermal estradiol 50mcg/24hrs
Trandsermal norethisterone 170mcg/24hrs for 14 days/28
£11.09
FEMSEVEN SEQUI M Weekly Transdermal estradiol 50mcg/24hrs
Transdermal levonorgestrel 10mcg/24hrs for 14 days/28 £13.18
Tailor made sequential combined therapy is useful in patients who develop PMS type symptoms on a fixed HRT, particularly if the regime contains a progestogen of testosterone derivation (norethisterone, norgestrel and levonorgestrel). FEMOSTON, PREMIQUE CYCLE & TRIDESTRA are fixed preparations using the less androgenic medroxyprogesterone acetate or dydrogesterone.
PROGESTOGENS - Progestogens are given with estrogen to protect the womb lining from becoming thickened from stimulation by estrogen. Progestogens are generally not required after a hysterectomy (removal of the womb). (See Menopause and HRT after hysterectomy)
In the Perimenopause, progestogens are given for part of each 4 week cycle of estrogen, leading to a 4 weekly bleed in most users. This is known as “Sequential†HRT.
Please note: Patients should consult a health professional to decide on the appropriate treatment option to be prescribed.
As well as being given as part of a ready made combined therapy, the following progestogens can be given with estrogen only regimes:
PROVERA -
also available as Climanor (5mg tabs)
MPA 10 mgs daily for 14 days per 28 days £3.27 for 28 5mg tablets
UTROGESTAN micronised progesterone 2 x 100mg daily at bedtime for 12 days per 28 days (days 15-26 inclusive) £4.28 for 15 200mg capsules
Careful explanation is required as to the timing of administration of the separate progestogen, in order to synchronise it with the existing cycle.
MIRENA
Mirena is a levonorgestrel (type of progestogen) releasing system which sits inside the womb, gradually releasing the progestogen into the womb. It is licensed in the UK and Ireland as a contraceptive agent, for treatment of heavy periods and, from August 2004, also for the progestogen component of HRT. It can be used in both the perimenopause and postmenopause and it is particularly useful for:
Persistent progestogenic side effects from systemic HRT despite changes in type and route of progestogen.
When contraception is required along with HRT in the perimenopause.
When withdrawal bleeds on sequential HRT are heavy, after investigation if indicated. (see WHEN TO BE REFERRED )
With Mirena in place, systemic estrogen alone can be taken as the Mirena provides adequate protection of the womb lining and the estrogen dose and route can be tailored to meet the individual's needs.
Progestogenic absorption throughout the body is minimal so reducing progestogenic side effects. The effect of Mirena on the womb lining can significantly reduce bleeding and when used as part of an HRT regimen, in time, 30 to 60% of women have no bleeding at all. Although Mirena used for contraception is licensed for 5 years, the license for use for the progestogen part of HRT is currently 4 years.
Price: £88.00
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HRT preparations: for PostmenopausePlease note: Patients should consult a health professional to decide on the appropriate treatment option to be prescribed.
POST MENOPAUSAL -
Continuous combined therapies.
"Period free" or continuous combined therapy can be used by women who are 54 + yrs, or more than 1 yr post menopausal at any age. The criteria should be fulfilled in order to offer such treatment to women who no longer have a continuing ovarian cycle, so that steady levels of both estrogen and progestogen can be achieved. When there are steady levels of estrogen and progestogen from daily administration of both, the womb lining stays thin. Although some bleeding in the first 6 months of therapy is common, there should not be bleeding after that and the lining does not go through the stages of stimulation and then shedding as it does during a normal cycle and with sequential therapy. Start with low dose preparations and increase as necessary for symptom control. The products marked * are licensed for osteoporosis treatment/prevention.
See WHY AND WHEN TO OFFER CONTINUOUS COMBINED THERAPY.
TABLETS
a. Ultra low dose
Femoston conti low dose Estradiol 0.5mg, Dydrogesterone 2.5mg £8.14
b. Low dose
ANGELIQ* 1 mg estradiol & 2mg drospirenone £9.67
FEMOSTON CONTI* 1 mg estradiol & 5mg dydrogesterone daily
£8.14
INDIVINA 1+2.5* 1mg estradiol valerate & 2.5mg MPA daily
£6.86
INDIVINA 1+5* 1mg estradiol valerate & 5mg MPA daily
£6.86
KLIOVANCE* 1mg estradiol & 0.5 mgs norethisterone daily.
£4.40
PREMIQUE LOW DOSE 0.3mg conjugated estrogen & 1.5mg MPA daily £2.17
c. Medium dose
INDIVINA 2+5* 2mgs estradiol valerate & 5 mg MPA daily.
£6.86
d. Higher dose
ELLESTE DUET CONTI* 2 mgs estradiol & 1 mg norethisterone daily £5.67
KLIOFEM* 2 mgs estradiol & 1 mg norethisterone daily
£3.81
NUVELLE CONTINUOUS* 2 mgs estradiol &1mg norethisterone daily
£6.33
e. Gonadomimetic
LIVIAL* (TIBOLONE) gonadomimetic synthetic preparation with weak estrogenic, progestogenic & androgenic properties
£10.36
Because of its androgenic component, Livial can be particularly helpful for postmenopausal patients with reduced libido. Current evidence suggests that Livial does not increase mammographic breast density, as occurs with other types of HRT and long term use of Livial is thought to be associated with a similar increased risk of breast cancer to that of estrogen alone, which is less than that of estrogen plus progestogen.
TRANSDERMAL - PATCH
EVOREL CONTI* 2 x Weekly M Transdermal estradiol 50mcg & transdermal norethisterone 170 mcg for 28 days
£13.00
FEMSEVEN CONTI Weekly M 50mcg estradiol and 7mcg levonorgestrel per 24 hours
£15.48
Tailored continuous combined effect allows flexibility but is less convenient to take. Use any continuous tablet or non-tablet estrogen with one of the following:-
PROVERA Medroxyprogesterone 2.5 or 5 mgs daily
UTROGESTAN Micronised progesterone 100mg at bedtime from day 1 to 25 of each 28 day cycle
Usually start with the lowest dose of progestogen and increase if persistent bleeding. Patients should be advised to expect some bleeding in the first few months of treatment, but should have settled by six months. Any bleeding persisting beyond 6 months of continuous combined therapy, or bleeding occurring at a later date, should be investigated.
WHY & WHEN TO CONSIDER CONTINUOUS COMBINED THERAPY
Why?
No physiological reason for menstrual bleeds if can be avoided.
Most women prefer a no-period option.
Cheaper for patient - one prescription charge instead of the two for sequential combined therapy.
Thought to be less risk of endometrial hyperplasia (thickening of the womb lining) in long term with continuous combined compared to sequential therapy.
When?
Patient known to be post-menopausal at whatever age, ideally by having at least one year of amenorrhoea (no periods).
If sequential therapy started while still having periods, wait till age 54 years. At 54 years 80% of women will have cessation of ovarian function and are likely to settle on continuous combined (period-free) therapy.
Change from sequential to continuous combined by finishing current sequential pack and start new therapy at the end of the expected bleed.
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Topic: A list of all HRT Preparations (Read 5374 times)