Download Chapter 7 - Lancashire Teaching Hospitals

Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
Chapter 7
Obstetrics, Gynaecology, and Urinary-Tract Disorders
7.1 Drugs used in obstetrics.
7.1.1 Prostaglandins and oxytocics
7.1.1.1 Drugs affecting the ductus arteriosus
Ergometrine injection Red
with oxytocin
 injection (“Syntometrine”)
 NB. This is by I.M injection. Intravenous injection no longer recommended.
Oxytocin injection Red
Dinoprostone – Red
 Vaginal Gel
 Pessaries
Carboprost injection – Red
Closure of the ductus arteriosus
Ibuprofen injection – Red
Maintenance of patency
Alprostadil 500microgram/ml injection – Red
7.1.2 Mifepristone
Mifepristone tablets – Red
7.1.3 Myometrial relaxants
Atosiban – Red
 Injection
 Concentrate for I.V. Infusion
Beta agonists
Salbutamol injection – Red
7.2 Treatment of vaginal and vulval conditions
7.2.1 Preparations for vaginal and vulval changes
Topical HRT for vaginal atrophy
Oestrogens
 Gynest intravaginal cream 0.01% or pessaries 500micrograms Green
 Vagifem vaginal tablets MR 10micrograms Green
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
Additional prescribing advice:
 Topical oestrogens should be used in the smallest effective amount to minimise systemic
effects.
 Safety of long-term or repeated use is uncertain; treatment should be reviewed at least
annually
 Ovestin 0.1% is available for those with a peanut allergy Green
7.2.2 Vaginal and vulval infections
See Intranet Antibiotic Guidelines – Genital Tract
Additional prescribing advice:
 Clotrimazole is available over the counter.
 Candidal vulvitis is treated locally with clotrimazole cream but is invariably associated with
vaginal candidiasis. Vaginal candidiasis is treated with clotrimazole pessaries or cream
inserted high into the vagina.
 The partner may be the source of re-infection and, if symptomatic, should be treated with
cream at the same time.
N.B. Bacterial and viral infections normally require systemic treatment.
7.3 Contraceptives.
7.3.1 Combined hormonal contraceptives
General notes
MHRA advice, February 2014: Combined hormonal contraceptives and venous
thromboembolism
A review of the latest evidence on the risk of thromboembolism in association with combined
hormonal contraceptives (CHCs) has concluded that:
 the risk of blood clots with all low-dose CHCs is small
 there is good evidence that the risk of venous thromboembolism (VTE) may vary
between products, depending on the progestogen
 CHCs that contain levonorgestrel, norethisterone, or norgestimate have the lowest risk
of VTE
 the benefits of any CHC far outweigh the risk of serious side effects
 prescribers and women should be aware of the major risk factors for thromboembolism,
and of the key signs and symptoms
• Different doses of oestrogen may be associated with different side effect profiles in
individual women.
• The androgenicity of different progestogens appears to be related to consistent differences
in side-effects. Less androgenic progestogens (e.g. desogestrel) are of benefit to women with
acne.
• Most contraceptive failures are due to poor compliance which is strongly influenced by
acceptability. It is important therefore to accept that women may prefer one brand to another
despite similar or identical composition.
• There is no good evidence that triphasic or biphasic COC's are associated with better cycle
control; they are more complicated to use.
• When the pill is used for management of gynaecological conditions, such as menorrhagia or
dysmenorrhoea, the risk/benefit ratio changes and it may be prescribed for women who would
have relative contraindications if they were using it solely for contraception.
• Some drugs, including enzyme-inducers and antibiotics, may impair the efficacy of oral
contraceptives; see BNF for details.
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
Group 1 - First line
The cheapest and most straightforward options and lowest VTE risk for COCs listed.
Ethinylestradiol 35mcg/norethisterone 500mcg (Brands: Brevinor®; Ovysmen®) - GREEN
Ethinylestradiol 30mcg/ levonorgestrel 150mcg (Brands: Levest®; Microgynon 30®;
Ovranette®; Rigevidon® ) - GREEN
Group 2 - Second line
May be useful if acne or other androgenic side effects are problematical, with the first line
choice of pill.
Cilest®(ethinylestradiol 35mcg/ norgestimate 250mcg) - GREEN
Femodene®; Millinette 30/75® (ethinylestradiol 30 mcg/ gestodene 75mcg) - GREEN
Gedarel 30/150®; Marvelon® (ethinylestradiol 30mcg/desogestrel 150mcg) - GREEN
Group 3 – Second line
This pill with lower oestrogen content (20 micrograms) may be useful if nausea, breast
tenderness or general headaches (not migraine) are problematical with the first line choice of
pill.
Gedarel 20/150®; Mercilon® (ethinylestradiol 20mcg/desogestrel 150mcg) - GREEN
Group 4 - Second line
Useful alternatives for breakthrough bleeding when other causes excluded.
Loestrin 30®(ethinylestradiol 30mcg/ norethisterone 1.5mg) - GREEN
Norimin® tablets (ethinylestradiol 35mcg/ norethisterone 1mg) - GREEN
Note: Everyday pills (eg MicrogynonED®) (21 active tablets followed by 7 inactive tablets)
may be useful for women who find it difficult to remember to restart after the pill free week.
Group 5 - Third line
For women with acne, not settling with two previously tried Group 2 second line pills.
Yasmin® tablets (ethinylestradiol 30mcg/ drospirenone 3mg) - GREEN
Transdermal (standard strength)
Evra® is not recommended for first line use but may be more suitable for younger, or less
compliant women, or those with GI disturbance whilst taking oral contraceptives.
Evra® transdermal patch - GREEN
(ethinylestradiol 33.9 micrograms/24hrs, norelgestromin 203 micrograms/24hrs)
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
7.3.2 Progestogen-only contraceptives
7.3.2.1 Oral progestogen-only contraceptives
First choice:
Micronor/Noriday - GREEN
Second choice:
Norgeston - GREEN
Additional prescribing advice:
 These are useful for women in whom oestrogens are contra-indicated, or if breastfeeding.
 There is no evidence for any clinical advantage of any one brand of POP; Micronor® is
currently less expensive than alternatives.
 Desogestrel (GREEN) should not routinely be used as an alternative to COCs but is
reserved for women who have problems adhering to the 3 hour window for other oral
progestogen only contraceptives. (Desogestrel can be taken up to 12 hours late before it
is considered a ‘missed pill’)
 Desogesterol - Brands include: Cerazette®, Cerelle® but generic prescribing is
recommended
7.3.2.2 Parenteral progestogen-only contraceptives
For IUD/IUS and Contraceptive implant fitting special training is required (primary care - see
nGMS enhanced services contract for details and contact Local Authority for further
information as necessary). NICE guidance states that these methods together with Depo
Provera® (LARC methods) are the most cost effective option and that their use should be
encouraged.
The MHRA has also advised that;

In adolescents, medroxyprogesterone acetate (Depo-provera®) be used only when
other methods of contraception are inappropriate;

In all women, benefits of using medroxyprogesterone acetate beyond 2 years should
be evaluated against risks;

In women with risk factors for osteoporosis an alternative method of contraception
instead of medroxyprogesterone acetate should be considered.
First choice:
Medroxyprogesterone acetate (Depo-provera) GREEN
Implants:
First choice:
Etonogestrel (Nexplanon) GREEN
Additional prescribing advice:
 Nexplanon® insertion and removal requires specialist training.
 Nexplanon® is a low dose long-acting progestogen. Contraceptive effect lasts for up to 3
years. The manufacturer advises that in heavier women, blood etonogestrel
concentrations are lower and the implant may not provide effective contraception during
the third year. Earlier replacement is advised.
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
7.3.2.3 Intra-uterine progesterone-only system (IUS)
To be fitted by specially trained individuals only
Note: For the majority of women with regular light periods an intra-uterine device (IUD)
would be the first line choice due to the avoidance of potential troublesome
intermenstrual bleeding with an IUS for the first 6 months, and it being the most cost
effective option.
IUS is beneficial for women requiring contraception who also have heavy menstrual bleeding.
Follow NICE or Map of Medicine guidance on women who may or may not need
gynaecological investigation before an IUS is fitted.
First choice:
Levonorgestrel 20micrograms/24hrs intra-uterine system (Mirena®) GREEN
7.3.3 Spermicidal contraceptives
Gygel - Green
Additional prescribing advice:
 Spermicides are not recommended for use as the sole method of contraception. They are
suitable for use with barrier methods, such as diaphragms or caps; however, spermicidal
contraceptives are not generally recommended for use with condoms as there is no
evidence of any additional protection compared with non-spermicidal lubricants. All
currently available spermicides contain nonoxinol '9' (N9) as the active compound.
Spermicidal contraceptives are not suitable for use in those with or at high risk of sexually
transmitted infections (including HIV) High frequency use of the spermicide nonoxinol 9
has been associated with genital lesions, which may increase the risk of acquiring these
infections.
7.3.4 Contraceptive devices
Intra-uterine devices
First choices: T-Safe® 380A Quickload or Multiload® Cu375 (or Mirena®) - Green
Additional prescribing advice:
 IUD insertions and removals should be performed by someone who has been properly
trained, regularly updated and performs regular insertions. They should provide full patient
counselling backed where available by a patient information leaflet.
 Copper IUDs provide long-acting highly effective contraception for at least 5 years and do
not rely on compliance for their efficacy. The most effective intra-uterine devices have at
least 380mm of copper and have banded copper on the arms. Devices which contain less
than 300mm of copper should no longer be used as they are less effective.
 GyneFix® is a frameless flexible device which may be associated with a reduction in
dysmenorrhoea. Smaller than the framed devices, it is particularly useful for nulliparous
women. Since the device is anchored to the myometrium it may be useful for women who
have a history of expulsion of a framed device.
Diaphragms
First choice: Ortho All- flex® - Green
Second choice: Reflexions® - Green
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
Condoms
Additional prescribing advice:
 Condoms are available free of charge from Family Planning Services, Brook, C-card
outlets and certain GPs.
 Condoms are the only method, which protect against sexually transmitted diseases
including HIV; condom users should be informed about emergency contraception.
7.3.5 Emergency hormonal contraception
First line - offer emergency IUD as the most effective method of emergency contraception.
Second line – if woman declines IUD, then levonorgestrel for presentation 0-72 hours after
unprotected sexual intercourse (UPSI), or ulipristal for presentation 72-120 hours after UPSI.
If an emergency IUD cannot be fitted immediately, emergency hormonal contraception should
still be offered as appropriate in case the woman does not return for IUD, or an IUD cannot be
fitted.
First choice:
Levonelle® (levonorgestrel 1500microgram) GREEN
EllaOne® (ulipristal acetate 30mg) (72 – 120 hours after UPSI) GREEN – primary care
Secondary care - Only approved for the safe centre, RPH
7.4 Drugs for genito-urinary disorders
7.4.1 Drugs for urinary retention
ALPHA-BLOCKERS
Indications: benign prostatic hyperplasia
First choice
Tamsulosin MR - Green
Second choice
Alfuzosin - Green
Additional prescribing advice:
 Watchful waiting may be preferable to treatment in men with mild to moderate symptoms.
 Alpha-blockers are the treatment of choice and likely to provide symptom relief in men with
prostates of any size. Effects should be noticed in several days, with full response after 46 weeks. The benefit may be seen for up to 3 years in those who continue to take the
drug. There is lack of data beyond 3 years.
 All alpha-blockers are equally effective but there are differences in tolerability.
 Caution in patients already receiving antihypertensives, these patients may need lower
starting doses.
 Alpha blockers should be avoided in patients with a history of postural hypotension and
micturition syncope
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
5alpha-reductase inhibitors
Alternative treatment to alpha-blockers; particularly in men with a significantly enlarged
prostate.
Finasteride Amber 0
Additional prescribing advice:
 Review treatment at 3-6 months and then every 6-12 months. Several months’ treatment



may be required before benefit is obtained and any benefit could be lost after 3-6 months if
treatment is discontinued.
Finasteride decreases plasma levels of PSA by approximately 50%. After 6 months of
treatment, the PSA value should be doubled for comparison with normal ranges in
untreated men.
Women of childbearing potential should avoid handling crushed or broken tablets.
Finasteride is excreted in the semen and use of a condom is recommended if sexual
partner is pregnant or likely to become pregnant.
7.4.2 Drugs for urinary frequency, enuresis and incontinence
Urinary incontinence
First choices:
Oxybutynin immediate release - Green
 Side effects may be reduced by starting at a lower dose
 Oxybutynin Patch – restricted for use in patients who benefit from oral oxybutynin but
cannot tolerate its side effects.
Tolterodine - Green
Second choice:
Trospium MR - Green




Additional prescribing advice:
Combine drug therapy with conservative methods for managing urge incontinence such as
pelvic floor exercises and bladder training; stress incontinence is generally managed by
non-drug methods.
Anti-muscarinic drug therapy should be reviewed after 3-6 months.
Duloxetine may be offered to women as second line treatment in preference to surgery or
if surgery is not suitable. Green
NICE TA290 – Mirabegron can be prescribed if the anti-muscarinics do not work, if they
are not suitable, or their side effects are unacceptable. (Green with restrictions)
Nocturnal enuresis in children
Desmopressin tablets - amber 0
Additional prescribing advice:
 Common in young children but treatment is not appropriate in those under 5 years. It is
usually not needed in under 7 years and in cases where the child or parents are not
anxious about the bedwetting.
 Do not give intranasally for nocturnal enuresis due to an increased incidence of side
effects.
 Treatment is usually on a short-term basis – treatment should not be continued for longer
than 3 months without interrupting treatment for 1 week for a full patient re-assessment.
 Used also in Multiple sclerosis patients for nocturnal frequency.
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
7.4.3 Drugs used in urological pain
Alkalinisation of urine
Indications: relief of discomfort in mild urinary tract infections; alkalinisation of urine
Potassium citrate Mixture - Green
Additional prescribing advice:
 Many patients obtain good relief from the symptoms of cystitis with over-the-counter
medicines.
 Sodium bicarbonate is used as a urinary alkalinisation agent in some metabolic and renal
disorders.
 May cause hyperkalaemia with prolonged high dosage. Use with great caution in renal
impairment, cardiac disease and in patients on potassium-sparing diuretics or ACE
inhibitors.
 Potassium citrate tablets (unlicensed) – named patient basis only - red
Acidification of urine
Ascorbic acid tablets - Green
 Acidification has been undertaken with ascorbic acid but is not always reliable.
7.4.4 Bladder instillations and urological surgery
Bladder instillations
Maintenance of indwelling urinary catheters
First choice:
 Sodium chloride 0.9% 50ml urotrainer or 100ml bladder irrigation
Second choice:
 “Solution G” (citric acid 3.23%, magnesium oxide 0.38%, sodium bicarbonate 0.7%,
disodium edetate 0.01%)
Consultant /Hospital Only
 Cystistat or Gepan (hyaluronic acid used in interstitial cystitis) – Unlicensed use
 BCG bladder instillation – ImmuCyst/OncoTice
Urological surgery
 Glycine 1.5% for irrigation
 Sodium chloride 0.9% in 3L irrigation
Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Joint Formulary 2014
7.4.5 Drugs for erectile dysfunction
Sildenafil - Green
Tadalafil - Green
Alprostadil (prostaglandin E1)
Alprostadil injection
Additional prescribing advice:
 Drug treatments for erectile dysfunction may only be prescribed on the NHS under certain
circumstances. See latest issue of BNF.
 GPs can issue private prescriptions for these drugs and devices for patients on their list
but cannot charge patients for issuing a private prescription.
 Treatment should be available from specialist services in cases where erectile dysfunction
is causing severe distress.
 Examination of the patient is important to check for anatomical abnormalities and
Peyronie's disease, which may need referral to Urology.
 Diabetes needs to be excluded and cardiovascular risk factors addressed because they
are commonly present.
 Tadalafil may be suitable alternative for patients who develop visual disturbances with
sildenafil or for whom a longer duration of action is required.
 Sildenafil and tadalafil are contra-indicated in men receiving nitrates in any form and
nicorandil. Consider discontinuing nitrates if no longer needed.
 Cardiovascular disease and multiple antihypertensive drug regimens are not contraindications to sildenafil or tadalafil therapy provided the man is capable of ordinary daily
tasks (and therefore sexual activity) without cardiac symptoms.
 Intracavernosal self-injection with alprostadil is a suitable second choice to sildenafil if
treatment with sildenafil fails or is contraindicated.
 All patients commencing intracavernosal injection therapy require supervised instruction
on its use and advice on action required should a prolonged erection (>6 hours) occur