Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
6.4.1 Hormone Replacement Therapy (HRT)
HRT should no longer be used a first line intervention to prevent osteoporosis. Preparations marked with an asterisk are those licensed for osteoporosis as well as relief of menopausal symptoms, all other preparations are only licensed for menopausal symptoms.
• In view of increasing evidence that HRT may have harmful effects on CVD, this should be carefully discussed with patients at commencement and annually at review.
• Oral preparations recommended 1st line on cost, although transdermal route may be more appropriate for some patients e.g. diabetics
• HRT should be prescribed by brand name to avoid confusion
Unopposed
oestrogen
Elleste Solo®1mg tablets: £5.06 (84)
2mg tablets: £5.06* (84)
Elleste Solo® tablets are first line on cost grounds.
Transdermal patches
as Evorel®
25mcg patch: £3.42 (8)
50mcg patch: £3.88* (8)
75mcg patch: £4.12* (8)
100mcg patch:£4.28* (8)
Evorel® is recommended where a patch formulation is required, due to lower cost, range of doses available and patient acceptability of matrix patches.
Cyclical combinedElleste Duet®1mg tablets: £9.20 (84)
2mg tablets: £9.20* (84)
Elleste Duet® tablets are first line on cost grounds.
Femoston®1/10mg tablets: £16.16* (84)
2/10mg tablets: £16.16* (84)
Femoston® (Estradiol and Dydrogesterone) offers alternative with a C21 progestogen.
Continuous combined:Kliovance®Tablets: £13.20* (84)Continuous combined products should not be used until 12 months after the menopause. Irregular bleeding patterns may occur for the first few months and may persist for some women, requiring a move back to cyclical preparations and/or investigation.
Kliovance® has identical composition to Elleste Duet Conti®, but at a lower cost
Kliofem®Tablets: £11.43* (84)
Femoston Conti®Tablets: £24.43* (84)
Tibolone is now non-formulary. It is expensive and benefits over HRT have not been demonstrated for menopausal symptoms. The MHRA have advised of increased risk of stroke in older women (LIFT study) and in February 2009 noted the increased risk of recurrent breast cancer when tibolone was used for vaso-motor symptoms in women with a history of breast cancer (LIBERATE trial).
ProgestogensNorethisterone5mg tablets: £2.09 (30)Norethisterone (15mg/day from days 5 to 26 of menstrual cycle) is an option for management of heavy menstrual bleeding, however it is not recommended as first line by NICE Clinical Guideline No.44. Norethisterone may cause more androgenic effects than some other progestogens.
Medroxy-progesterone2.5mg tablets: £1.84 (30)
5mg tablets: £1.23 (10)
10mg tablets: £22.16 (90)
Medroxyprogesterone may produce less androgenic adverse effects than Norethisterone.