Updates on physical interventions

Alternative hormone medication options in case of supply issues:

Finasteride

Finasteride is in short supply. Where there is a problem sourcing Finasteride, Dutasteride  0.5 milligrams is a suitable alternative: https://www.medicines.org.uk/emc/product/8917/smpc

Oestrogens

  • Estradiol tablets: Progynova, Elleste Solo, Zumenon : all equivalent at the same doses
  • Estradiol gel: If Sandrena is unavailable then Oestrogel is an alternative option.
    2 x applications of Oestrogel equivalent to 1mg Sandrena
  • Estradiol patches: Progynova TS, Evorel, Estradot : all equivalent at the same doses

Testosterones

  • Short acting injections: Sustanon and Testosterone Enantate are equivalent at same doses and intervals.
    If neither of those are available then Virormone injections 100mg IM weekly can be used (must be administered by trained healthcare professional in health-care setting)
  • Long-acting injections: Nebido (must be administered by trained healthcare professional in health-care setting). There is no alternative long acting preparation but can switch to short acting injections or gel once the testosterone level falls below 15 nmol/L.
  • Testosterone gel: Testogel 16.2mg/g pump; Tostran 2% pump ; Testogel 50mg sachets; Testim 50mg sachets;
    Testogel and Testim 50mg sachets can be switched to 2 x applications of Testogel pump or 4 x applications of Tostran 2% pump

Replacement treatment for ethinylestradiol

Added October 2018

There are supply issues with ethinyloestradiol.   Our clinic has for some years now has ceased advising the use of ethinylestradiol due to safer products now being available.

Our standard recommended treatment is now estradiol valerate. For patients that are currently on ethinylestradiol 50-150 mcg we advise switching them to 4 – 6 mg Progynova (estradiol valerate).  Alternatively estradiol hemihydrate can be used (Elleste Solo or Zumenon).

Monitoring: bloods should be taken 8 weeks after this change for: oestradiol, prolactin and liver function. Bloods should be taken 4-6 hours after the tablets have been taken.

The oestradiol aim is 400-600pmol/L.

Dose titration is usually 2mg adjustments, or 1mg if only a little out of range.

When the dose of a preparation is changed, repeat blood tests need to be taken 8 weeks after the change. Once the hormone regimen is stabilised, bloods should be taken six-monthly for two years then annually if stabilised.

Safety

Smoking:  if the patient is smoking the dose should be kept at 2mg until they have ceased smoking completely for 3 months. Vaping and e-cigarettes are acceptable. This is due to clotting and cardiovascular risks being increased with smoking in combination with hormone treatment.

Cut-offs for action with the monitoring bloods

Prolactin:

Small rises in prolactin are often seen with oestrogen therapy.

  1. New rise of >750 mIU/L: Repeat test
  2. New rise of >1000 mIU/L: Seek advice from local endocrinology department

Liver function tests: Values of greater than 3x the upper limit of normal: seek advice.


Updates on testosterone replacement supply

Added April 2018

Sustanon 250mg/ml solution for injection

While there are shortages of Sustanon, an alternative option is: Testosterone Enantate 250 mg/ ml Solution for Injection At the same dose, frequency and monitoring.

Read about Testosterone Enantate on the EMC website

Testogel sachets

Testogel sachets have been discontinued. In their place we now recommend using either: Testogel 16.2mg/g gel or Tostran 2% gel  

Read about Testogel 16.2mg/g gel on the EMC website One pump delivers 20.25 mg testosterone  (if your patient was on 50 mg testogel sachet, give 2 pumps  (40.5 mg testosterone) and check blood levels in 8 weeks.

Read about Tostran 2% gel on the EMC website Give 40mg (4 depressions of pump) and check blood levels in 8 weeks.