▶ Risk of endometrial cancer The increased risk of endometrial
cancer depends on the dose and duration of oestrogenonly HRT.
In women with a uterus, the addition of a progestogen
cyclically (for at least 10 days per 28-day cycle) reduces the
additional risk of endometrial cancer; this additional risk is
eliminated if a progestogen is given continuously.
However, this should be weighed against the increased risk
▶ Risk of ovarian cancer Long-term use of combined HRT or
oestrogen-only HRT is associated with a small increased
risk of ovarian cancer. This excess risk disappears within a
▶ Risk of venous thromboembolism Women using combined or
oestrogen-only HRT are at an increased risk of deep vein
thrombosis and of pulmonary embolism especially in the
In women who have predisposing factors (such as a
personal or family history of deep vein thrombosis or
pulmonary embolism, severe varicose veins, obesity,
trauma, or prolonged bed-rest) it is prudent to review the
need for HRT, as in some cases the risks of HRT may
Travel involving prolonged immobility further increases
the risk of deep vein thrombosis.
▶ Risk of stroke Risk of stroke increases with age, therefore
older women have a greater absolute risk of stroke.
Combined HRT or oestrogen-only HRT slightly increases
▶ Risk of coronary heart disease HRT does not prevent coronary
heart disease and should not be prescribed for this
purpose. There is an increased risk of coronary heart
disease in women who start combined HRT more than
10 years after menopause. Although very little information
is available on the risk of coronary heart disease in
younger women who start HRT close to the menopause,
studies suggest a lower relative risk compared with older
▶ Other conditions The product literature advises caution in
other conditions including hypertension, renal disease,
asthma, epilepsy, sickle-cell disease, melanoma,
otosclerosis, multiple sclerosis, and systemic lupus
erythematosus (but care required if antiphospholipid
antibodies present). Evidence for caution in these
conditions is unsatisfactory and many women with these
conditions may stand to benefit from HRT.
l INTERACTIONS → Appendix 1: hormone replacement
▶ Common or very common Alopecia . arthralgia . breast
abnormalities . depression . leg cramps . menstrual cycle
irregularities . vaginal discharge . weight changes
▶ Uncommon Anxiety . cervical abnormalities . contact lens
ischaemic . epilepsy exacerbated . galactorrhoea . glucose
▶ Frequency not known Endometrial hyperplasia . erythema
SIDE-EFFECTS, FURTHER INFORMATION Cyclical HRT
(where a progestogen is taken for 12–14 days of each
28-day oestrogen treatment cycle) usually results in
regular withdrawal bleeding towards the end of the
progestogen. Continuous combined HRT commonly
produces irregular breakthrough bleeding in the first
4–6 months of treatment. Bleeding beyond 6 months or
after a spell of amenorrhoea requires further investigation
to exclude serious gynaecological pathology.
l CONCEPTION AND CONTRACEPTION HRT does not provide
contraception and a woman is considered potentially
fertile for 2 years after her last menstrual period if she is
under 50 years, and for 1 year if she is over 50 years. A
woman who is under 50 years and free of all risk factors for
venous and arterial disease can use a low-oestrogen
combined oral contraceptive pill to provide both relief of
menopausal symptoms and contraception; it is
recommended that the oral contraceptive be stopped at
50 years of age since there are more suitable alternatives.
If any potentially fertile woman needs HRT, non-hormonal
contraceptive measures (such as condoms) are necessary.
Measurement of follicle-stimulating hormone can help to
determine fertility, but high measurements alone
(particularly in women aged under 50 years) do not
necessarily preclude the possibility of becoming pregnant.
l PREGNANCY Manufacturer advises avoid—not indicated
l BREAST FEEDING Avoid until weaning or for 6 months
after birth (adverse effects on lactation).
l HEPATIC IMPAIRMENT Avoid in active liver disease
liver function returns to normal), and liver tumours.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Conjugated oestrogens 300 microgram Premarin 0.3mg tablets | 84 tablet P £6.07 DT = £6.07
Conjugated oestrogens 625 microgram Premarin 0.625mg tablets
| 84 tablet P £4.02 DT = £4.02
Conjugated oestrogens 1.25 mg Premarin 1.25mg tablets | 84 tablet P £3.58 DT = £3.58
Combinations available: Conjugated oestrogens with
bazedoxifene acetate 28-Mar-2017
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, conjugated oestrogens (equine) p. 754.
Menopausal symptoms (in women with at least 12 months
since last menses for whom treatment with progestogencontaining therapy is not appropriate)
▶ Adult: 0.45/20 mg daily continuously
DOSE EQUIVALENCE AND CONVERSION
▶ Dose expressed as x/y mg conjugated
l INTERACTIONS → Appendix 1: hormone replacement
complaints . nausea . peripheral oedema . skin reactions . vulvovaginal candidiasis
▶ Rare or very rare Embolism and thrombosis
▶ Frequency not known Dry eye . eye disorders . eye
inflammation . eye pain . palpitations . vision disorders
BNF 78 Female sex hormone responsive conditions 755
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 3, 25
Conjugated oestrogens 450 microgram, Bazedoxifene (as
Menopausal symptoms | Osteoporosis prophylaxis
▶ Adult: 2 mg daily, started on day 1–5 of menstruation
(or at any time if cycles have ceased or are infrequent),
to be taken with cyclical progestogen for 12–14 days of
each cycle in women with a uterus
▶ Adult: Apply 1 patch twice weekly continuously,
started within 5 days of onset of menstruation (or at
any time if cycles have ceased or are infrequent), to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, initiate therapy with MX
40, subsequently adjust according to response
▶ Adult: Apply 1 patch twice weekly continuously,
started within 5 days of onset of menstruation (or at
any time if cycles have ceased or are infrequent), to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, initiate therapy with MX
80, subsequently adjust according to response
▶ Adult: 1 mg daily, starting on day 1 of menstruation (or
at any time if cycles have ceased or are infrequent), to
be taken with cyclical progestogen for 12–14 days of
each cycle in women with a uterus
Menopausal symptoms not controlled with lower strength
▶ Adult: 2 mg daily, started on day 1 of menstruation (or
at any time if cycles have ceased or are infrequent), to
be given with cyclical progestogen for 12–14 days of
each cycle in women with a uterus
▶ Adult: Apply 1 patch twice weekly continuously,
started within 5 days of onset of menstruation (or at
any time if cycles have ceased or are infrequent), to be
used with cyclical progestogen for at least 12 days of
each cycle in women with a uterus, initiate therapy
with MX25 for first 3 months; subsequently adjust
▶ Adult: Apply 1 patch twice weekly continuously,
started within 5 days of onset of menstruation (or at
any time if cycles have ceased or are infrequent), to be
used with cyclical progestogen for at least 12 days of
each cycle in women with a uterus, initiate therapy
with MX50; subsequently adjust according to response
▶ Adult: Apply 1 patch twice weekly continuously, to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, initiate therapy with
25 patch for 3 months; subsequently adjust according
▶ Adult: Apply 1 patch twice weekly continuously, to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, initiate therapy with
50 patch; subsequently adjust according to response
Menopausal symptoms | Osteoporosis prophylaxis
▶ Adult: Apply 1 patch twice weekly continuously,
started within 5 days of onset of menstruation (or at
any time if cycles have ceased or are infrequent), to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, therapy should be
initiated with Evorel 50 patch; subsequently adjust
according to response; dose may be reduced to Evorel
25 patch after first month if necessary for menopausal
Menopausal symptoms | Osteoporosis prophylaxis
▶ Adult: Apply 1 patch once weekly continuously, to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, initiate therapy with
FemSeven 50 patches for the first few months,
subsequently adjust according to response
▶ Adult: Apply 1.5 mg once daily continuously, increased
if necessary up to 3 mg after 1 month continuously, to
be applied over an area twice that of the template
provided, starting within 5 days of menstruation (or
anytime if cycles have ceased or are infrequent), to be
used with cyclical progestogen for at least 12 days of
each cycle in women with a uterus
▶ Adult: Apply 1.5 mg once daily continuously, to be
applied over an area twice that of the template
provided, starting within 5 days of menstruation (or
anytime if cycles have ceased or are infrequent), to be
used with cyclical progestogen for at least 12 days of
each cycle in women with a uterus
DOSE EQUIVALENCE AND CONVERSION
▶ For Oestrogel ®: 2 measures is equivalent to estradiol
▶ Adult: 1–2 mg daily continuously, to be started on day
1 of menstruation (or at any time if cycles have ceased
or are infrequent), to be taken with cyclical
progestogen for 12–14 days of each cycle in women
756 Sex hormone responsive conditions BNF 78
▶ Adult: 2 mg daily continuously, to be taken with
cyclical progestogen for 12–14 days of each cycle in
Menopausal symptoms | Osteoporosis prophylaxis
▶ Adult: Apply 1 patch once weekly continuously,
alternatively apply 1 patch once weekly for 3 weeks,
followed by a 7-day patch-free interval (cyclical), to be
used with cyclical progestogen for 12–14 days of each
cycle in women with a uterus, initiate therapy with
Progynova TS 50, subsequently adjust according to
response, women receiving Progynova TS 100 patches
for menopausal symptoms may continue with this
strength for osteoporosis prophylaxis
▶ Adult: Apply 1 mg once daily, to be applied over area
1–2 times size of hand; with cyclical progestogen for
12–14 days of each cycle in women with a uterus, dose
may be adjusted after 2–3 cycles to lowest effective
dose; usual dose 0.5–1.5 mg daily
▶ Adult: Initially 1 mg daily, to be started within 5 days of
onset of menstruation (or any time if cycles have
ceased or are infrequent), increased if necessary to
2 mg daily, to be taken with a cyclical progestogen for
12–14 days of each cycle in women with a uterus
▶ Adult: 2 mg daily, to be taken with a cyclical
progestogen for 12–14 days of each cycle in women
l CONTRA-INDICATIONS Active arterial thromboembolic
disease (e.g. angina or myocardial infarction). active
thrombophlebitis .Dubin-Johnson syndrome (or monitor
closely). history of breast cancer. history of recurrent
venous thromboembolism (unless already on
myocardial infarction). Rotor syndrome (or monitor
closely).thrombophilic disorder. undiagnosed vaginal
bleeding . untreated endometrial hyperplasia . venous
l CAUTIONS Acute porphyrias p. 1058 . diabetes (increased
risk of heart disease). history of breast nodules—closely
monitor breast status (risk of breast cancer). history of
endometrial hyperplasia; factors predisposing to
thromboembolism . history of fibrocystic disease—closely
monitor breast status (risk of breast cancer). hypophyseal
tumours . increased risk of gall-bladder disease . migraine
(or migraine-like headaches). presence of
antiphospholipid antibodies (increased risk of thrombotic
events). prolonged exposure to unopposed oestrogens
may increase risk of developing endometrial cancer.risk
factors for oestrogen-dependent tumours (e.g. breast
cancer in first-degree relative). symptoms of
endometriosis may be exacerbated . uterine fibroids may
▶ Risk of breast cancer It is estimated that using all types of
HRT increases the risk of breast cancer within 1–2 years of
initiating treatment. The increased risk is related to the
duration of HRT use (but not to the age at which HRT is
started) and this excess risk disappears within 5 years of
Radiological detection of breast cancer can be made
more difficult as mammographic density can increase with
▶ Risk of endometrial cancer The increased risk of endometrial
cancer depends on the dose and duration of oestrogenonly HRT.
In women with a uterus, the addition of a progestogen
cyclically (for at least 10 days per 28-day cycle) reduces the
additional risk of endometrial cancer; this additional risk is
eliminated if a progestogen is given continuously.
However, this should be weighed against the increased risk
▶ Risk of ovarian cancer Long-term use of combined HRT or
oestrogen-only HRT is associated with a small increased
risk of ovarian cancer. This excess risk disappears within a
▶ Risk of venous thromboembolism Women using combined or
oestrogen-only HRT are at an increased risk of deep vein
thrombosis and of pulmonary embolism especially in the
In women who have predisposing factors (such as a
personal or family history of deep vein thrombosis or
pulmonary embolism, severe varicose veins, obesity,
trauma, or prolonged bed-rest) it is prudent to review the
need for HRT, as in some cases the risks of HRT may
Travel involving prolonged immobility further increases
the risk of deep vein thrombosis.
▶ Risk of stroke Risk of stroke increases with age, therefore
older women have a greater absolute risk of stroke.
Combined HRT or oestrogen-only HRT slightly increases
▶ Risk of coronary heart disease HRT does not prevent coronary
heart disease and should not be prescribed for this
purpose. There is an increased risk of coronary heart
disease in women who start combined HRT more than
10 years after menopause. Although very little information
is available on the risk of coronary heart disease in
younger women who start HRT close to the menopause,
studies suggest a lower relative risk compared with older
▶ Other conditions The product literature advises caution in
other conditions including hypertension, renal disease,
asthma, epilepsy, sickle-cell disease, melanoma,
otosclerosis, multiple sclerosis, and systemic lupus
erythematosus (but care required if antiphospholipid
antibodies present). Evidence for caution in these
conditions is unsatisfactory and many women with these
conditions may stand to benefit from HRT.
l INTERACTIONS → Appendix 1: hormone replacement
▶ Common or very common Headaches . nausea . skin
irregularities . muscle complaints . pelvic pain . weight
BNF 78 Female sex hormone responsive conditions 757
vascular disease .tumour growth . visual impairment. vulvovaginal candidiasis
infarction . sexual dysfunction . steepening of corneal
curvature . vaginal discharge . vomiting
▶ With oral use Carbohydrate metabolism change . epilepsy
exacerbated . hypertriglyceridaemia . increased risk of
coronary artery disease . neoplasms . pancreatitis . systemic lupus erythematosus (SLE)
SIDE-EFFECTS, FURTHER INFORMATION Cyclical HRT
(where a progestogen is taken for 12–14 days of each
28-day oestrogen treatment cycle) usually results in
regular withdrawal bleeding towards the end of the
progestogen. Continuous combined HRT commonly
produces irregular breakthrough bleeding in the first
4–6 months of treatment. Bleeding beyond 6 months or
after a spell of amenorrhoea requires further investigation
to exclude serious gynaecological pathology.
l CONCEPTION AND CONTRACEPTION HRT does not provide
contraception and a woman is considered potentially
fertile for 2 years after her last menstrual period if she is
under 50 years, and for 1 year if she is over 50 years. A
woman who is under 50 years and free of all risk factors for
venous and arterial disease can use a low-oestrogen
combined oral contraceptive pill to provide both relief of
menopausal symptoms and contraception; it is
recommended that the oral contraceptive be stopped at
50 years of age since there are more suitable alternatives.
If any potentially fertile woman needs HRT, non-hormonal
contraceptive measures (such as condoms) are necessary.
Measurement of follicle-stimulating hormone can help to
determine fertility, but high measurements alone
(particularly in women aged under 50 years) do not
necessarily preclude the possibility of becoming pregnant.
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Avoid; adverse effects on lactation.
l HEPATIC IMPAIRMENT Avoid in active liver disease
liver function returns to normal), and liver tumours.
▶ History of breast nodules or fibrocystic disease—closely
monitor breast status (risk of breast cancer).
▶ The endometrial safety of long-term or repeated use of
topical vaginal oestrogens is uncertain; treatment should
be reviewed at least annually, with special consideration
given to any symptoms of endometrial hyperplasia or
l DIRECTIONS FOR ADMINISTRATION
▶ With transdermal use Patch should be removed after
3–4 days (or once a week in case of 7-day patch) and
replaced with fresh patch on slightly different site;
recommended sites: clean, dry, unbroken areas of skin on
trunk below waistline; not to be applied on or near breasts
or under waistband. If patch falls off in bath allow skin to
cool before applying new patch.
▶ With transdermal use Patient counselling is advised for
estradiol patches (administration).
▶ With topical use Patient counselling is advised for estradiol
OESTROGEL ® ▶ With topical use Apply gel to clean, dry,
intact skin such as arms, shoulders or inner thighs and
allow to dry for 5 minutes before covering with clothing.
Not to be applied on or near breasts or on vulval region.
Avoid skin contact with another person (particularly male)
and avoid other skin products or washing the area for at
least 1 hour after application.
SANDRENA ® ▶ With topical use Apply gel to intact areas of
skin such as lower trunk or thighs, using right and left
sides on alternate days. Wash hands after application. Not
to be applied on the breasts or face and avoid contact with
eyes. Allow area of application to dry for 5 minutes and do
not wash area for at least 1 hour.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Bedol (ReSource Medical UK Ltd)
Estradiol 2 mg Bedol 2mg tablets | 84 tablet P £5.07 DT = £5.06
▶ Elleste Solo (Meda Pharmaceuticals Ltd)
Estradiol 1 mg Elleste Solo 1mg tablets | 84 tablet P £5.06 DT =
Estradiol 2 mg Elleste Solo 2mg tablets | 84 tablet P £5.06 DT =
Estradiol valerate 1 mg Progynova 1mg tablets | 84 tablet P £7.30 DT = £7.30
Estradiol valerate 2 mg Progynova 2mg tablets | 84 tablet P £7.30 DT = £7.30
Estradiol 1 mg Zumenon 1mg tablets | 84 tablet P £6.89 DT =
Estradiol 2 mg Zumenon 2mg tablets | 84 tablet P £6.89 DT =
▶ Elleste Solo MX (Meda Pharmaceuticals Ltd)
Estradiol 40 microgram per 24 hour Elleste Solo MX 40
transdermal patches | 8 patch P £5.19 DT = £5.19
Estradiol 80 microgram per 24 hour Elleste Solo MX 80
transdermal patches | 8 patch P £5.99 DT = £5.99
▶ Estraderm MX (Merus Labs Luxco S.a R.L.)
Estradiol 50 microgram per 24 hour Estraderm MX 50 patches |
8 patch P £5.51 DT = £3.88 | 24 patch P £16.46 DT = £11.66
▶ Estradot (Novartis Pharmaceuticals UK Ltd)
Estradiol 25 microgram per 24 hour Estradot
25micrograms/24hours patches | 8 patch P £5.99 DT = £3.42
Estradiol 37.5 microgram per 24 hour Estradot
37.5micrograms/24hours patches | 8 patch P £6.00 DT = £6.00
Estradiol 50 microgram per 24 hour Estradot
50micrograms/24hours patches | 8 patch P £6.02 DT = £3.88
Estradiol 75 microgram per 24 hour Estradot
75micrograms/24hours patches | 8 patch P £7.00 DT = £4.12
Estradiol 100 microgram per 24 hour Estradot
100micrograms/24hours patches | 8 patch P £7.27 DT = £4.28
Estradiol 25 microgram per 24 hour Evorel 25 patches |
Estradiol 75 microgram per 24 hour Evorel 75 patches | 8 patch P £4.12 DT = £4.12
Estradiol 100 microgram per 24 hour Evorel 100 patches | 8 patch P £4.28 DT = £4.28
▶ FemSeven (Theramex HQ UK Ltd)
Estradiol 50 microgram per 24 hour FemSeven 50 patches |
4 patch P £6.04 DT = £6.04 | 12 patch P £18.02 DT = £18.02
Estradiol 75 microgram per 24 hour FemSeven 75 patches | 4 patch P £6.98
Estradiol 100 microgram per 24 hour FemSeven 100 patches | 4 patch P £7.28 DT = £7.28
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