6.8 Sex hormone responsive conditions

Sex hormones

Link to British Menopause Society Tools for Clinicians

Link to Menopause Matters Decision Tree

BNSSG HRT Prescribing Pathway

6.8.1 Female sex hormone responsive conditions

There is currently good availability of most HRT products. However, if formulary HRT products become unavailable, prescribers should liaise with their community pharmacist for the most up to date information regarding Out of Stocks. 

Oestrogens

Women with uterus

Sequential Combined HRT

Elleste Duet^® (oral) (TLS Green)

(estradiol & norethisterone)

Femoston^® 1/10, 2/10 tablets (oral) (TLS Green)

(estradiol & dydrogesterone)

Evorel^® Sequi patch (TLS Green)

(estradiol & norethisterone) 

Continuous Combined HRT

Kliovance^® (oral continuous) (TLS Green)

(estradiol & norethisterone)

Kliofem^® (oral continuous) (TLS Green)

(estradiol & norethisterone)

Femoston^® - Conti  (TLS Green)

(estradiol & dydrogesterone)

Bijuve^® (TLS Blue)

(estradiol / micronised progesterone) - second line treatment option and alternative to Femoston-Conti where first line options have not been tolerated / are not suitable.

Evorel^® Conti patch (TLS Green)

(estradiol & norethisterone)

FemSeven^® Conti patch (TLS Green)

(estradiol & levonorgestrel)

Norethynodrel Derivatives

Tibolone (TLS Green)

Oestrogens

Women without uterus

Elleste Solo^® (oral) (TLS Green)

(estradiol)

Evorel^® patch (TLS Green)

(estradiol 25, 50, 75 & 100mcg/24 hrs)

Estradot^® patch (TLS Blue)

(Estradiol 25, 37.5, 50, 75 & 100mcg/24 hrs) -second line brand option for patients where Evorel patch reported to lack adhesion, be poorly absorbed or where localised reactions to the glue are reported.

FemSeven^® patch (TLS Green)

(estradiol 50, 75 & 100mcg /24hrs)

Oestrogel^® gel (transdermal) (TLS Green)

(estradiol)

Sandrena^® gel (transdermal) (TLS Green)

(estradiol)

Lenzetto^® transdermal spray (TLS Blue)

(estradiol)

• Reserved for patients where transdermal treatment is indicated (e.g. oral HRT contra-indicated, not tolerated or ineffective) and where transdermal patches are inappropriate.

Ethinylestradiol

Ethinylestradiol (TLS Green)

Progestogens

Norethisterone (TLS Green)

Medroxyprogesterone (TLS Green)

Micronised Progesterone (oral) (TLS Green)

Gepretix^® is the preferred brand (most cost effective option)

Selective oestrogen receptor modulators

Specific indication:

Raloxifene (TLS Blue)

• For the treatment and prevention of postmenopausal osteoporosis i.e. where no effect on the endometrium and / or anti-oestrogenic effect on the breast is required

Nortestosterone derivatives

Dienogest tablets (TLS Amber Specialist Recommended)

• For adult female patients with confirmed or suspected endometriosis

6.8.2 Anti-oestrogens

Ovulation stimulants

Specific indication:

Clomifene (TLS Blue)

• Anovulatory infertility
• See Remedy and NICE CG156 Fertility problems: assessment and treatment for further information

Tamoxifen (TLS Blue)

• Anovulatory infertility

6.8.3 Male sex hormone responsive conditions

Information about testosterone replacement therapy for male patients with hypogonadism is available on the Endocrine System Guidelines page

Testosterone gel (TLS Green)

• For licensed indications - men only

Testosterone gel (Tostran^® 2% gel / Testogel^® 40.5mg/2.5g gel sachets) (TLS Amber 3 months)

• Please note the approved criteria for the initiation of testosterone gel are outlined in the shared care protocol and are as follows:

• • Low libido causing distress and
  • Ongoing symptoms despite optimised oestrogen and progesterone HRT and
    
  • All other causes (biopsychosocial approach) have been excluded and
  • total testosterone <1.5nmol/L

Testosterone may be initiated by a specialist in menopause in primary care under the shared care protocol.

A specialist in menopause for the purposes of testosterone prescribing is: a British Menopause Society accredited specialist or equivalent prescriber who can demonstrate that they have received training in, and have clinical experience of, treating women with testosterone preparations. This could therefore be a GP or ANP or Pharmacist Independent Prescriber working in primary care if they meet the following criteria:

1. A healthcare professional who holds a recognised menopause qualification such as:

• BMS Management of the Menopause Certificate
• FSRH Menopause Care Professional Certificate (MCPC)

and

2. Maintains skills and knowledge in line with GMC / NMC requirements for revalidation

• To be a prescriber with knowledge of the drug regimens and side effects
• Attends a national or regional menopause scientific update session at least once every three years (e.g. BMS, FSRH, primary care forum, etc);
• Provides a minimum of 100 menopause related consultations per year, of which at least 50 are new.

Testosterone oily injection (Nebido^® and Sustanon 250^®) (TLS Amber 3 months)

See Shared Care Protocol

Testosterone implant (TLS Red)

6.8.4 Male sex hormone anatagonism

Anti-Androgens

Cyproterone (TLS Red)

• N.B. Amber for prostate cancer

Finasteride (TLS Green)

Dutasteride (TLS Blue)

• For patients who are intolerant of finasteride. Alone or in combination with Tamsulosin

• For information: Charing Cross information Hormonal treatment for Trans men

Anabolic steroids

None

6.8.5 Hormone Therapy for Gender Reassignment

Hormone therapy for gender reassignment

NHSE England Circular SSC 1620 Primary Care Responsibilities in Prescribing and Monitoring Hormone Therapy and Transgender and Non-Binary Adults (updated)

GMC guidance for doctors treating trans patients

Tavistock and Portman Clinical Information and guidance for hormone therapy

Devon Partnership NHS Trust Pharmacological Treatment of Gender Dysphoria (click 'Gender Dysphoria')

Government restrictions on use of puberty suppressing hormones (puberty blockers): information for prescribers and pharmacists / dispensing doctors

Updated information for primary care - government restrictions on use of puberty suppressing hormones (puberty blockers)

Local Guidance

• BNSSG Transgender Prescribing Information for GPs

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