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                                    SECTION 7

                                    Drugs Used in Obstetrics, Gynaecology and
                                    Urinary-Tract Disorders

                                7.2 TREATMENT OF VAGINAL AND VULVAL
                                CONDITIONS

                                7.2.1 Topical Hormones

                                    Estriol cream (Ortho-gynest/Ovestin)
                                    Estriol pessaries
                                    Oestrogens conjugated cream (Premarin)
                                    Oestradiol vaginal tablets (Vagifem)

                                    NOTE
                                    Vagifem tablets should be reserved for women who
                                    find a cream preparation unacceptable, as it is an
                                    expensive product.

                                7.2.2 Vaginal and vulval infections

                                    a) Preparations for vaginal and vulval
                                    candidiasis
                                    Clotrimazole
                                    Nystatin

                                    NOTE
                                    Clotrimazole is the preferred topical preparation for
                                    vaginal candidiasis.

                                    b) Preparations for other vaginal infections
                                    Clindamycin vaginal cream
                                    Povidone-iodine pessaries




                                7.3 CONTRACEPTIVES

                                7.3.1 Combined oral contraceptives

                                                    Ethinylestradiol
                                    Brand                            Progestogen          Dose
                                                    dose
                                    Loestrin 20               norethisterone 1mg
                                    Mercilon    20 micrograms desogestrel    0.15mg
                                    Femodette                 gestodene      0.075mg
                                    Eugynon
                                    30
                                    Microgynon 30 micrograms levonorgestrel 0.25mg
   30                              levonorgestrel   0.15mg
   Loestrin 30                     norethisterone   1.5mg
   Femodene                        gestodene        0.075mg
   Marvelon                        desogestrel      0.15mg



  Brevinor                 norethisterone 0.5mg
  Cilest     35 micrograms norgestimate 0.25mg
  Dianette                 cyproterone    2mg
  Microgynon = Ovranette
  Eugynon 30 = Ovran 30
  Femodene = Minulet

  Yasmin & Evra have been approved for use by family
  planning only. GPs are advised to refer any patients with
  complex problems likely to need Yasmin or Evra to the Family
  Planning service.

  High Dose Preparations

  There are no longer any high dose preparations
  available.

  Click here for a link to advice for patients taking
  phenytoin or carbamazepine.

  Phasic Preparations (see note 4)

  Trinordiol
  Logynon (ED)

  NOTES

1. Combined oral contraceptives (COCs) containing both
   oestrogen and progestogen are the most 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.
   Preparations containing the older progestogens
   levonorgestrel and norethisterone are to be
   preferred.

   Family planning recommend Ovranette first line,
   unless acne is a problem, when Brevinor is
   recommended first line.
2. Venous disease - There is an increased risk of
   venous thromboembolism (VTE) in users of oral
   contraceptives but this risk is considerably smaller
   than that associated with pregnancy (60 cases per
   100,000 pregnancies). For users of second generation
   COCs (those containing levonorgestrel) the incidence
   of VTE is about 15 per 100,000 women per year of
   use. For users of COCs containing desogestrel or
   gestodene the risk of VTE is about 25 per 100,000
   women per year of use. However, the absolute risk of
  VTE in women who are taking third generation COCs
  is very small. After stopping the pill, the risk of VTE
  returns to normal by three months.

   Provided that women are fully informed of, and
   accept, these very small risks and do not have
   medical contraindications, it should be a matter of
   clinical judgement and personal choice which type of
   oral contraceptive should be prescribed.
3. Arterial disease - Arterial disease is rarer but much
   more serious. It is related to age and the risk is
   strongly influenced by smoking. Myocardial infarction
   (MI) is increased by a factor of between three and
   five times compared with non-users. The increased
   risk is primarily concentrated in older women (>35)
   and is increased ten times among smokers.
   Diabetes has not been shown to increase the risk of
   thromboembolism.
4. Phased preparations are available but they are
   more complicated to use and generally more
   expensive. They may help to improve cycle control
   with a lower dose increase in some women, where
   this is inadequate with a recommended (monophasic)
   preparation above.

  Emergency Contraception

  Levonorgestrel (Levonelle 1500) tablet

  NOTE
  Click here for the Full Guidance on Emergency
  Contraception from the Faculty of Family Planning &
  Reproductive Healthcare.

  Women using liver enzyme-inducing drugs should be
  advised that an IUD is the preferred option for
  Emergency Contraception (Grade A).

  Women who are using liver enzyme-inducing drugs
  who are given 1.5 mg tablets of LNG (Levonelle One
  Step or Levonelle 1500) should be advised to take a
  total of 3 mg (two tablets) as a single dose, as soon
  as possible and within the 72 hours of UPSI.
  This use is outside the product licence (Good Practice
  Point).




7.3.2 Progestogen-only contraceptives

7.3.2.1 Oral Progestogen-only contraceptives

  Desogestrel (Cerazette)
  Ethyndiol (Femulen)
  Levonorgestrel (Norgeston)
  Norethisterone (Noriday)
7.3.2.2 Parenteral Progestogen-only contraceptives

     Medroxyprogesterone (Depo Provera)

     Significant long term side-effects of Depo-Provera
     (DMPA) include:

   Weight gain - many women will gain up to six pounds
1.
   during the first year.
   A delay in the resumption of fertility of up to one year
2.
   after cessation of use.
3. A possible reduction in bone mineral density. It is
   almost certainly not sufficient to cause an increased
   risk of fracture in pre-menopausal women. It may be
   sensible however to discontinue at the age of 45 to
   allow for recovery of bone mineral density before
   post-menopausal bone loss ensues.

     IMPLANTS
     Etonogestrel (Implanon)

     Implanon is a single rod implant which is inserted
     subdermally and is effective for up to 3 years.

     In overweight women, the implant may not provide
     effective contraception during the third year and
     earlier replacement should be considered in such
     patients.

     The doctor or nurse administering (or removing) the
     system should be fully trained in the technique and
     should provide full counselling backed by the
     manufacturer's approved leaflet.

7.3.2.3 Intrauterine Progestogen-only device

     Levonorgestrol (Mirena)

     Efficacy of contraceptive methods
                   Method failure rate    User-failure rate
                    Rate/100 woman       Rate/100 woman
                          year                 years
     COC                  0.1                   2-8
     POP                   3                    10
     DMPA                 0.4                   0.4
     Mirena               0.2                   0.2
     Spermicides          4-28                 4-28

It has been estimated that Levonelle prevents 85% of
expected pregnancies. Efficacy appears to decline with
time after intercourse (95% within 24 hours, 85% 24-48
hours, 58% if used between 48 and 72 hours).
The method failure rate (reflecting perfect use-measured
during clinical trials) is compared with user failure rates
reflecting rates among average users who sometimes
forget to use the method or make mistakes.

7.4 DRUGS FOR GENITO-URINARY DISORDERS

7.4.1 Drugs for Urinary Retention

  Alfuzosin (1st line)
  Tamsulosin (2nd line) prescribe generically
  Indoramin
  Prazosin
  Distigmine Bromide


7.4.2 Drugs for Urinary Frequency, Enuresis and
Incontinence

  Oxybutynin (1st line) Standard release NOT XL
  Tolterodine (2nd line) Standard release NOT XL
  Trospium (3rd line)
  Duloxetine Urology or Gynaecology Consultant
  initiation only for moderate to severe stress
  incontinence

  NOTES:

1. Objective assessment of urinary frequency by
   frequency volume chart should be obtained before
   starting drug therapy. Metabolic disorders, such as
   diabetes or bladder obstruction should be excluded.
2. Simple bladder training will be sufficient for many
   patients with urinary frequency. There are self-help
   booklets which will help many patients understand the
   importance of fluid intake and caffeine intake in
   frequency which may avoid needless medication.
3. In addition to anticholinergic effects oxybutynin may
   cause abdominal discomfort, facial flushing,
   headache, dizziness, drowsiness, arrhythmia,
   diarrhoea.

7.4.3 Drugs used in urological pain

  Potassium Citrate effervescent tablets
  (Effercitrate)
  Sodium Bicarbonate powder

  NOTE
  One Effercitrate tablet is equivalent to 5ml of the
  traditional mixture Potassium Citrate. It should be
  noted that each tablet contains 13.9mmol K+.

7.4.4 Bladder instillations and urological surgery

  Sodium Chloride 0.9% (Uriflex S)
  Solution G - Citric Acid 3.23% (Uriflex G)
  Solution R - Citric Acid 6.0% (Uriflex R)

   NOTES
1. Prophylactic use
   The prophylactic use of topical antiseptics e.g.
   chlorhexidine, to prevent bacteriuria is of doubtful
   value in preventing infection of the urinary tract;
   infection with resistant organisms has been reported.
   Therefore prophylactic bladder irrigations are not
   recommended.
2. Therapeutic use
   For established bladder infection in catheterised
   patients appropriate systemic therapy may be
   necessary if the patient shows systemic signs of
   infection such as raised temperature.
   Sodium chloride 0.9% washouts may be helpful as an
   adjunct. Chlorhexidine 1 in 5000 solution (0.02%) is
   not recommended as it may irritate the mucosa and
   cause burning and haematuria.
   For established encrustation Solution G (citric acid
   3.2% with other ingredients) should be used daily. If
   necessary this can be changed to Solution R which is
   a more concentrated citrate solution (contains citric
   acid 6%).
3. Smaller volumes (e.g. 30-50ml) of bladder
   instillations are being used more frequently
   nowadays.
   Contact point: Continence adviser 01332 267
4.
   976

7.4.5 Drugs for impotence

  Sildenafil
  Tadalafil
  Alprostadil injection
  Sublingual apomorphine (Uprima)
  Papaverine injection
  Phentolamine injection

  NOTE
  The recommended quantity to prescribe one tablet a
  week for most patients, as excessive prescribing
  could lead to unlicensed, unauthorised and possible
  dangerous use of these treatments (HSC 1999/148).
  Please prescribe sensible quantities as these drugs
  are abused and have a high street value.

  Alprostadil, sildenafil, tadalafil and sublingual
  apomorphine are the only listed preparations licensed
  for the treatment of erectile dysfunction. Uprima
  should be used in patients in whom treatment with
  sildenafil has not been successful. It is available on
  the NHS for the same categories of patients who may
  receive sildenafil.
   Revised by the Prescribing
Advisory Group February 2005

								
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