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[bear]

Hi Clovie,

I'm afraid Utrogestan for HRT is not readily available within NHS Scotland for economic reasons. This is the 2009 decision mentioned by your GP. Utrogestan was still being marketed by its original manufacturer, Ferring.

https://www.scottishmedicines.org.uk/medicines-advice/micronised-progesterone-utrogestan-fullsubmission-54209/

NSH Wales has recently approved it for HRT, if combined preparations are not suitable/tolerated:

http://www.wales.nhs.uk/sites3/Documents/814/HRT%5FABUHBpathway%26Formulary%5BPrimaryCare%26O%2BG%5DFINAL.pdf

If the cheaper generic micronised progesterone becomes available (like in France and other countries), I suppose the Scottish Medicines Consortium could change this decision.

Meanwhile, you could ask for a referral to a menopause clinic, they might be able to prescribe it off-licence for menopause (off-label) [edited for clarification].

I'm going to suggest to Emma (admin) that a note explaining this could be added to Utrogestan on the Treatments board section... it's odd that a Scotland based website doesn't mention this problem regarding prescribing Utrogestan in Scotland.

BeaR.

[Choc Ice]

Hi Clovie, I've been a bit busy, but the 2009 recommendations came from the SMC, If you google HRT guidance Scotland  , and look for micronised progesterone you will find it.
It says , and I'm quoting “ micronised progesterone was as effective as another progestogen in protecting the endometrium from hyper plastic changes associated with oestrogen treatment.

 They add “ However, the manufacturers did not present a sufficiently robust economic analysis to gain acceptance by the SMC”

So it does sound as though that was a financial reason initially.

The second piece I found came from Tayside Formulary, Scotland NHS uk.

It says under, “ Non- Formularly items, that micronised progesterone is coloured amber,  meaning  that utrogestan “ maybe prescribed  2nd line under direction of Tayside menopause clinic as per local protocol.”

That's all I've got, hope that helps, also my GP has prescribed both oestrogel and utrogestan for me, so it Isn't a Scottish policy!
I mean it doesn't seem to be a national, country wide practice

[Hurdity]

Hi Clovie,

I'm afraid Utrogestan for HRT is not readily available within NHS Scotland for economic reasons. This is the 2009 decision mentioned by your GP. Utrogestan was still being marketed by its original manufacturer, Ferring.

https://www.scottishmedicines.org.uk/medicines-advice/micronised-progesterone-utrogestan-fullsubmission-54209/

NSH Wales has recently approved it for HRT, if combined preparations are not suitable/tolerated:

http://www.wales.nhs.uk/sites3/Documents/814/HRT%5FABUHBpathway%26Formulary%5BPrimaryCare%26O%2BG%5DFINAL.pdf


Meanwhile, you could ask for a referral to a menopause clinic, they might be able to prescribe it off-licence.


BeaR.

bear - this is incorrect  The whole point about all of this discussion is that Utrogestan IS licensed in UK and therefore should be available. There is no question of off-licence prescribing and we have seen ( and in the links I posted about other threads) that it is prescribed sometimes - thanks Choc Ice! Clovie should not have to be referred to a menopause clinic - although i am sure this might be helpful if a lengthy wait, nor go privately.

I do feel l am like a broken record here! What we need is clarification as to whether the Scottish system is like the English - whereby there are local recommendations etc (in realtion to some LICENSED medicines, but the doctor can override these on the computer system provided they can justify it.

The key point here is the small print at the end of the the document you linked to bear.

"This  advice  does  not override the individual responsibility of health professionals to make decisions in the exercise of their clinical judgement in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. "

As far as I would be concerned - that says it all!

There is no other body-identical progesterone available - full stop!!!

Hope this helps clovie?

Hurdity x

[Tracey E]

Hi Clovie,

I'm afraid Utrogestan for HRT is not readily available within NHS Scotland for economic reasons. This is the 2009 decision mentioned by your GP. Utrogestan was still being marketed by its original manufacturer, Ferring.

https://www.scottishmedicines.org.uk/medicines-advice/micronised-progesterone-utrogestan-fullsubmission-54209/

NSH Wales has recently approved it for HRT, if combined preparations are not suitable/tolerated:

http://www.wales.nhs.uk/sites3/Documents/814/HRT%5FABUHBpathway%26Formulary%5BPrimaryCare%26O%2BG%5DFINAL.pdf

If the cheaper generic micronised progesterone becomes available (like in France and other countries), I suppose the Scottish Medicines Consortium could change this decision.

Meanwhile, you could ask for a referral to a menopause clinic, they might be able to prescribe it off-licence.

I'm going to suggest to Emma (admin) that a note explaining this could be added to Utrogestan on the Treatments board section... it's odd that a Scotland based website doesn't mention this problem regarding prescribing Utrogestan in Scotland.

BeaR.

That's really interesting Bear, thank you. It just seems a terrible shame that there can't be a uniformed approach over the whole of the UK. I do think that free prescriptions are impacting negatively on prescribing certain medications in Scotland. Crikey Utrogestan isn't that expensive.

[KiltedCupid]

Tracey E - you're right, NHS Scotland is an entirely different body and apparently the best performing of all the NHS bodies within the UK, unfortunately for some, they can and do make decisions on drugs and how they are prescribed independently of other NHS boards and licensing. However, that doesn't help Clovie's plight. And in that respect, I shall write to Dr Currie and ask her to post clarification on Utro in Scotland in order that we all know where we stand.

[KiltedCupid]

Hi Clovie and anyone else using Utro and living in Scotland.

I wrote to both Emma and Dr Currie this morning asking for clarification on Utro prescribing in SNHS. Emma has kindly posted a link in the Oestrogel/utrogestan thread but to save you a journey, it's the same link as BeaR has posted above.

Hopefully Dr Currie will also clarify.

[bear]

bear - this is incorrect  The whole point about all of this discussion is that Utrogestan IS licensed in UK and therefore should be available. There is no question of off-licence prescribing and we have seen ( and in the links I posted about other threads) that it is prescribed sometimes - thanks Choc Ice! Clovie should not have to be referred to a menopause clinic - although i am sure this might be helpful if a lengthy wait, nor go privately.

I do feel l am like a broken record here! What we need is clarification as to whether the Scottish system is like the English - whereby there are local recommendations etc (in realtion to some LICENSED medicines, but the doctor can override these on the computer system provided they can justify it.

The key point here is the small print at the end of the the document you linked to bear.

"This  advice  does  not override the individual responsibility of health professionals to make decisions in the exercise of their clinical judgement in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. "

As far as I would be concerned - that says it all!

There is no other body-identical progesterone available - full stop!!!

Hope this helps clovie?

Hurdity x

Hi there,

As I understand it, Utrogestan is ‘off licence' in NHS Scotland for treating menopause, the same way as Utrogestan 100mg is ‘off licence' for vaginal route in NHS England, hence the term ‘off-licence' as in 'off-licence use' or 'off-label' (I will edit my previous post for clarification).

https://www.nhs.uk/conditions/medicines-information/

I'm sorry, but no matter what the BMS recommends or patients do on their own account, these are the current NHS Scotland recommendations.

If the NHS was a single body it would be called NHS UK. Therefore, I'd suggest a more cautious approach. Besides, all prescriptions are free in Scotland, which justifies their decision to not recommend Utrogestan based on costs.

Tayside non formulary section lists Utrogestan as ‘not recommended by SMC', but ‘may be prescribed 2nd line under direction of Tayside Menopause clinic as per local protocol', hence my suggestion to ask for a Menopause Clinic referral. That doesn't mean all Menopause clinics in Scotland have the same formulary indication, though.

BeaR.

PS. You don't mind calling me 'bear', so why 'LICENSED'? I thought you didn't like caps 

[KiltedCupid]

BeaR - in a nutshell, that's the case. SNHS is different and, it would appear, varies from board to board even within SNHS itself. I worked on a campaign many years ago to launch the new NHS Scotland livery and had to contact all the boards independently as they run almost as separate businesses. We even had meetings with the then Scottish Health Minister as it was crucial that each board and indeed the entire SNHS and it's role was communicated clearly to the public.

What a job that was!

[Choc Ice]

It does seem to be a bit of a lottery up here ( Scotland), when I went to collect my prescription, my pharmacist ( who is really good and helpful) said that it was available " after having been given the "OK"' so I guess it isnt a given that we get it. I should have asked what that meant, ( my bad, sorry), I was just soo relieved to get something after the comedy of my patches being unavailable.

I think it means we have to be a bit more proactive and vocal in our needs,  or we will end up being given just what is the cheapest and easiest rather than what is the best.

As an aside, I used to be a Medical Rep, and when our branded products went off patent  ( after 7 years) they became "generic" which is Supposed to be exactly the same, and much cheaper ( which is why health boards like them) . The active chemical formula is the same, but the fillers and the components used to bind the rest together are not. This explains why frequently many people generics do not suit, because the generic houses use different chalks, binders to complete the product. So sometimes it is not  always the wisest option to go for the unbranded one. Unfortunately you are not going to know until you try. Awful, the luck of the draw!

[KiltedCupid]

Choc Ice - that's really interesting and probably explains why ladies on US sites hate their generic  alternatives and can almost always tell the difference. I don't think I've ever had a generic hrt product in the UK, apart from a certain gel, but I'd rather not start another gel-gate. I really hope they don't become commonplace here.

[Hurdity]

Hi there,

As I understand it, Utrogestan is ‘off licence' in NHS Scotland for treating menopause, the same way as Utrogestan 100mg is ‘off licence' for vaginal route in NHS England, hence the term ‘off-licence' as in 'off-licence use' or 'off-label' (I will edit my previous post for clarification).

https://www.nhs.uk/conditions/medicines-information/

I'm sorry, but no matter what the BMS recommends or patients do on their own account, these are the current NHS Scotland recommendations.

If the NHS was a single body it would be called NHS UK. Therefore, I'd suggest a more cautious approach. Besides, all prescriptions are free in Scotland, which justifies their decision to not recommend Utrogestan based on costs.

Tayside non formulary section lists Utrogestan as ‘not recommended by SMC', but ‘may be prescribed 2nd line under direction of Tayside Menopause clinic as per local protocol', hence my suggestion to ask for a Menopause Clinic referral. That doesn't mean all Menopause clinics in Scotland have the same formulary indication, though.

BeaR.

PS. You don't mind calling me 'bear', so why 'LICENSED'? I thought you didn't like caps 

AS far as I know this is still not right - it's not off-label or off-licence. Off-label is prescribing something for a different purpose than which it was manufactured and trialled eg Clonidine (a blood-pressure medication) for hot flushes, and beta-blockers (heart medication) for anxiety (although the latter may now be on-label).

Yes I know they are the scottish recommendations but once again - the small print indicates that these are only recommendations and can be overriden and does not alter the status of utrogestan as a licensed medication in UK - as far as I understand it.

I know Scotland is different but it's still part of the UK (for the moment!). Just as in England, Scottish local formularies have different local recommendations.

Once again, what we need is clarification as to whether the small print (in the guidelines) together with the status of utrogestan as a licensed medication in UK, is sufficient for docs to override the Scottish 2009 recommendations if the patient chooses for example to have body-identical progesterone - for whatever reason. If this can't be done except through referral to a menopause clinic then at least members will know - but at the moment it just isn't clear because of the patchy NHS provision throughout the country. Well not to me anyway!

Hurdity x

[bear]

Hi again,

Maybe that's how you understand it. Dr. Newson agrees with my use of 'off-licence' (page 5).

https://pcwhf.co.uk/wp-content/uploads/2019/01/PCWHF-Easy-HRT-prescribing-guide-31_01.pdf

It's not just about local formularies and local recommendations, it's about costs and it's the SMC recommendation.

How can that not be clear to you? NHS Scotland doesn't agree to buy Utrogestan for menopause (although they do buy it for ART) when there are other options available. I'm sure the BMS is trying to change that, but it takes a lot of work and negotiations between authorities, medical specialists and manufacturers. I'm sure this will change soon, because Utrogestan generic version is already available (same manufacturer, Besins, and others) and the price is bound to drop. Well done NHS Scotland, a lot of money has been saved!

BeaR.

[Ladybt28]

Not that it adds much to the discussion but regarding costs and free prescriptions - in NI prescriptions are free but we can get gel, utrogestan and testosterone on the NHS.  My GP practice didn't bat an eyelid when they were prescribed. Obviously it is on the formulary list and no one is bothered about cost.  Possibly not a responsible attitude but it cuts out the prescribing battle many women face.  My own GP uses oestrogel and was very familiar with Utrogestan, probably uses it too 

Only comments have been from a pharmacist who said "you do know testosterone isn't licensed for women" to which I set her straight about how and why it was used and to which she replied "oh you learn something new everyday"!   Other than that nothing mentioned by our lot about licences.  Suppose I'm really lucky.  Just shows how prescribing attitudes vary around the UK.

[KiltedCupid]

Ladybt28 - there's big changes being proposed for Scotland over the next few years. Independence is looming and to that effect, Scotgov want to put their best foot forward in terms of being seen to favour certain demographics. Whether we like it or not, fertile women are a priority, as they should be, and my guess is that the health budget for them will increase and some more expensive drugs eg utro, will take a hit for those in the population who can use something less expensive. I completely understand this thinking and applaud efforts to keep certain demographics favoured eg, elderly, infertile, mental health, it's a fairer society. We all have budgets and need to carve up the funds in the fairest way possible whilst providing the necessities.

[Hurdity]

Hi again,

Maybe that's how you understand it. Dr. Newson agrees with my use of 'off-licence' (page 5).

https://pcwhf.co.uk/wp-content/uploads/2019/01/PCWHF-Easy-HRT-prescribing-guide-31_01.pdf

It's not just about local formularies and local recommendations, it's about costs and it's the SMC recommendation.

How can that not be clear to you? NHS Scotland doesn't agree to buy Utrogestan for menopause (although they do buy it for ART) when there are other options available. I'm sure the BMS is trying to change that, but it takes a lot of work and negotiations between authorities, medical specialists and manufacturers. I'm sure this will change soon, because Utrogestan generic version is already available (same manufacturer, Besins, and others) and the price is bound to drop. Well done NHS Scotland, a lot of money has been saved!

BeaR.

Er.... yes Louise Newson is talking about off-licence vaginal use of utrogestan in general (in UK) - no-one is disputing that as the correct term. Its prescription in Scotland or not is nothing to do with off-license or off-label - as you know, but due to recommendations as you have said.

And yes - the 2009 decision by the SMC is absolutely clear to me. To repeat - nevertheless it can be, is, and has been prescribed in Scotland on NHS from the posts we have seen on this and the other threads I linked to, not always by menopause specialists.

And again to repeat, the small print, as I would interpret it "This  advice  does  not override the individual responsibility of health professionals to make decisions in the exercise of their clinical judgement in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. "" suggests that any such recommendations can potentially be overriden.

We just need to know if, even in the face of individual formularies upholding the refusal, whether doctors can override this even without referral to a menopause clinic - as they can in England, provided a case is made by the patient. 

Also we need to know whether due to the shortages the recommendations can be varied - eg here is a letter sent by Scottish government about hRT shortages in which Utrogestan is listed as available. The letter implies that individual discretion might be used: https://www.sehd.scot.nhs.uk/pca/PCA2019%28P%2918.pdf. For example this wording: "The  table  also  provides  an  update  of  all  HRT preparations  that  remain  available.    Clinicians may  be required to switch patients to alternative HRT products that contain the same active ingredients for a temporary period". Well temporary is better than nothing and is certainly different from blanket refusal!

Clovie - I hope this is helpful? You can see the issue is complex and very much not straightforward!

Hurdity x