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7. Obstetrics, Gynaecology and Urinary-Tract Disorders

NICE CG97: Lower urinary tract symptoms in men: assessment and management

CD&D APC Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

Dinoprostone
BNF | BNFC | SPC

0.75mg in 0.75ml injections
3mg vaginal tablets
10mg pessary

Drug protocol: neonatal prostaglandin infusion (CDDFT intranet access only)

Oxytocin
BNF | BNFC | SPC

10 units in 1ml injection

Synometrine
BNF | BNFC | SPC

Injection (ergometrine maleate 500 microg & oxytocin 5 units)

Ergometrine
BNF | BNFC | SPC

500 micrograms in 1ml injection

Carboprost
BNF | BNFC | SPC

250 micrograms in 1ml injection

Mifeprostone
BNF | BNFC | SPC

200mg tablets

Atosiban
BNF | BNFC | SPC

6.75mg in 0.9ml injection & 37.5mg in 5ml (7.5mg/ml) concentrate for IV infusion

Drug protocol: atosiban (CDDFT intranet access only)

Estriol
BNF | BNFC | SPC

0.01% intravaginal Cream (Gynest)

0.1% intravaginal Cream (Ovestin)

 

Estradiol
BNF | BNFC | SPC

10 microgram vaginal tablets (Vagifem)

Vaginal Ring - 7.5 microgram/hour (Estring)

a) Candidiasis
First Choice = Clotrimazole


b) Other Infections
Metronidazole Vaginal Gel
Clindamycin Vaginal Cream

Clotrimazole
BNF | BNFC | SPC

Cream - 1% & 2%

Pessary - 100mg, 200mg, 500mg

Clindamycin Vaginal Cream
BNF | BNFC | SPC

Vaginal Cream - 2%

Metronidazole Vaginal Gel
BNF | BNFC | SPC

Vaginal Gel - 0.75%

Guidelines:

NICE CG30: Long-acting reversible contraception

MHRA Drug Safety Update (June 2015): Intrauterine contraception: uterine perforation—updated information on risk factors

MHRA Drug Safety Update (March 2014) – Interaction of hormonal contraceptives with St John’s Wort

 

Please note that the examples of brands listed below include the most cost-effective at the time of publication of this chapter (May 2017) and the current most cost-effective brand for primary or secondary care should be prescribed where possible.

MHRA Drug Safety Update (March 2014) – risk of VTE

Please note that the examples of brands listed below include the most cost-effective at the time of publication of this chapter (May 2017) and the current most cost-effective brand for primary or secondary care should be prescribed where possible.

The first line combined hormonal contraceptive for all women requiring CHC.

First line

  • Levonorgestrel 150micrograms with ethinylestradiol 30micrograms - brand names include Rigevidon and Microgynon 30

(Note: The Sexual Health Service choice is Maexeni 150/30)

Second line (alternative progesterone)

  • Norethisterone 1.5mg with ethinylestradiol 30micrograms - Loestrin 30

 

Third line (slightly higher oestrogen content therefore helpful if vaginal dryness is affecting libido)

  • Norethisterone 500micrograms with ethinylestradiol 35micrograms – Brevinor
  • Norgestimate containing products are relatively expensive but are a benefit for those with progestagenic side effects (mood changes, skin problems):

Norgestimate 250micrograms with ethinylestradiol 35micrograms – Lizinna

(Note: The Sexual Health Service choice is Cilest)

 

Fourth line (these oral preparations contain the third generation progesterones gestodene, desogestrel and drosperidone and therefore carry an increased risk of VTE compared to second generation progesterones. They should be reserved for women who are intolerant of other CHCs. These products are usually reserved for women who have progestogenic side effects on a first line pill and so need a more oestrogen-dominant pill. Due to the increased VTE risk the patient must be made aware before prescribing)

  • Gestodene 75micrograms with ethinylestradiol 30micrograms (gives better cycle control if less progestogenic activity is required) – Millinette

(Note: The Sexual Health Service choice is Aidulan 30/75)

  • Desogestrel 150micrograms with ethinylestradiol 30micrograms (less progestogenic and more 'skin friendly') – Gedarel 30/150

(Note: The Sexual Health Service choice is Munalea 150/30)

  • Drosperinione 3mg with ethinylestradiol 30micrograms (beneficial if woman has acne plus hirsutism; plus a lower risk of VTE compared to Co-cyprindiol and should therefore be considered instead of Co-cyprindiol) – Lucette  

(Note: The Sexual Health Service choice is Yiznell)

Levonorgestrel 150micrograms with ethinylestradiol 30micrograms
BNF | BNFC | SPC

Brand names include Rigevidon and Microgynon 30

(Note: The Sexual Health Service choice is Maexeni 150/30)

Norethisterone 1.5mg with ethinylestradiol 30micrograms
BNF | BNFC | SPC

Brand = Loestrin 30

Norethisterone 500micrograms with ethinylestradiol 35micrograms
BNF | BNFC | SPC

Brand = Brevinor

Norgestimate 250micrograms with ethinylestradiol 35micrograms
BNF | BNFC | SPC

Brands include Lizinna.

(Note: The Sexual Health Service choice is Cilest)

Gestodene 75micrograms with ethinylestradiol 30micrograms
BNF | BNFC | SPC

Brands include Millinette.

(Note: The Sexual Health Service choice is Aidulan 30/75)

Desogestrel 150micrograms with ethinylestradiol 30micrograms
BNF | BNFC | SPC

Brands include Gedarel 30/150

(Note: The Sexual Health Service choice is Munalea 150/30)

Drosperinione 3mg with ethinylestradiol 30micrograms
BNF | BNFC | SPC

Brands include Lucette

(Note: The Sexual Health Service choice is Yiznell)

Please note that the examples of brands listed below include the most cost-effective at the time of publication of this chapter (May 2017) and the current most cost-effective brand for primary or secondary care should be prescribed where possible.

Low dose oestrogen content (consider switching to a product with a lower oestrogen component if there is significant nausea / vomiting. Be aware that these products may be less effective at inhibiting ovulation compared to products with a higher oestrogen component and are also more likely to have breakthrough bleeding)

  • Norethisterone 1mg with ethinylestradiol 20micrograms - Loestrin 20

The following low dose oestrogren oral preparations contain third generation progesterones and therefore carry an increased risk of VTE. They should be reserved for women who are intolerant of other CHCs:

  • Gestodene 75micrograms with ethinylestradiol 20micrograms - Millinette

(Note: The Sexual Health Service choice is Aidulan 20/75)

  • Desogestrel 150micrograms with ethinylestradiol 20micrograms – Gedarel 20/150

(Note: The Sexual Health Service choice is Munalea 20/150)

Norethisterone 1mg with ethinylestradiol 20micrograms
BNF | BNFC | SPC

Brand = Loestrin 20

Gestodene 75micrograms with ethinylestradiol 20micrograms
BNF | BNFC | SPC

Brand = Millinette

(Note: The Sexual Health Service choice is Aidulan 20/75)

Desogestrel 150micrograms with ethinylestradiol 20micrograms
BNF | BNFC | SPC

Brand = Gedarel 20/150

(Note: The Sexual Health Service choice is Munalea 20/150)

For patients at risk of 'missed pills' and for those with persistent breakthrough bleeding (where other causes have been excluded). These products contain ethinylestridiol and levonorgestrel in varying amounts to correspond with each “phase”

  • Logynon or TriRegol (same ingredients)
Logynon®
BNF | BNFC | SPC

6 Ethinylestradiol 30 microg. & levonorgestrel 50 microg. + 5 Ethinylestradiol 40 microg. & levonorgestrel 75 microg. + 10 ethinylestradiol 30 microg. & levonorgestrel 125 microg.

Tri-Regol®
BNF | BNFC | SPC

6 Ethinylestradiol 30 microg. & levonorgestrel 50 microg. + 5 Ethinylestradiol 40 microg. & levonorgestrel 75 microg. + 10 ethinylestradiol 30 microg. & levonorgestrel 125 microg.

For use by a small number of women with gastrointestinal absorption problems or with compliance issues. The contraindications for CHC are the same for oral and transdermal preparations.

Evra patch is approximately 7x the cost of the first line oral ethinylestradiol 30micrograms / levonogestrel 150micrograms preparations.

Evra®
BNF | BNFC | SPC

Self-adhesive patches releasing approx. 20 micrograms ethinylestradiol and 150 micrograms norelgestromin/ 24 hours

For use by a small number of women with gastrointestinal absorption problems or with compliance issues.

NICE CG30 - Long-acting reversible contraception

 

Please note that the examples of brands listed below that are highlighted in green include the most cost-effective at the time of publication of this chapter (May 2017).

 

7.3.2a Oral Progestogen-Only Contraceptives

First line (preferred due to 12 hour window to take a missed pill, compared to 3 hours with alternative progesterones)

  • Desogestrel 75micrograms - brand names include Cerazette and Cerelle

 (Note: The Sexual Health Service choice is Feanolla)

 

Alternative progesterones

  • Levonorgestel 30micrograms – Norgeston
  • Norethisterone 350micrograms - Noriday

 

7.3.2b Parenteral Progestogen-Only Contraceptives

  • Etonogestrel - Nexplanon

Replaced Implanon and differs in that it is impregnated with radio opaque material.

 

Medroxyprogesterone

  • Intramuscular preparation - Depo-Provera 150mg
  • Subcutaneous preparation (consider this preparation when unsure if needle will reach the muscle, or if there is very little muscle) - Sayana Press 104mg

 

7.3.2c Levonorgestrel Intra-Uterine System

Prescribe by brand to ensure correct replacement time period:

Levonorgestrel-releasing intrauterine systems: prescribe by brand name. Drug Safety Update January 2016. MHRA. www.gov.uk/drug-safety-update/levonorgestrel-releasing-intrauterine-systems-prescribe-by-brand-name)

  • 5 year contraceptive protection - Mirena
  • 3 year contraceptive protection – Jaydess, Levosert

Please note that the examples of brands listed below include the most cost-effective at the time of publication of this chapter (May 2017) and the current most cost-effective brand for primary or secondary care should be prescribed where possible.

First line (preferred due to 12 hour window to take a missed pill, compared to 3 hours with alternative progesterones)

  • Desogestrel 75micrograms - brand names include Cerazette and Cerelle

 (Note: The Sexual Health Service choice is Feanolla)

 Alternative progesterones

  • Levonorgestel 30micrograms – Norgeston
  • Norethisterone 350micrograms - Noriday
Desogestrel 75microgram
BNF | BNFC | SPC

Brands include Cerazette and Cerelle

(Note: The Sexual Health Service choice is Feanolla)

Norethisterone 350microgram
BNF | BNFC | SPC

Brand = Noriday

Levonorgestel 30microgram
BNF | BNFC | SPC

Brand = Norgeston

  • Etonogestrel - Nexplanon

Replaced Implanon and differs in that it is impregnated with radio opaque material.

 Medroxyprogesterone

  • Intramuscular preparation - Depo-Provera 150mg
  • Subcutaneous preparation (consider this preparation when unsure if needle will reach the muscle, or if there is very little muscle) - Sayana Press 104mg
Medroxyprogesterone Acetate
BNF | BNFC | SPC

Intramuscular preparation - Depo-Provera 150mg

Subcutaneous preparation (consider this preparation when unsure if needle will reach the muscle, or if there is very little muscle) - Sayana Press 104mg

 

MHRA Drug Safety Update (Jan 2016): Levonorgestrel-releasing intrauterine systems: prescribe by brand name

Etonogestrel
BNF | BNFC | SPC

68mg implant (Nexplanon® )

Replaced Implanon and differs in that it is impregnated with radio opaque material.

MHRA Drug Safety Update (June 2016): Nexplanon (etonogestrel) contraceptive implants: reports of device in vasculature and lung

Prescribe by brand to ensure correct replacement time period:

Levonorgestrel-releasing intrauterine systems: prescribe by brand name. Drug Safety Update January 2016. MHRA. www.gov.uk/drug-safety-update/levonorgestrel-releasing-intrauterine-systems-prescribe-by-brand-name)

  • 5 year contraceptive protection - Mirena
  • 3 year contraceptive protection – Jaydess, Levosert
Mirena (Levonogestrel 52mg)
BNF | BNFC | SPC

IUD

MHRA Drug Safety Update (Jan 2016): Levonorgestrel-releasing intrauterine systems: prescribe by brand name

5 year contraceptive protection

Jaydess (Levonorgestrel 13.5mg)▼
BNF | BNFC | SPC

IUD

Only be used for women choosing the intra-uterine system who have a shortened uterine cavity which excludes the use of levonogestrel 52mg

MHRA Drug Safety Update (Jan 2016): Levonorgestrel-releasing intrauterine systems: prescribe by brand name

3 year contraceptive protection.

Levosert (Levonogestrel 52mg)
BNF | BNFC | SPC

20 micrograms/24 hours Intrauterine Delivery System

The intrauterine delivery system contains 52 mg levonorgestrel.

3 year contraceptive protection.

MHRA Drug Safety Update (Jan 2016): Levonorgestrel-releasing intrauterine systems: prescribe by brand name

MHRA Safety Warning – June 2015 - Intrauterine contraception: uterine perforation—updated information on risk factors

First line - 5 year replacement

  • Nova T 380

Second line  - 10 year replacement

  • TT380 Slimline
  • T-Safe 380 A QL
Nova T 380
BNF | BNFC | SPC

First Line

5 year replacement

TT380 Slimline
BNF | BNFC | SPC

Second line

10 year replacement

T-safe Cu380 AQL
BNF | BNFC | SPC

Second line

10 year replacement

Emergency contraception. FSRH guideline. March 2017. www.fsrh.org/standards-and-guidance/current-clinical-guidance/emergency-contraception/

 

Please note that the examples of brands listed below that are highlighted in green include the most cost-effective at the time of publication of this chapter (May 2017).

 

7.3.5a Emergency Oral Hormonal Contraception (EOHC)

  • Levonorgestrel 1500micrograms - brand names include Upostelle
  • Ulipristal Acetate 30mg -  EllaOne

 

A Copper Interuterine Contraception Device (Cu-IUCD) is the most effective form of emergency contraception and should be the first line method for most women (pregnancy rate <0.1%). For those women who decline or are deemed unsuitable for Cu-IUCD insertion, selection of the most appropriate EOHC should not just be based on hours since unprotected sexual intercourse (UPSI) but be dependent on a risk assessment including:

  • Estimated pregnancy risk from timing within cycle
  • Proximity to ovulation
  • Relevant medical or drug history
  • Recent use of EOHC
  • Risk of further UPSI if Quickstart or standard method is delayed
  • Body weight / body mass index

 

See FSRH emergency contraception guideline at www.fsrh.org/standards-and-guidance/current-clinical-guidance/emergency-contraception/  for further information and decision analysis algorithms.

Levonorgestrel 1500micrograms
BNF | BNFC | SPC

Brands include Upostelle.

MHRA Drug Safety Update (Sept 2016): Levonorgestrel-containing emergency hormonal contraception: advice on interactions with hepatic enzyme inducers and contraceptive efficacy.

(N.B. Elevated levels of CYP3A4 enzymes can persist for up to 4 weeks after cessation of the enzyme-inducing medicine. This decrease in plasma levonorgestrel may reduce contraceptive efficacy of levonorgestrel-containing emergency hormonal contraceptives).

Ulipristal Acetate 30mg
BNF | BNFC | SPC

Pack containing one ulipristal acetate 30mg tablet.

Brands include Ellaone

Ulipristal (EllaOne): see NTAG recommendation – is recommended as the preferred drug treatment option for post-coital contraception for patients who present between 72 and 120 hours following unprotected intercourse. Levonorgestrel is still recommended for patients who present at up to 72 hours following unprotected intercourse.

Alfuzosin
BNF | BNFC | SPC

XL tablets - 10mg 

Tamsulosin
BNF | BNFC | SPC

MR Capsules - 400microgram 

Tamsulosin capsules are the preferred formulation. The use of tablets should be avoided.

Doxazosin MR
BNF | BNFC | SPC
Doxazosin
BNF | BNFC | SPC

1mg, 2mg & 4mg tablets

Oxybutynin
BNF | BNFC | SPC

Tablets - 2.5mg, 3mg, 5mg

THIRD LINE

Transdermal Patch - 3.9mg/24hours

Immediate release formulations are first choice. Modified release formulations should not be used.

Tolterodine
BNF | BNFC | SPC

Tablets - 1mg, 2mg

Fesoterodine
BNF | BNFC | SPC

SECOND LINE 

MR Tablets - 4mg, 8mg 

Bethanechol
BNF | BNFC | SPC
Mirabegron▼
BNF | BNFC | SPC

Tablets - 25mg, 50mg

Mirabegron: NICE TA290

MHRA Drug Safety Update (Oct 2015): Mirabegron - risk of severe hypertension and associated cerebrovascular and cardiac events

Solifenacin
BNF | BNFC | SPC

Tablets - 5mg, 10mg

Darifenacin
BNF | BNFC | SPC

MR Tablets - 7.5mg, 15mg

Tropsium
BNF | BNFC | SPC
Duloxetine
BNF | BNFC | SPC

CD&D APC Grey List: Duloxetine: for the treatment of stress incontinence it may be offered as 2nd line therapy in combination with pelvic floor muscle training in women who prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, women should be counselled about its adverse effects

Desmopressin
BNF | BNFC | SPC

100 & 200 microgram tablets
120 microgram sublingual tablets


Nasal formulations no longer licensed for treating nocturnal enuresis.

Amitriptyline
BNF | BNFC | SPC

10mg, 25mg & 50mg tablets
25mg in 5ml sugar-free oral solution

Imipramine
BNF | BNFC | SPC

10mg & 25mg tablets

25mg in 5ml syrup u

Desmopressin (Noqdirna)
BNF | BNFC | SPC

25 microgram and 50 micromgram oral lyophilisate tablets

Indicated for symptomatic treatment of nocturia due to idiopathic nocturnal polyuria in adults.

Potassium Citrate
BNF | BNFC | SPC

Mixture BP

For alkalinisation of urine

Pentosan Polysulphate
BNF | BNFC | SPC

50mg capsulesu

Sodium Hyaluronate
BNF | BNFC | SPC

40mg in 50ml solution for instillation into the bladder (Cystistat®)u

Glycine
BNF | BNFC | SPC

1.5% large volume solutions (up to 3 litres)

Sodium Chloride
BNF | BNFC | SPC

0.9% large volume solutions (up to 3 litres)

Water
BNF | BNFC | SPC

Large volumes (up to 3 litres)

Chlorhexidine
BNF | BNFC | SPC

Catheter patency solution

0.02% (1 in 5,000) solution in 100ml sachets

Sodium Chloride Catheter Patency Solution
BNF | BNFC | SPC

Catheter patency solution

0.9% solution in 100ml sachets

Solution G
BNF | BNFC | SPC

Urotainer Twin Suby G®

2 x 30ml sachets (citric acid 3.23%, magnesium oxide 0.38%,
sodium bicarbonate 0.7%, disodium edetate 0.01%)

Solution R
BNF | BNFC | SPC

Urotainer Twin Solution R®
2 x 30ml sachets (citric acid 6%, gluconolactone 0.6%, magnesium
carbonate 2.8%, disodium edetate 0.01%)

See CD&D APC GUIDELINES FOR MANAGEMENT OF ERECTILE DYSFUNCTION (ED) IN ADULTS (≥ 18 YEARS)

Alprostadil
BNF | BNFC | SPC

Injection - 5 microgram, 10 microgram, 20 microgram, 40 microgram

Urethral Application (MUSE) - 250 microgram, 500 microgram, 1mg

Sildenafil
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg

Treatment of pulmonary hypertension and secondary Raynaud’s disease is specialist only - see Chapter 2

Tadalafil
BNF | BNFC | SPC

Tablets - 10mg, 20mg

Avanafil
BNF | BNFC | SPC

50mg, 100mg & 200mg tablets

Tadalafil Once Daily
BNF | BNFC | SPC
Aviptadil with Phentolamine▼
BNF | BNFC | SPC

Injection (Invicorp)

Alprostadil Cream
BNF | BNFC | SPC

See CD&D APC GUIDELINES FOR MANAGEMENT OF ERECTILE DYSFUNCTION (ED) IN ADULTS (≥ 18 YEARS)

Dapoxetine
BNF | BNFC | SPC

The Northern (NHS) Treatment Advisory Group does not recommend the use of dapoxetine for premature ejaculation.