7: Obstetrics, gynaecology and urinary tract disorders
Approved: 4 Oct 2017. Last amended: 16 Sep 2024.
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
Estriol 0.01% cream
Ovestin®
0.1% cream (estriol)
Estradiol
10mcg vaginal tablets
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
Gloucestershire Continence and Urology Products Formulary
Gloucestershire Continence Passport
7.4.2.1 First-line:
Solifenacin
Tolterodine
1mg, 2mg
7.4.2.2 Second-line:
Trospium
20mg
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
Vibegron
Third line for patients who have been unable to tolerate at least 2 antimuscarinic drugs. NICE TA999
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 tablets for PRN use. Alternatively, 5mg daily may be used, particularly when adverse effects are experienced with higher PRN doses.
Only prescribe by generic name.
Specific Indication
Alprostadil
(Vitaros®) cream – only for use when a PDE5 inhibitor is unsuitable (see local guideline)
Alprostadil
(Caverject®) injection – only for use when a PDE5 inhibitor is unsuitable (see local guideline)
Invicorp®
Aviptadil 25mcg / phentolamine 2mg injection – only for use when a PDE5 inhibitor is unsuitable (see local guideline)