▶With intramuscular useWithhold breast-feeding for
neonates with severe or persistent jaundice requiring
medical treatment.
lHEPATIC IMPAIRMENTWhen used as a contraceptive;
caution in severe liver disease and recurrent cholestatic
jaundice, avoid in liver tumour. Caution when used for
sexual maturation and to postpone menstruation; avoid if
severe.
lRENAL IMPAIRMENTUse with caution in non-
contraceptive indications.
lPATIENT AND CARER ADVICE
Diarrhoea and vomiting with oral contraceptivesVomiting and
persistent, severe diarrhoea can interfere with the
absorption of oral progestogen-only contraceptives. If
vomiting occurs within 2 hours of taking an oral
progestogen-only contraceptive, another pill should be
taken as soon as possible. If a replacement pill is not taken
within 3 hours of the normal time for taking the
progestogen-only pill, or in cases of persistent vomiting or
very severe diarrhoea, additional precautions should be
used during illness and for 2 days after recovery.
Starting routine for oral contraceptivesOne tablet daily, on a
continuous basis, starting on day 1 of cycle and taken at
the same time each day (if delayed by longer than 3 hours
contraceptive protection may be lost). Additional
contraceptive precautions are not required if
norethisterone is started up to and including day 5 of the
menstrual cycle; if started after this time, additional
contraceptive precautions are required for 2 days.
Changing from a combined oral contraceptiveStart on the day
following completion of the combined oral contraceptive
course without a break (or in the case of ED tablets
omitting the inactive ones).
After childbirthOral progestogen-only contraceptives can
be started up to and including day 21 postpartum without
the need for additional contraceptive precautions. If
started more than 21 days postpartum, additional
contraceptive precautions are required for 2 days.
Contraceptives by injectionFull counselling backed bypatient
information leafletrequired before administration—
likelihood of menstrual disturbance and the potential for a
delay in return to full fertility. Delayed return of fertility
and irregular cycles may occur after discontinuation of
treatment but there is no evidence of permanent
infertility.
Missed oral contraceptive pillThe following advice is
recommended:‘If you forget a pill, take it as soon as you
remember and carry on with the next pill at the right time.
If the pill was more than 3 hours overdue you are not
protected. Continue normal pill-taking but you must also
use another method, such as the condom, for the next
2 days.’
The Faculty of Sexual and Reproductive Healthcare
recommends emergency contraception if one or more
progestogen-only contraceptive tablets are missed or
taken more than^3 hours late and unprotected intercourse
has occurred before 2 further tablets have been correctly
taken.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: oral suspension
Solution for injection
▶Noristerat(Bayer Plc)
Norethisterone enantate 200 mg per 1 mlNoristerat 200 mg/ 1 ml
solution for injection ampoules| 1 ampouleP£ 4. 05
Tablet
▶Norethisterone (Non-proprietary)
Norethisterone 5 mgNorethisterone 5 mg tablets| 30 tabletP
£ 2. 23 DT = £ 2. 06▶Noriday(Pfizer Ltd)
Norethisterone 350 microgramNoriday 350 microgram tablets|
84 tabletP£ 2. 10 DT = £ 2. 10
▶Primolut N(Bayer Plc)
Norethisterone 5 mgPrimolut N 5 mg tablets| 30 tabletP
£ 2. 26 DT = £ 2. 06
▶Utovlan(Pfizer Ltd)
Norethisterone 5 mgUtovlan 5 mg tablets| 30 tabletP£ 1. 40
DT = £ 2. 06 | 90 tabletP£ 4. 217.2 Male sex hormone
responsive conditions
Androgens, anti-androgens and
anabolic steroids
Androgens
Androgens cause masculinisation; they are used as
replacement therapy in androgen deficiency, in delayed
puberty, and in those who are hypogonadal due to either
pituitary or testicular disease.
When given to patients with hypopituitarism androgens
can lead to normal sexual development and potency but not
to fertility. If fertility is desired, the usual treatment is with
gonadotrophins or pulsatile gonadotrophin-releasing
hormone which stimulates spermatogenesis as well as
androgen production.
Intramuscular depot preparations oftestosterone esters
are preferred for replacement therapy. Testosterone
enantate or propionate or alternativelySustanon®, which
consists of a mixture of testosterone esters and has a longer
duration of action, can be used. For induction of puberty,
depot testosterone injections are given monthly and the
doses increased every 6 to 12 months according to response.
Single ester testosterone injections may need to be given
more frequently.
Oraltestosterone undecanoateis used for induction of
puberty. An alternative approach that promotes growth
rather than sexual maturation uses oral oxandrolone p. 481.
Chorionic gonadotrophin has also been used in delayed
puberty in the male to stimulate endogenous testosterone
production, but has little advantage over testosterone.
Testosterone topical gel is also available but experience of
use in children under 15 years is limited. Topical
testosterone is applied to the penis in the treatment of
microphallus; an extemporaneously prepared cream should
be used because the alcohol in proprietary gel formulations
causes irritation.Anti-androgens and precocious puberty
The gonadorelin stimulation test is used to distinguish
betweengonadotrophin-dependent (central) precocious
pubertyandgonadotrophin-independent precocious puberty.
Treatment requires specialist management.
Gonadorelin analogues, used in the management of
gonadotrophin-dependent precocious puberty, delay
development of secondary sexual characteristics and growth
velocity.
Testolactone p. 482 and cyproterone acetate p. 482 are
used in the management of gonadotrophin-independent
precocious puberty, resulting from McCune-Albright
syndrome, familial male precocious puberty (testotoxicosis),
hormone-secreting tumours, and ovarian and testicular
disorders. Testolactone inhibits the aromatisation of
testosterone, the rate limiting step in oestrogen synthesis.
Cyproterone acetate is a progestogen with anti-androgen
properties.480 Sex hormone responsive conditions BNFC 2018 – 2019
Endocrine system6