| Formulary Chapter 7: Obstetrics, Gynaecology, and urinary-tract disorders - Full Chapter
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| Chapter Links... |
 FSRH Clinical Guideline: Contraceptive Choices for Young People |
| FSRH: Standards & Guidance |
| FSRH: UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) |
 LSCMMG: Primary Care Management of Erectile Dysfunction |
| LSCMMG: Primary Care Management of Overactive Bladder in Female Adults |
| MHRA: Medicines with teratogenic potential: what is effective contraception and how often is pregnancy testing needed? |
| NICE CG30: Long-acting reversible contraception |
| NICE CG97: Lower urinary tract symptoms in men: management |
| NICE NG123: Urinary incontinence and pelvic organ prolapse in women: management |
| NICE NG133: Hypertension in pregnancy: diagnosis and management |
| NICE NG194: Postnatal care |
| NICE NG210: Pelvic floor dysfunction: prevention and non-surgical management |
| NICE NG3: Diabetes in pregnancy: management from preconception to the postnatal period |
| NICE NG88: Heavy menstrual bleeding: assessment and management |
| Details... |
| 07.02 |
Treatment of vaginal and vulval conditions |
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Vaginal dilators (Amielle Comfort)
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Formulary
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Sexual pain-penetration disorder (SPPD) in combination with pychosexual therapy.
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Ospemifene
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Formulary
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Vulvovaginal or vaginal atrophy in postmenopausal women.
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LSCMMG: Ospemifene
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| 07.02.01 |
Preparations for vaginal and vulval changes |
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| 07.02.01 |
Topical HRT |
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Transdermal oestrogens are absorbed and should be used in the smallest effective amount and if required long term should be combined with an oral progestogen in women with an intact uterus. For low-dose vaginal oestrogen, a progesterone is not needed for endometrial protection, as systemic absorption of vaginal oestrogen is minimal. |
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Estradiol vaginal 10 microgram tablet
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Formulary
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Vaginal tablets 10microgram
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MHRA: Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping
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Estriol cream
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Formulary
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0.1% vaginal cream, 0.01% vaginal cream
Currently estriol vaginal cream can be prescribed in two forms:
· Estriol 0.1% (Ovestin®) cream which contains 0.5mg estriol per 0.5g application
· Estriol 0.01% (formerly Ortho-Gynest®) cream which contains 0.5mg estriol per 5ml application
Despite Ovestin® 0.1% cream being 10 times stronger, the amount of cream delivered per application is 10 times less than that of Estriol 0.01% cream, meaning that both creams deliver an identical amount of estriol per application, that being 0.5mg.
Contains nuts - contraindicated in patients with hypersensitivity to nuts
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Estriol gel 50mcg/g
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Formulary
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2nd line agent - only to be considered in women who are unable to use estriol pessaries.
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Estriol pessaries
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Formulary
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0.03mg pessaries, 0.5mg pessaries
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Oestrogens, Topical (Estring®)
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Formulary
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Only used in patients who can't use gel or patches.
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Prasterone
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Formulary
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Vulvovaginal or vaginal atrophy in postmenopausal women having moderate to severe symptoms.
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LSCMMG: Prasterone
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| 07.02.01 |
Non-hormonal preparations |
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| 07.02.02 |
Vaginal and vulval infections |
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| 07.02.02 |
Fungal infections |
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Clotrimazole
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Formulary
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Pessary 500mg
Vaginal cream 10%
Cream 1%
Consider OTC purchase for some conditions.
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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| 07.02.02 |
Other vaginal infections |
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Clindamycin (Dalacin®)
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Formulary
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Vaginal cream 2%
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Traffic Light Status Information
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Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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