Treatment of Disorders Occurring in Obstetrics and Gynaecology

First Choice: PARACETAMOL OR MEFENAMIC ACID

Second Choice: NAPROXEN

Prescribing Notes:

• Consider reducing dose of PARACETAMOL to 0.5g four times daily in patients with low body weight (< 50kg), renal/hepatic impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism).
• For optimal effect, regular analgesics should be initiated just before anticipated onset of menstruation.
• If contraception is required then combined oral contraceptives should be considered since they may prevent the pain of dysmenorrhoea. Please refer to the Contraceptives section.

First Choice: LEVONORGESTREL releasing intrauterine system (Mirena^®) (if at least 12 months treatment expected)

Second Choice: TRANEXAMIC ACID or oral NSAID (MEFENAMIC ACID or NAPROXEN) or combined oral contraceptive.

Third Choice:

• NORETHISTERONE or depot progestogen injection
• If a non-hormonal option is required: TRANEXAMIC ACID or NAPROXEN

Prescribing Notes:

• For combined oral contraceptives and depot progestogens, please refer to the Contraceptives section.
• Mirena^® is an effective first line treatment for menorrhagia.
• Women offered Mirena^® should be advised of changes in the bleeding pattern, particularly in the first few cycles and maybe lasting longer than 6 months. They should therefore be advised to persevere for at least 6 cycles to see the benefits of treatment.
• NSAIDs should be preferred to TRANEXAMIC ACID when there is menorrhagia with dysmenorrhoea.
• Use of NSAIDs and/or TRANEXAMIC ACID should be stopped if symptoms do not improve within 3 menstrual cycles.
• When a first choice treatment has proved ineffective a second or third line drug treatment option should be considered rather than immediate referral for surgery.
• TRANEXAMIC ACID is contra-indicated in patients at risk of thromboembolism.

Contraception required:

• First Choice: combined oral contraceptive

Contraception NOT required:

• First Choice: NORETHISTERONE
• Second Choice: MEDROXYPROGESTERONE ACETATE

Prescribing Notes:

• For combined oral contraceptives, please refer to the Contraceptives section.
• For postmenopausal women, please refer to Hormone replacement therapy (HRT) for menopausal symptoms.

First Choice: combined oral contraceptive or MEDROXYPROGESTERONE ACETATE

Second Choice: TRIPTORELIN (Decapeptyl SR^®) (on specialist advice)

Prescribing Notes:

• For combined oral contraceptives, please refer to the Contraceptives section.
• Symptoms, particularly pelvic pain and abnormal uterine bleeding, may be better controlled if the combined oral contraceptive is taken continuously for 90 days.
• Side–effects of gonadorelin analogues related to the inhibition of oestrogen production may be reduced by hormone replacement (e.g. with an oestrogen and a progestogen or with tibolone).

First Choice: CLOBETASOL PROPIONATE (Dermovate^®)

Prescribing Notes:

• Moisturisers are helpful for softening and protecting the skin.
• Emulsifying ointment or Dermol^® may be useful as soap substitutes. Lubricants may also be beneficial if sexual intercourse is painful.

To be initiated and prescribed on specialist advice:

• CLOMIFENE CITRATE (CLOMIPHENE CITRATE)
• CHORIONIC GONADOTROPHIN (Human Chorionic Gonadotrophin; HCG)
• FOLLITROPIN ALFA & FOLLITROPIN DELTA (Recombinant Human Follicle Stimulating Hormone; FSH)

Prescribing Notes:

• All infertility drugs, including CLOMIFENE CITRATE, should be initiated and prescribed by hospital specialists.

Please refer to the BNF treatment summary.

First choice: no drug treatment

Prescribing Notes:

• Hormonal manipulation may be useful e.g. combined oral contraceptive or Depo-Provera^®, in some circumstances.
• There is no convincing evidence of a useful drug treatment for PMT.

First Choice: no drug treatement

Prescribing Notes:

• Most cases of galactorrhoea are mild and resolve spontaneously.
• BROMOCRIPTINE can be useful for patients with persistent galactorrhoea following specialist referral and investigation. Consider drug causes e.g. CHLORPROMAZINE, METOCLOPRAMIDE, CIMETIDINE, DOMPERIDONE.

First choice: combined oral contraceptive; Please refer to the Contraceptives section.

If hirsutism:

• First choice: ETHINYLESTRADIOL WITH DESOGESTREL (Gedarel^®)
• Second Choice: CO-CYPRINDIOL (Dianette^®)

Prescribing Notes:

• In accordance with CSM guidance, Dianette^® should be withdrawn 3 to 4 cycles after the treated condition has completely resolved.
• Polycystic ovarian syndrome consists of a collection of symptoms some or all of which may not require drug treatment; weight reduction is the first essential line of management for obese patients.
• For acne, please refer to the Acne and Rosacea section.
• If there are concerns regarding infertility, both the male and female partners should be referred to a clinic. Ovulation induction with anti-oestrogens may be required and should only be prescribed with appropriate monitoring.
• As with Gedarel^®, Femodene^® contains a less androgenic progestogen and may be used instead of Gedarel^® in women with hirsutism or acne.

Prescribing Notes:

• Medical management of non–viable pregnancy (including incomplete miscarriage) and induction of abortion is performed in specialist licensed units. Currently first choice is MIFEPRISTONE followed by a prostaglandin.
• Methotrexate is first choice medical treatment for ectopic pregnancy under hospital supervision (off-label).

To indicate the category of a formulary medicine, updated sections adopt the following key: