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 Formulary Chapter 7: Obstetrics, gynaecology, and urinary-tract disorders - Full Chapter
Notes:

Coronavirus guidance

Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.

The list of resources will be updated as new material becomes available so please check back regularly for updates.

The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.

Obstetrics, gynaecology, and urinary-tract disorders

Review date: Sept 2022

Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Medications which are indicated for medically assisted reproduction, including ovulation induction (e.g. clomifene, letrozole and tamoxifen) and assisted reproduction, such as In Vitro Fertilisation or Ex Vitro Fertilisation (e.g. gonadotrophins) are restricted to use by specialist secondary care physicians, and are categorised as RED drugs for these purposes.

Chapter Links...
 Details...
07.03  Expand sub section  Contraceptives
07.03.01  Expand sub section  Combined hormonal contraceptives
 note 

 

Green 


Products in this section are generally similar in terms of efficacy, safety and cost. In the light of this the main considerations in selecting a product are the prescribing clinicians’ view of suitability based on individual patient factors, and the patient’s own views. Refer to BNF for products available

Exceptions are listed below:

 Paediatrics: all combined hormonal contraceptives are Green  post menarche

 

Combined oral contraceptives should be prescribed by brand to promote patient familiarity and compliance

Estradiol & dienogest
View adult BNF View SPC online View childrens BNF
Formulary tablets estradiol 1mg, 2 mg,3 mg,4 mg, dienogest 2 mg and 3 mg
Qlaira®
standard strength
GREENFor heavy menstrual bleeding


BLACKFor oral contraception

 
   
Estradiol & nomegestrol
View adult BNF View SPC online View childrens BNF
Formulary
Black
Tablets estradiol 1.5mg, nomegestrol acetate 2.5mg.
Zoely®
 
   
07.03.01  Expand sub section  Emergency contraception
07.03.02  Expand sub section  Progestogen-only contraceptives
07.03.02.01  Expand sub section  Oral progestogen-only contraceptives to top
 note 

Traditional progestogen-only contraceptives (norethisterone) work by altering cervical mucus to prevent sperm penetration and for some women ovulation is also inhibited. The primary mode of action of the desogestrel-only pill is inhibition of ovulation. There is no data to suggest that some POPs are better at preventing pregnancy than others.

Paediatrics: all oral progestogen-only contraceptives are Green  post menarche

Desogestrel
View adult BNF View SPC online View childrens BNF
Formulary
Green
Tablets 75 micrograms
Cerazette®, Cerelle®, Zelleta®
 
   
Levonorgestrel
View adult BNF View SPC online View childrens BNF
Formulary
Green
Tablets 30 micrograms
Norgeston ®
 
   
Norethisterone
View adult BNF View SPC online View childrens BNF
Formulary
Green
Tablets 350 micrograms
Micronor ®, Noriday ®
 
   
07.03.02.02  Expand sub section  Parenteral progestogen-only contraceptives
Etonogestrel
View adult BNF View SPC online View childrens BNF
Formulary
Green

Implant containing 68 mg (Nexplanon ® )

Green  Paediatrics: post menarche

 
   
Medroxyprogesterone Acetate
View adult BNF View SPC online View childrens BNF
Formulary
Green

Injection 150 mg/1mL for intramuscular injection (Depo-Provera®)

Injection 104 mg/0.65mL for subcutaneous injection (Sayana Press®)

Prescribers must clearly specify the route of administration to avoid confusion.

Amber Initiated  Paediatrics under 16 years of age

 
   
07.03.02.03  Expand sub section  Intra-uterine progestogen-only contraceptive
 note 

Special training required for fitting intra-uterine system.

Levonorgestrel
View adult BNF View SPC online View childrens BNF
Formulary
Green

Intra-uterine delivery system

Prescribe by brand name as products are not interchangeable:

20 micrograms/24 hours (Mirena®)- 5 year duration of action

20 micrograms/24 hours (Levosert®)- 3 year duration of action

6 micrograms/24 hours (Jaydess®) - 3 year duration of action

9 micrograms/24 hours (Kyleena®) - 5 year duration of action 

Green Paediatrics: if sexually active Red  Paediatrics: if NOT sexually active

 
Link  MHRA Drug Safety Update, Levonorgestrel-releasing intrauterine systems: prescribe by brand name
   
07.03.03  Expand sub section  Spermicidal contraceptives
Nonoxinol 9
View adult BNF View SPC online View childrens BNF
Formulary
Green

Gel 2%.

Green  Paediatrics: if sexually active

 
   
07.03.04  Expand sub section  Contraceptive devices
07.03.04  Expand sub section  Intra-uterine devices to top
 note  The most effective IUD have at least 380mm2 of copper and have banded copper on the arms. Smaller devices have been introduced to minimise side effects. All devices are available, choice will depend on individual patient factors.
07.03.05  Expand sub section  Emergency Contraception
 note 

All eligible women presenting between 0-120 hours following UPSI or within 5 days of expected ovulation should be offered a copper IUD because of the low documented failure rate.

Ulipristal is a drug treatment option for post coital contraception for women who present between 72 and 120 hours following unprotected intercourse or contraceptive failure.

Copper IUD
View adult BNF View SPC online View childrens BNF
Formulary
Green

See section 7.3.4

Green  Paediatrics: if sexually active

 
   
07.03.05  Expand sub section  Hormonal methods
Levonorgestrel
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 1.5 mg Upostelle

Green  Paediatrics: post menarche

 
   
Ulipristal Acetate
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 30 mg

Green  Paediatrics: post menarche

 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection.  Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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