netFormulary
Data extracted : 22/09/2017
 Formulary Section 7: Obstetrics, Gynaecology, and urinary-tract disorders
 Details...
07.01.01 Prostaglandins and oxytocics

Section being updated.  Currently contains only TAS approved drugs since 2000.  Historically used drugs not yet included

Dinoprostone   (Propess®)
For specialist obstetric use only
07.01.03 Myometrial relaxants
NB This section is not yet complete. It includes drugs which have gone through the TAS process only since 2000, not those used historically
Restricted Drug  Atosiban  
Pre term labour
Restricted Drug  Nifedipine capsule 
Only for use as a tocolytic in line with trust guidance on pre-term labour.
07.02.02 Vaginal and vulval infections
See Antimicrobial Guidance for primary care on antimicrobial website for further details.  Link below  
Link   Leicestershire Guidance: Antimicrobial guidelines for primary care
07.03 Contraceptives
Link   Clinical Knowledge Summary: Missed Pill Advice (choose from menu on left hand side)
Link   NICE CG30: Long-acting reversible contraception
07.03.01 Combined hormonal contraceptives

  • Combined oral contraceptives (COCs) containing both oestrogen and progestogen are effective. A low hormone content pill should be tried initially and the patient maintained on a preparation with the lowest oestrogen and progestogen content consistent with good cycle control and minimal side effects.

  • Pills containing desogestrel, gestodene and norgestimate probably have less adverse effects on lipids than the older preparations containing norethisterone or levonorgestrel. However, they have been found to pose a slightly higher risk of thromboembolism (x 1.7). There is insufficient information on relative thromboembolic risk with norgestimate (Cilest®) Patients should be informed of the higher risk of thromboembolism with pills containing desogestrel or gestodene if these are prescribed. They are best avoided in women with additional risk factors for thromboembolism including obesity, or a history of thrombosis from any cause. 

  • Phased preparations are available, but they are more complicated to use and generally more expensive. They may help to improve cycle control in some women where this is inadequate with a recommended (monophasic) preparation.

  • Yasmin® is more expensive, with no evidence of significant advantages, compared to other similar combined oral contraceptives and should only be used if other choices are not acceptable. The MHRA concluded that VTE risk  for drospirenone-containing COCs, including Yasmin, is higher than for levonorgestrel-containing COCs (so-called ‘second generation’ pills) and may be similar to the risk for COCs that contain desogestrel or gestodene (so-called ‘third generation’ pills) but less than that associated with pregnancy.
Link   MHRA Advice: Combined hormonal contraceptives: risk of venous thromboembolism—clarification of advice
Link   MHRA Advice: St John’s wort: interaction with hormonal contraceptives, including implants—reduced contraceptive effect.
First Choice:
Brevinor® 
First Choice:
Loestrin 20® 
First Choice:
Loestrim 30® 
First Choice:
Microgynon 30® 
Generic equivalents may have a slightly lower cost acquisition e.g. Levest®, Rigevidon®. Check prices regularly as they do fluctuate.
First Choice:
Norimin® 
First Choice:
Norinyl-1® 
First Choice:
Ovranette® 
First Choice:
Ovysmen® 
Second Choice:
Cilest® 
Second Choice:
Femodene® 
Second Choice:
Femodette® 
Second Choice:
Marvelon® 
Second Choice:
Mercilon® 
Restricted Drug  Evra®patch 
More costly choice. Reserve as an option for patients with compliance issues with oral combined hormonal contraception
Restricted Drug  Nuvaring® 
More costly choice. Reserve as an option for patients with compliance issues with oral combined hormonal contraception.
07.03.02 Progestogen-only contraceptives
07.03.02.01 Oral progestogen-only contraceptives

  • Progestogen-only contraceptive pills (POPs) are slightly less effective than combined preparations and may cause irregular menstruation. However, the desogestrel-containing POP (Cerazette®) may be as effective as combined preparations. They are suitable for patients for whom oestrogen is contra-indicated, e.g. those with hypertension, valvular heart disease, diabetes or migraine. They are preferred to the combined type in those who are breast-feeding and may be started any time after 3 weeks postpartum.

  • The least expensive POP should be prescribed unless there are good reasons to the contrary.
First Choice:
Femulen® 
First Choice:
Micronor® 
First Choice:
Norgeston® 
First Choice:
Noriday® 
Restricted Drug  Cerazette® 
Due to cost should be reserved for those who find it difficult to adhere to the strict regime of established POPs
07.03.02.02 Parenteral progestogen-only contraceptives
Medroxyprogesterone acetate (Depo-Provera® and Sayana Press®) given by intramuscular or subcutaneous injection, are highly effective contraceptives and should be used:

  • Only after other methods have been discussed with the patient and considered to be unsuitable or unacceptable;

  • In women of all ages, careful re-evaluation of the risks and benefits of treatment should be carried out in those who wish to continue use for more than 2 years;

  • In women with significant lifestyle and/or medical risk factors for osteoporosis, other methods of contraception should be considered.
Progestogen-only Subdermal Implant

  • Ideally, an implant should be inserted between Days 1 and 5 (inclusive) of a normal menstrual cycle. No additional contraception is required. An implant can be inserted at any other time in the menstrual cycle if the clinician is reasonably certain that the woman is not pregnant and that there is no risk of conception. Additional contraception (barrier method or abstinence) should be advised for 7 days after insertion. If the woman is amenorrhoeic, the clinician must be reasonably certain that the woman is not pregnant and that there is no risk of conception; additional contraception should be used for 7 days.

  • Can be inserted immediately if Mirena®(LNG-IUS) was used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant. As bleeding with the LNG-IUS may not reflect ovarian activity the LNG-IUS should be continued for at least 7 days.

  • Can be inserted immediately if IUD was used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant. The IUD should be continued for at least 7 days.

  • A progestogen-only implant can be inserted on the days of surgical or second part of medical abortion or immediately following miscarriage: no additional contraception is required. If started > 5 days after abortion or miscarriage, additional contraception is required for 7 days.

  • Progestogen-only implants can safely be used by women who are breastfeeding.

  • Women can have a progestogen-only implant inserted up to and including Day 21 postpartum with immediate contraceptive protection. If inserted after Day 21 then condoms or abstinence should be advised for 7 days.
Link   FSRH Guidance: Progestogen only Implants
Medroxyprogesterone acetate  (Depo-Provera®)
Preparation for intramuscular administration
Medroxyprogesterone acetate  (Sayana Press®)
Given by subcutaneous injection
Licence allows for self administration
Nexplanon® 
Subdermal implant
07.03.02.03 Intra-uterine progestogen-only contraceptive

  • The TCu380S and the LNG-IUS are the most effective intrauterine devices available and are recommended as first choices

  • TCu380A and TCu380S can remain in place for 10 years and other Cu-IUDs for 5 years. However, if fitted after the age of 40 years it may be retained until after the menopause is confirmed.

  • Women should be informed that the LNG-IUS (Mirena®) is licensed for 5 years of use as a contraceptive

  • Women who have the LNG-IUS inserted at the age of 45 years or over for contraception can retain the device until the menopause is confirmed or until contraception is no longer required

  • Prophylactic antibiotics are NOT required for the insertion or removal of intrauterine contraception even in women with conditions where the risk of infective endocarditis may be increased

  • Clinicians who insert intrauterine contraception should be appropriately trained, maintain competence and attend regular updates in dealing with emergencies

  • The long-term use of intrauterine contraception is highly cost effective. Intrauterine contraception is more cost effective than combined oral contraception (even at 1 year of use) or progestogen-only injectables.
Link   FSRH Guidance: Intrauterine contraception
Link   MHRA Advice: Levonorgestrel-releasing intrauterine systems: prescribe by brand name
Link   NICE CG30: Long-acting reversible contraception
07.03.05 Emergency Contraception

  • For emergency contraception one Levonelle® tablet should be taken as soon as possible, preferably within 12 hours, and no later than 72 hours after unprotected intercourse. It is not as effective as regular oral contraceptive use.

  • Barrier contraception or abstinence is essential until the next period which may occur on time (or could be earlier or later). Future contraception should be discussed. Exclude pregnancy if next expected menstrual period is more than 7 days overdue or if the patient has unilateral abdominal pain.
    Note: the copper intra-uterine device (IUD) is a more effective post-coital treatment and can be fitted up to five days after unprotected sexual intercourse (or up to 5 days after the earliest calculated ovulation). Risk of sexually transmitted disease should be explored and appropriate screening carried out at the time of fitting. Prophylactic azithromycin should be considered in appropriate circumstances. The device can be removed with the first normal menstruation or, if appropriate, retained for long-term use. The progestogen-releasing intra-uterine system ’Mirena’ is not suitable for this indication.

  • Emergency Hormonal Contraception (EHC) can be obtained from community pharmacies and some pharmacies offer free supply to selected patient groups through PCT commissioned Emergency Hormonal Contraception schemes.

  • Use of EHC after 120 hours is unlicensed. Supply under a PGD should be within the licensed indications.
Link   FSRH Guidance: Emergency Contraception
Link   FSRH Statement: Quick starting hormonal contraception after EllaOne September 2015
Link   MHRA Advice: Levonorgestrel and ulipristal remain suitable emergency contraceptives for all women, regardless of body weight or body mass index
First Choice:
Levonorgestrel 1500 micrograms  (Levonelle® 1500)
Levonelle 1500® is available for supply on prescription.
Levonelle One Step can be sold to women over 16 years.
Restricted Drug  Ulipristal Acetate  (ellaOne®)
For use after 72 hours (3 days) to 120 hours (5 days) of unprotected sexual intercourse or contraceptive failure only.
Use before 72 hours for patients at high risk of pregnancy restricted to Mr Oloto for trial period.
After taking ulipristal for emergency contraception a woman should not start a hormonal contraceptive method for at least 5 days and be advised to use barrier methods or to abstain from sex until effective hormonal contraceptive cover has been achieved. See FSRH statement below for further detail.

07.04 Drugs for genito-urinary disorders
07.04.01 Drugs for urinary retention
Link   Leicestershire Guidance: Male Lower Urinary Tract Symptoms - Prescribing Pathway
Link   NICE CG 97: Lower urinary tract symptoms in men
Tamsulosin Hydrochloride  
Restricted Drug  Vesomni® (Tamsulosin+solifenacin) 
In line with pathway
07.04.02 Drugs for urinary frequency, enuresis, and incontinence

  • Objective assessment of urinary frequency using a frequency & volume chart must be obtained before starting drug therapy. Exclude metabolic disorders (such as diabetes) and bladder obstruction. Simple bladder training will be sufficient for many patients with urinary frequency. Self-help booklets are available to help patients understand the importance of fluid and caffeine intake in urinary frequency. These will reinforce advice given in the outpatient environment and reduce needless use of medication.

  • In general evidence for the efficacy of drugs in relieving symptoms of incontinence is limited. Drugs that are used for urinary incontinence have an anticholinergic effect increasing bladder capacity and reducing unstable detrusor contractions. They are therefore inappropriate for overflow incontinence.

  • If problems persist despite drug therapy referral for urodynamic assessment should be considered. Patients with overflow incontinence should be referred to an urologist for further assessment and treatment.

  • Cumulative anticholinergic medication use  has been shown to be associated with an increased risk for dementia. The long-term impact of prescribing these drugs should be considered when initiating them as the untoward effects may not be reversed by withdrawing them later down the line.
Link   Leicestershire Guidance: Overactive Bladder Prescribing Pathway
Link   NICE CG 171: Urinary incontinence in women
07.04.02 Urinary incontinence
First Choice:
Oxybutynin Hydrochloride 
Has a smooth muscle relaxant activity in addition to its anticholinergic action. Usefulness is often limited by side effects. Do not offer oxybutynin IR to frail, elderly patients
First Choice:
Tolterodine IR  
Second Choice:
Trospium Chloride 20mg 
Has fewer drug interactions and less cognitive side effects so may be more suitable for elderly patients. Currently Flotros brand has a lower cost in primary care than other preparations.
Second Choice:
Tolterodine Tartrate XL 
Reserve for patients who cannot tolerate the side effects of oxybutynin. Option if once daily dosage is essential for compliance
Second Choice:
Oxybutynin Hydrochloride XL 
Second Choice:
Solifenacin Succinate 
May be preferable where urgency is a major symptom or where the option of variable dosing is an advantage.
Duloxetine 
Stress incontinence

Also green for use in diabetic neuropathy in line with Leicestershire neuropathic pain guidance
Restricted Drug  Oxybutynin Patch  (Kentera®)
For use only in patients who cannot take oral medication
Restricted Drug  Mirabegron  
Use in overactive bladder in line with NICE TA 270 only for patients who have been fully assessed and have failed to benefit from anticholinergics, or are intolerant of them.

Date of entry of decision to Formulary: July 2013
07.04.05 Drugs for erectile dysfunction

  • Men presenting to hospital clinics with erectile dysfunction (ED) will be seen by specialists, who will be the only people with authority to prescribe drugs for erectile dysfunction within UHL. Those presenting to their GP with ED may receive a prescription from their GP.

  • NHS Prescribing of drugs and appliances (vacuum pumps and constrictor rings) is limited to specific groups of patients.

  • See below for links to a summary of eligibility criteria and related Health Service Circulars.

  • If prescribed on an FP10 the prescription must be endorsed ‘SLS’

  • For patients who fall outside the above criteria, private prescriptions may be written, however the prescriber should not charge a fee for issuing such a prescription.

  • The recommendation for drug treatment is that one treatment per week should be adequate.

  • At UHL all treatment options are discussed with the patient who will be referred for further counselling as appropriate according to treatment choice.  If this is an appliance their GP will be advised on which product to prescribe.
Link   Further Information: Eligibility for Prescribing on the NHS
Restricted Drug  Sildenafil  (Viagra®)
Sildenafil generic is first line choice due to lower cost. Prescribing of branded product on NHS limited to specific patient groups only however this no longer applies to the generic product - see link below to Amendment to Regulations. SLS endorsement is not required
In UHL prescribing limited to specialist urology and diabetes erectile dysfunction clinics.
Restricted Drug  Vardenafil  (Levitra®)
Prescribing on NHS limited to specific patient groups only
In UHL prescribing limited to specialist urology and diabetes erectile dysfunction clinics.
Second line choice after sildenafil where these products appropriate to use.
Restricted Drug  Tadalafil  
For Erectile Dysfunction for patients who have not responded to sildenafil or to vardenafil (Green on traffic lights for this indication).
NHS limitations on groups and frequency of prescribing apply. Once daily dosage is not approved for this indication.

Following radical prostatectomy specialist use only by Andrology service. Scripts for this indication will be annotated as ’Andrology’ by the prescriber.(Classified Red on traffic light list).
07.04.05 Alprostadil

Alprostadil (Caverject* and MUSE) are available for intercavernosal injection or intra-urethral application.
Patient eligibility criteria also apply. Restricted at UHL for use by specialists.

Link   Leicestershire Evaluation: Alprostadil (Vitaros®) in Erectile Dysfunction
07.04.06 Drugs for premature ejaculation
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