Approved: 4 Oct 2017. Last amended: 6 Mar 2020.

7.1 Drugs used in obstetrics

7.1.1 Prostaglandins, Oxytocics and Mifepristone: termination of pregnancy

7.1.1.1 Termination of pregnancy

  • Misoprostol

    (unlicensed use)

  • Mifepristone
  • 7.1.1.2 Induction and augmentation of labour

  • Dinoprostone

    Vaginal tablet 3mg

  • Dinoprostone

    (Propess®) pessary 10mg

  • Oxytocin
  • 7.1.1.3 Third stage of labour

  • Ergometrine
  • Oxytocin
  • Syntometrine®

    Intramuscular (oxytocin with ergometrine)

  • Carboprost
  • Misoprostol

    (unlicensed use)

  • 7.1.1.4 Ductus arteriosus

    Specialist advice should be sought

    7.1.2 Myometrial relaxants

    Recommended

  • Nifedipine

    (unlicensed use)

  • Alternative

  • Atosiban
  • Terbutaline

    (subcutaneous)

  • 7.2 Treatment of vaginal and vulval conditions

    7.2.1 Preparations for vaginal and vulval changes

    For non-vaginal HRT preparations refer to Section 6.4.1

  • Gynest®

    0.01% cream (estriol)

  • Ovestin®

    0.1% cream (estriol)

  • Vagifem®

    10mcg vaginal tablets (estradiol)

  • 7.2.2 Vaginal and vulval infections: fungal infections

    Treatment of vaginal infection with oral fluconazole 150mg (as a single dose) is also effective

    Recommended

  • Clotrimazole

    Pessary 500mg

  • Clotrimazole

    Cream 1%

  • Specific Indication

  • Nystatin

    Vaginal cream 100,000 units/g (unlicensed) – 'azole' resistant candidiasis

  • Nystatin

    Pessaries 100,000 units (unlicensed) – 'azole' resistant candidiasis

  • 7.2.3 Vaginal and vulval infections: other infections

  • Balance Activ Rx®

    Vaginal gel (lactic acid 4.9%, glycogen 0.1%)

  • Dalacin® 2%

    Vaginal cream (clindamycin)

  • Zidoval® 0.75%

    Vaginal gel (metronidazole)

  • 7.2.4 Non-infectious vulval/vaginal conditions: Lichen sclerosus / Lichen planus / Eczema / Psoriasis

    7.2.4.1 Emollients (see section 13.2)

  • ZeroAQS®

    Cream

  • Epaderm®

    Cream / ointment

  • 7.2.4.2 Topical Corticosteroids: (see section 13.4)

  • Eumovate®

    Cream / ointment

  • 7.2.4.3 Topical Steroids with antimicrobials

  • Trimovate®

    Cream

  • Lotriderm®

    Cream

  • 7.2.5 Non-infectious vulval/vaginal conditions: Vulvodynia / vestibulitis / chronic pelvic pain

  • Amitriptyline
  • Gabapentin
  • Lidocaine

    Injection

  • Depo-Medrone®
  • 7.2.6 Cervical and uterine disorders

    Specific Indication

  • Solcogyn®

    (unlicensed) – Cervical ectropion. Specialist use only

  • 7.3 Contraceptives

    Women requiring contraception should be given information about and offered a choice of all methods, including long-acting reversible contraception (LARC) methods.

    Contraceptive service providers should be aware that:

    • all currently available LARC methods (intrauterine devices, the intrauterine system, injectable contraceptives and implants ) are more cost effective than the combined oral contraceptive pill even at 1 year of use
    • intrauterine devices, the intrauterine system and implants are more cost effective than the injectable contraceptives
    • increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies.

    7.3.1 Combined hormonal contraceptives: Oral

    7.3.1.1 20mcg (low strength)

    Recommended

  • Gedarel 20/150®

    (ethinylestradiol 20 mcg / desogestrel 150 mcg)

  • Alternative

  • Millinette 20/75®

    (ethinylestradiol 20 mcg / gestodene 75 mcg)

  • Loestrin 20®

    (ethinylestradiol 20 mcg / norethisterone acetate 1 mg) – Consultant use only

  • 7.3.1.2 30mcg (standard strength)

    Recommended

  • Levest®

    (ethinylestradiol 30 mcg / levonorgestrel 150 mcg)

  • Alternative

  • Gedarel 30/150®

    (ethinylestradiol 30 mcg / desogestrel 150 mcg)

  • Millinette 30/75®

    (ethinylestradiol 30 mcg / gestodene 75 mcg)

  • Loestrin 30®

    (ethinylestradiol 30 mcg / norethisterone acetate 1.5 mg)

  • Specific Indication

  • Microgynon 30 ED®

    (ethinylestradiol 30 mcg / levonorgestrel 150 mcg) – Only where compliance is a problem with a 7-day tablet-free interval.

  • Dretine®

    (Ethinylestradiol 30 mcg/ drospirenone 3mg) – acne / side-effects with progestogenic pills

  • 7.3.1.3 35mcg (higher strength)

    Recommended

  • Lizinna®

    (ethinylestradiol 35mcg / norgestimate 250 mcg)

  • Alternative

  • Brevinor®

    (ethinylestradiol 35mcg / norethisterone 500 mcg)

  • Norimin®

    (ethinylestradiol 35mcg / norethisterone 1mg)

  • Specific Indication

  • Co-cyprindiol

    (ethinylestradiol 35 mcg / cyproterone acetate 2mg) – acne / hirsuitism. Change to Acondro® or Gedarel® 30/150 once acne / hirsutism controlled.

  • 7.3.1.4 Transdermal

    Recommended

  • Evra®

    (ethinylestradiol 33.9 mcg / norelgestromin 203 mcg per 24 hours)

  • 7.3.1.5 Vaginal

    Recommended

  • NuvaRing®

    (ethinylestradiol 15 mcg / etonorgestrel 120 mcg per 24 hours)

  • 7.3.2 Progestogen-only contraceptives: Oral progestogen-only contraceptives

    Recommended

  • Cerelle®

    (desogestrel 75mcg)

  • Alternative

  • Micronor®

    (norethisterone 350mcg)

  • Norgeston®

    (levonorgestrel 30mcg)

  • 7.3.3 Parenteral progestogen-only contraceptives: Injectable

    Recommended

  • Depo-Provera®

    (medroxyprogesterone acetate 150mg/ml) intramuscular injection

  • Alternative

  • Sayana Press®

    (medroxyprogesterone acetate 104mg/0.65ml [160mg/ml]) subcutaneous injection – for patients who have been adequately trained to self-inject and with good compliance.

  • 7.3.4 Parenteral progestogen-only contraceptives: Implant

    Recommended

  • Nexplanon®

    (etonogestrel 68mcg)

  • 7.3.5 Intra-uterine progestogen-only device

    Recommended

  • Mirena®

    (levonorgestrel 52 mcg)

    • Idiopathic menorrhagia. Effective for 5 years
    • Protection from endometrial hyperplasia during oestrogen replacement therapy. Evidence of effectiveness for 4 years

  • Kyleena®

    (levonorgestrel 19.5mcg)

    • Contraception for up to 5 years
  • 7.3.6 Spermicidal contraceptives

  • Gygel®

    (nonoxinol ‘9’ 2%)

  • 7.3.7 Contraceptive devices

    Not listed in Formulary – see BNF

    7.3.8 Emergency contraception

    Recommended

  • Upostelle®

    (levonorgestrel 1.5 mg)

  • Specific Indication

  • EllaOne®

    (ulipristal 30mg) – for patients presenting 72-120 hours after unprotected sexual intercourse

  • 7.3.9 Controlling unscheduled vaginal bleeding with progestogen-only contraception

    Once fully investigated for other causes of unscheduled bleeding with progestogen-only contraception (Mirena or Nexplanon) the following can be used:

  • Norethisterone

    5mg to 15mg a day for 3 weeks

  • Combined oral contraceptives

    (if no contra indications) either cyclically or continuously

  • 7.4 Drugs for genito-urinary disorders

    7.4.1 Drugs for urinary retention

    Benign Prostatic Hyperplasia (BPH) is treated either surgically or medically with alpha-blockers or with the anti-androgens (e.g. finasteride): section 6.4.2

    Recommended

  • Tamsulosin MR

    (capsules)

  • Alternative

  • Doxazosin

    (standard release)

  • 7.4.2 Drugs for urinary frequency, enuresis, and incontinence

    Urinary Incontinence – NICE guidelines

    7.4.2.1 First-line:

  • Tolterodine

    1mg, 2mg

  • 7.4.2.2 Second-line:

  • Trospium

    20mg

  • Solifenacin

    5mg, 10mg

    First-line where once daily dosing will improve compliance significantly (e.g. patients with once daily carers)

  • 7.4.2.3 Third-line:

    Specific Indication

  • Mirabegron

    Third line for patients who have been unable to tolerate at least 2 antimuscarinic drugs. NICE TA290

  • Oxybutynin transdermal patch

    (Kentera®) – patients with long-term swallowing difficulty

  • 7.4.3 Drugs used in urological pain

    Ureteric colic may be relieved with pethidine (section 4.7.2) or NSAIDs (section 10.1.1).

    Alkalinisation of urine

  • Potassium citrate
  • Sodium bicarbonate
  • Specific Indication

  • Pentosan polysulfate sodium

    Bladder pain syndrome, as per NICE TA601

  • 7.4.4 Bladder instillations and urological surgery

    Recommended

  • Sodium Chloride 0.9%
  • Glycine 1.5%

    (Irrigation Solution)

  • Cystistat®

    (sodium hyaluronate)

  • Gepan® Instill

    (chondroitin sulphate 0.2%)

  • Specific Indication

  • iAluRil®

    (sodium hyaluronate 1.6%, sodium chondroitin sulphate 2%) – where recommended options are ineffective

  • 7.5 Drugs for erectile dysfunction

    7.5.1 Drugs for erectile dysfunction

    Drug treatments (other than generically available phosphodiesterase type-5 inhibitor sildenafil) for erectile dysfunction may not be prescribed on the NHS except in men who:

    • have diabetes, multiple sclerosis, Parkinson's disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, or spinal cord injury;
    • are receiving dialysis for renal failure;
    • have had radical pelvic surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant;
    • were receiving Caverject®, Cialis®, Erecnos®, MUSE®, Uprima®, Viagra®, or Viridal® for erectile dysfunction, at the expense of the NHS, on 14 September 1998;

    The prescription must be endorsed ‘SLS’.

    As stated within the Gloucestershire 'Do Not Prescribe List', generically available Phosphodiesterase type-5 inhibitors are recommended locally

    Recommended

  • Sildenafil

    Prescribe by generic name

  • Alternative

  • Tadalafil

    10mg or 20mg tablet, for PRN use

    Prescribe by generic name

  • Specific Indication

  • Alprostadil

    (Caverject®) injection – only for use when a PDE5 inhibitor is unsuitable

  • Invicorp®

    Aviptadil 25mcg / phentolamine 2mg injection – only for use when a PDE5 inhibitor is unsuitable

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