GGC Medicines: Menopause information and prescribing resources

Menopause information and prescribing resources

Key messages

Refer to available guidance for information on how to alleviate symptoms of the menopause (see links in further information below)
Refer to the NHSGGC Adult Medicines Formulary for preferred hormone replacement therapy (HRT) options
If ‘off-label’ testosterone is being considered for low sexual desire (when HRT alone is not effective), refer to NICE and British Menopause Society (BMS) guidance and the NHSGGC Unlicensed Medicines Policy

Background

Menopause refers to the last menstrual period, and can be confirmed after 12 months of amenorrhoea. Loss of ovarian function before 40 years of age is called premature ovarian insufficiency. Unlike the normal menopause, this can be reversible.

Menopause can cause symptoms such as:

Hot flushes and night sweats (vasomotor)
Cognitive impairment and mood disorder
Urogenital symptoms and altered sexual function
Sleep disturbance, muscle pain, and others

Evidence-based information about lifestyle measures to reduce symptoms includes regular exercise, weight loss, sleep hygiene practices, relaxation exercises, alcohol intake reduction, and dietary changes.

Hormone replacement therapy (HRT)

The aim of HRT is to replace the falling estradiol levels and relieve symptoms, especially vasomotor. Those with an intact uterus also need added progestogen to prevent endometrial hyperplasia secondary to estradiol therapy. Unopposed oestrogen should not be given to a patient with an intact uterus or without a Mirena® coil in situ. Refer to Patient Safety: Unopposed Oestrogen Prescribing for more information.

Combination (oral and transdermal) preparations are available along with standalone oestrogen. Transdermal preparations typically carry a lower risk of adverse drug reactions. Urogenital symptoms can be addressed with low-dose vaginal oestrogen along with moisturisers and lubricants as necessary.

HRT treatment options
Available treatment options are provided in the BMS Tools for Clinicians page, however, reference should be made to the NHSGGC Adult Medicines Formulary for preferred options.

Examples

Estradiol tablets – e.g. Elleste Solo® preparations
Estradiol patches – e.g. Evorel® preparations
Estradiol gels – Pump formulations e.g. Oestrogel® (restricted to patients who fail to tolerate oral or patch preparations)
Combination (oestrogen and progestogen) preparations – e.g. Elleste Duet® tablets or Evorel® Sequi®/Conti® patches

Stock shortages may factor into decisions made about brand and formulation choices along with patient-specific factors and preferences.

Testosterone
Testosterone is usually considered when there is persistent low libido after maximising oestrogen component of HRT and other psychological/lifestyle factors have been considered. Refer to BMS guidance. Testosterone can be used alongside oestrogen and progesterone HRT.

Testosterone is included in the NHSGGC Adult Medicines Formulary restricted to specialist initiation for the licensed indication of male hypogonadism. As testosterone for HRT is 'off-label’ it is out-with the remit of the Formulary. If being considered, prescribers should refer to NHSGGC Unlicensed Medicines Policy and Off-label or unlicensed use of medicines for further information on prescribing ‘off label’ medicines.

There are a number of topical testosterone preparations available. For example, Tostran® 2% gel is available in a pump formulation that allows accurate dosing and therefore is a practical option. BMS recommend a starting dose of one metered pump of 0.5g Tostran® (10mg testosterone) on alternate days. Patients should be advised to apply the dose to the abdomen, or to both inner thighs. Daily rotation between the abdomen and inner thighs is recommended to minimise application site reactions. Other testosterone topical formulations are available as tubes and sachets and therefore a part dose is less easy to administer accurately.

Further information and advice

The Sandyford Professional Menopause email can be helpful for complex situations ggc.menopausesupport@nhs.scot.

Published: 31/10/2022. Medicines Update blogs are correct at the time of publishing.