Alternatives when there are HRT shortages

HRT starting doses and conversions

Download a leaflet on HRT starting doses and conversions (PDF, 290Kb)

Alternative hormone medication options in case of supply issues:

If there are local supply issues with particular formulations of hormonal medications, there are alternatives (as outlined below). See our information leaflet on appropriate doses when switching formulations.

After any change in hormonal medications, please repeat the monitoring as indicated below and as per our clinical guidelines.

If further advice is needed, please don’t hesitate to contact us. The BNF and EMC website also have further information on the medications outlined in our clinical guidelines.

Oestrogens (estradiol)

NB: we use estradiol (valerate or hemihydrate) formulations as our standard oestrogen therapy. As these modern estradiol formulations are safer, we do not typically recommend Premarin or Ethinylestradiol.

Estradiol tablets: Progynova, Elleste Solo, Zumenon : all equivalent at the same doses
Estradiol gels:
- Sandrena gel, available as 0.5mg and 1mg sachets.
- Oestrogel 0.06% gel, each pump actuation delivers 0.75 mg estradiol.
Estradiol patches: Progynova TS, Evorel, Estradot, Estraderm: all equivalent at the same doses

Approximate conversions between estradiol formulations:

Estradiol tablets 2mg OD: Estradiol patches 50 micrograms twice a week: Estradiol gel 1mg OD
Estradiol tablets 4mg OD: Estradiol patches 100 micrograms twice a week: Estradiol gel 2mg OD
Estradiol tablets 6mg OD: Estradiol patches 150 micrograms twice a week: Estradiol gel 3mg OD
Estradiol tablets 8mg OD: Estradiol patches 200 micrograms twice a week: Estradiol gel 4mg OD

Monitoring after a change to oestrogen (estradiol) therapy:

After any change to dose or formulation of estradiol, monitoring is due 8 weeks later as follows:

Bloods for: oestradiol, testosterone, prolactin, liver function

For accurate results, the timing of blood tests should be:

Estradiol tablets: 4-6 hours after tablets swallowed whole as a single dose
Estradiol gel: 4-6 hours after gel applied to skin of body or legs (not arms)
Estradiol patch: 48-72 hours after patches applied to skin

*the target ranges for oestradiol levels are outlined in the clinical guidelines.

Testosterones

Testosterone gels:

- Testogel 16.2mg/g pump (each actuation delivers 20.25mg testosterone)
- Tostran 2% pump (each actuation delivers 10mg testosterone)
- Testavan 20mg/g pump (each actuation delivers 23 mg testosterone)
- Testogel 50mg/5g sachet (each sachet contains 50mg testosterone)

Short-acting testosterone injections:

Sustanon and Testosterone Enantate can be considered equivalent at the same doses and injection frequencies/intervals. NB: Sustanon should not be used in people with peanut allergy, so if a person has nut/peanut allergy then use testosterone enantate.

An alternative to Sustanon is Testosterone Enantate injections, which are equivalent at the same dose and frequency as Sustanon. Unfortunately, there have also been reports of shortages of Testosterone Enantate. Other alternatives are switching to a testosterone gel or long-acting Nebido injections. Three options for the alternatives are outlined below:

If the patient is switched from Sustanon to Testosterone Enantate repeat monitoring is due at the 4th injection after that change, as trough and peak monitoring as two separate blood tests, one week apart, as follows:

TROUGH blood test – (day of, before injection): testosterone (aim 8-12 nmol/l), full blood count, liver function tests, lipids (fasting 6 hrs prior to test)
PEAK blood test – (one week after injection): testosterone level (aim < 30 nmol/l)
Please also measure blood pressure and BMI.

If the patient prefers to switch to a testosterone gel, an appropriate starting dose is Testogel pump 16.2 mg/g gel at 2 actuations of the pump once per day (40.5 mg testosterone).

Care should be taken not to transfer any gel through skin to skin contact, in particular with either a female or a child, for 6 hours after gel is applied to skin. Once gel is dry, the skin covered with clothing, and hands are washed with soap and water, there is minimal risk of transfer.

If switched to Testogel, monitoring is due 8 weeks later as follows:

Blood should be drawn for: testosterone (aim 15-20 nmol/L), full blood count, fasting lipids, liver function.
The blood test should be taken 4-6 hours after the gel is applied to the skin making sure the gel is put on the body or legs, not the arms.
Please also measure blood pressure and BMI.

If the patient wishes to switch to long-acting Nebido injections they should be aware that, as compared to Sustanon/Testosterone Enantate, Nebido injections are usually given every 12 weeks (after an initial loading phase), and are, therefore, often more convenient with simpler monitoring requirements (just trough blood tests rather than trough and peak). The medication is delivered via larger injections, given slowly over about two minutes into the gluteal muscle, and may be more painful. There is a rare risk of pulmonary oil microembolism, which is easily treatable by supplemental oxygen, hence, as per the manufacturer’s guidance and out advice, Nebido injections should be given by healthcare professionals in a health care setting with access to oxygen such as GP practices. The patient should not be smoking and their weight should be over 55kg to switch to Nebido as per the following guidance (if less than 55kg, the dose should be reduced to Nebido 750 mg).

If the patient prefers to switch to Nebido injections, please let us know and send us recent (within last 3 months) safety bloods (full blood count, liver function, lipids) if there are no significant abnormalities and no polycythaemia (haematocrit should be less than 0.52), then we can provide you with the Nebido loading protocol.

Whatever formulation the patient is switched to, please send the next set of results to gic.endo@nhs.net (patients only) for review and advice on adjustments to therapy. Please confirm the dose and formulation of the hormonal medications when sending results.

Long-acting injections:

Nebido (must be administered by trained healthcare professional in health-care setting as per manufacturer’s instructions). There is no alternative long-acting testosterone preparation but it is possible to switch to short-acting testosterone injections or testosterone gels once the serum testosterone level falls below 15 nmol/L.

Monitoring after a change in testosterone therapy:

After any change to dose or formulation of testosterone, monitoring is due:

Testosterone gels: monitoring is due 8 weeks after any change to dose or brand of gel as follows:

Bloods for: testosterone, full blood count, liver function, fasting lipids
For accurate results, the timing of the blood test should be 4-6 hours after gel applied to skin of body or legs (not arms).

Sustanon/Testosterone Enantate: monitoring is due at the 4^th injection after any change to dose or injection frequency/interval, or if switching between the two formulations. This requires trough and peak monitoring as two separate blood tests, as follows:

TROUGH blood test – (day of, before injection): testosterone, full blood count, liver function tests, lipids (fasting 6 hrs prior to test)
PEAK blood test – (one week after injection): testosterone level

Nebido: monitoring is due at the 3^rd injection after any change in injection frequency/interval (or dose, but this is less common), with blood tests taken as a trough sample on the day of a Nebido injection, prior to the injection, as follows:

Bloods for: testosterone, fasting lipid profile, full blood count, liver function.
To note, no peak testosterone is needed.

*the target ranges for testosterone levels vary by testosterone formulation, and are outlined in the clinical guidelines.

GnRH analogues

As per our shared care guidelines, there are several options of GnRH analogues, including injectable or subcutaneous implant formulations given on a monthly, 3-monthly or 6-monthly basis. Before switching to a longer-acting formulation, it is worth checking that a patient is otherwise tolerating GnRH analogue therapy well. There is also a nasal spray for those who cannot tolerate injections.

We usually recommend either of the following GnRH analogues:

Decapeptyl (triptorelin) SR 11.25 mg (IM) every 12 weeks
Zoladex (goserelin) 10.8 mg (sub cut) every 12 weeks

Other alternative GnRH analogues:

Leuprorelin (Prostap) 11.25 mg (IM) every 3 months
Leuprorelin (Prostap) 3.75 mg (IM) monthly
Goserelin 3.75 mg (sub cut) monthly
Decapeptyl SR 3 mg (IM) monthly
Decapeptyl SR 22.5 mg (IM) every 6 months
Nafarelin (Synarel) nasal spray, 200-400 micrograms twice a day (see BNF)

Monitoring after a change to GnRH analogue therapy:

After any change to dose or formulation of a GnRH analogue, standard oestrogen therapy or testosterone therapy monitoring is due 8 weeks later.

Finasteride

When there is a problem sourcing Finasteride, Dutasteride 0.5 milligrams is a suitable alternative.