The Dr Louise Newson Podcast - 206 - Utrogestan supply issues: what it means and alternatives available

Episode Date: May 30, 2023

The supply of HRT medication Utrogestan is being restricted by the UK government because of shortages amid increase demand. Pharmacies will only dispense two months’ worth of Utrogestan 100mg capsules per prescription to help ensure continued access for women. In this special episode, Newson Health pharmacist prescriber and menopause specialist Faiza Kennedy joins Dr Louise to talk about the restrictions, and where and how to seek advice and help. They talk about the importance of taking a progesterone as part of your HRT regime if you still have a womb, as well as alternatives to Utrogestan, including progesterone in pessary form, the Mirena coil and combined forms of HRT containing both estrogen and progesterone. Faiza’s top three tips:  Only order the amount of Utrogestan you need to help everyone get through the shortfall Be organised about ordering your HRT prescriptions. Do it about two weeks before you run out so you have time in case you have any difficulties getting your supply or need to seek an alternative Reach out for help if you are struggling with your supply Click here for a balance article for more information about the current Utrogestan supply restrictions, plus alternatives. You can read more about Faiza here.

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based, information and advice about both the perimenopause and the menopause. So today on the podcast, I've got someone called Pfizer Kennedy, who is one of the few people that I do on my podcast. I actually know and I've seen in real life, which is wonderful because so many of my guests

are not people that I've ever met in real life. But Pfizer works very closely. She's one of our most senior pharmacists and I'm very grateful for all her work. So I thought today I would quiz her a bit about what's it like being a pharmacist in the menopause world, and also to talk about some of the HRT shortages, which, as many of you know, are ongoing and incredibly frustrating. So welcome, Pfizer. Thanks for coming today. Thank you. Thank you for having me. So when we first met, I think you'd emailed me and we were sort of pen pals for a while, weren't we? And then you came and sat in the clinic. Yes. So actually, I heard you being interviewed on the oral apothecary podcast, which is one of my

favorite podcast and actually hosted by three of my really good friends, Jamie Paul and Steve. And I heard you on this podcast and I thought, my goodness, I have to meet this woman and forced Jamie to introduce us and then stalked you by email and you invited me up to the clinic, which was lovely. And then, yes, a year on, I'm still here and I love it. Which is great. So, but you haven't always done menopause work, have you, as a pharmacist? No. I've had quite a varied career, but I suppose my last role was in general practice, which I loved. But if I'm honest, I've always liked the kind of the prevention. And then, of course, once you see it, you can't unsee it, can you?

So it's that joy, you know, when you see the difference. My favourite is seeing the follow-up patients because you just see that it's almost like the women become into focus and the ripple effect on their families, on their work life, on everything. It's just joyful. It's very transformation. I was talking to someone this afternoon, actually, and saying, I get stressed or I get overtired or just everything's a bit overwhelming, I just sit in my clinic and see patients. And it's very powerful. I've always been jealous of my husband, who's a

surgeon, because he can really transform people's life when they're having an operation, of course. But in general practice, I always felt I wasn't quite doing enough. And I always felt that I couldn't really make a huge difference. I could make some difference, of course. But doing menopoles care really is transformational, isn't it? It's very, it's very, very. few things in medicine, I see people and say, I do know how much I'll make you better, but I know this is probably the worst you're ever going to feel. And like you say, the first review, you start to see indifference. And then by the second or third of my annual follow-up patients, I really love because you're not just reviewing their HRT, you're looking at their lifestyle, you're looking

at the way, like you say, they're interacted with their family, they've often got different jobs, they've been promoted, or they've started work when they haven't for a while. And you're really setting them on a path, like you say, of preventative health care as well. So it's not just making them feel better. You know, someone's really clinically depressed and you give them antidepressants. Of course, they'll feel better, but you're not going to strengthen their bones and reduce their risk of heart disease, are you? Absolutely. And I remember you're telling me when we first met, actually, you were doing some reviews of medication and you would just be taking people off medication, didn't you? Yes. I seem to spend my life trying to take them off medication. But like I said,

Once you see it, you inspired me, Louise, and once I could see it, and then you give them HRT, and actually they can stay off that medication, which is a really powerful thing, I think. Yeah, because that's medications. Often, people are on, sometimes over years, there's layers of medication. So people have often started on, say, antidepressants for their low mood, and then they muscle and joint pains, they might get painkillers. And then their blood pressure increases without estrogen, so then they're on a blood pressure-loading treatment. and then they're found on a review to have raised cholesterol, so they then have a statin, and then maybe they're developing osteoporosis, so they're on a bisphosphonate. And before you know it, there's five or six medications on a prescription, aren't there? Yeah, absolutely.

And it's so sad and disheartening. And I think then they feel so much better on HRT and you think, goodness, you know, that would have been, you know, wish we'd started there, just replacing a woman's own hormones and seeing how they do. So one of the things often is that people talk about, go and see your G. for HRT or going to see your GP if you're struggling with symptoms. Whereas a lot of the time I'm thinking, well, the GPs are overwhelmed anyway with everything else that's going on. And menopause care actually I often think is better done by people. I'm not being rude about doctors because I am one. But as doctors, we often are a bit chaotic. We don't follow protocols the same way. And we've got

other skills as well. But I've always thought, wouldn't it be better if it was taken way more from GPs and it was given more to nurses and pharmacists. And, you know, a lot of pharmacists now that you can prescribe. Yes. So having a bit of autonomy, being able to see people and actually prescribe for them in a way that's safe is actually really good. And I think menopause care is one of the few things that really a lot of nurses and pharmacists, if they prescribe, can do with more autonomy probably than some other areas of

medicine. And so we've got quite a few. nurses and pharmacists, haven't we, working with us? We do. And you're right. And we also generally tend to have a bit more time, don't we? And so my little team that I look after, we look after patients in between their appointments with their own clinician as well. So we can help them just, you know, for quick questions or if they're unsure about things, we can reiterate messages and things. So that's really lovely, that the patient just gets an experience where they looked after in between appointments as well as during their appointments. But yes, I see patients

well, two days a week on my own. And then you develop the relationship with the patients. And it's so lovely because you learn so much from the patients as well, don't you? Yeah. I mean, I've always said it's a great privilege being a doctor. And it really is being any healthcare professional because even though our clinic is private, of course, we see people from all socio-economic backgrounds and actually different ethnicities as well. So we're still exposed to lots of people with lots of different stories, lots of different cultures,

there's lots of different ways that they've come to the clinic. You know, I've seen a lot of people who it's been their birthday and Christmas present combined from every single family member because they're desperate to feel better and they can't get help on the NHS. And so they're not all people that have money, but it's actually still really rewarding because we can help so many different communities. And like you say, there is this ripple effect. We know that every person that we help, they're often going to educate other people.

And a lot of people then say, because I've spoken to one of my friends and now she's gone to her doctor because she's got more confidence or she's gone and got HRT elsewhere. So I feel like we're sort of spreading out a lot more and I know for some people they feel a bit frustrated seeing my name or listening to our company's name. But actually I know that we're helping far more people than just the people who pay to come and see us, don't they? Yes, I think so it's really lovely when you end up treating a whole friend group. I always love it when they take it. tell me about how they heard about the clinic and what made them make the appointment.

But then also on the other side, I found that, you know, in the beginning, it can take some time to get the HRT plan right for that individual patient because that's what we focus on, isn't it? It's just individualising care. And then afterwards, often GPs will be quite happy to prescribe once the patient stabilised, because that can take a little bit of time, can't it? So I guess it's just helping, yes. Yeah, one of my friends recently said, oh, HRT prescribing is really easy. It's just the same for everyone. I said, no, it's absolutely not. And during the perimenopause, it can be really quite difficult to get the right dose, can't it? And then, you know, we do spend a lot of time

individualising both the type and dose, and it can really change. Even with the same patient, it can change over the months sometimes. So it's very important that people are given the right dose, the right type. But we can't always get the type that we want, can we? And I was thinking about this today, actually. So five years ago, I was away with my daughter because she was doing a trompone boot camp in Budapest and there was a shortage of then it was ever old patches and I remember getting hold of somebody in the government to say what's happening and speaking to a chief pharmacist for NHS England

and saying this is awful, this is outrageous. Actually, I cannot function without my ever old patches and the ester dot don't stick on for me, the gel just slides off And I was really worried personally, of course. But I was also worried for all my patients. And they said, oh, it's only a short term and da-da-da. And it took a few months of a lot of frustration. And then actually now, Everald's been taken over by another company, Theromax.

And that's absolutely fine. But I just then thought, goodness me, we've only just started to increase prescribing then. Some of my work had only just started. But now we've had the Davina documentary. We've got a lot more awareness. HART prescribing has gone from 10-ish percent to about 16 percent, not 60, 16 percent of men orples are women. It's still the minority, although we know for the majority of women, HRT has more benefits than risks. And as you know, we don't, none of us who work with us, do any paid work for pharmaceutical companies, but we have met with pharmaceutical companies over the last five years

and said the demand is going to increase. It's going to increase exponentially. What are you doing? How are you going to improve the stocks? And people talked about like a spike. Like, you know, with COVID we have this sort of spike. I said it's not a spike. It's going to continue as women understand the importance of considering hormones

for their future health as well. And there was still this, oh, but we can't. And then some of the way that they look at their stock is looking at what the government predicts. And that isn't always true because there are, I guess, many people who work or reports the government aren't that keen about women having HRT. So there's been this going on. But we've felt it and seen it. And then there's been shortages of gel.

There's been shortages of estrogen. There's been shortages of utergestin. And it's incredibly frustrating, isn't it, Pfizer? Yes, it is. And I mainly feel sorry for women. One of my main things has always been. And actually the whole team is we don't want patients, once they're on HRT, you definitely don't want them to have to interrupt their treatment. And if they're on estrogen, you definitely want them to have progester, if they still have a womb or if they've had a history of endometriosis or whatever.

So it's so important that the treatment is interrupted. And I was reflecting on this because it's been a tough few months, you know, with just making sure that treatment isn't interrupted for patients. And I thought, gosh, but still we're lucky. At least we have alternatives that are safe, they're effective. We can talk through different options with patients. I grew up in Africa and our family home is still in Kenya. And I know for a fact that HRT is, well, you know, there's hardly any in Africa. You know, it's very difficult to get a hold of.

So I guess on the positive side, isn't it great that we have these alternatives so we can make sure that patients can continue treatment. But yes, it has been a big challenge. And I guess all the teams in Newsome Health have been working so hard. in just contacting patients. Cloud RX pharmacy have been fantastic. Also, contacting patients saying please let us know. If you're close to running out, let us know. And then we've been phoning patients and actually not charging for any of those phone calls. And this is the pharmacist in me, Louise, because I like to call the patients because I like to know that they know how to use the

alternatives. And I can explain everything properly and give them the options because I've come across so many times where patients may not use whatever's prescribed in the best way, and then they don't get the best effect from it. Yeah, it's really important because medication, it took me many years to realize that it's not about just signing a prescription, it's about the compliance and people understanding, because if you don't understand, you're not going to do it. The amount of times I did home visits, and I'd look at all the medication we'd prescribe from the practice, and then I'd open the person's kitchen cupboard and everything would fall out on me because they would never take them because they didn't understand how to take them or they didn't

know what they were for. And so it's really important. So if we just start at some of the basics, if you don't mind. So HRT's three letters, hormone replacement therapy. I find that a bit frustrating because we're not always replacing hormones. We're just topping up what's missing, aren't we? Yeah. But the main hormone we always prescribe usually is estrogen, isn't it? So there are different ways. Can you explain the different ways of having estrogen? So mainly we prescribe it transdermly, which means through the skin. So, it comes as a gel, a patch or a spray. But just going on the example I was saying about making sure we explain things properly, I came across a patient the other day actually where she was applying

three pumps on the same arm and wasn't feeling better, you know, and just explaining actually if you spread it out, the better the absorption, because you need a large surface area. Those practical tips are so important and can make all the difference. Yes. Well, I did some training a few years ago to some local GPs. We had a whole, in fact, it was two hours, so it was an hour of just the theory and then an hour more about practical prescribing and everything else. And then about six weeks later, the GP phoned me up and he said, I'm a bit confused because you've sent someone out from your clinic on estrogen gel and fagifem, which is a vagina and estrogen.

I said, yes, and what else? And he said, well, no, that's all. She's had a hysterectomy. So she's just on the estrogen. But why on earth would you give the gel and the vaginal preparation? I said, well, the vaginal preparation is only for localized symptoms, you know, with later to urinary symptoms or vagina. or dryness, about a fifth of women have both. He said, yes, but she's on the gel. And I said, yes,

I don't really know what else you want me to say. He said, yeah, but surely the gels for the vagina as well. Oh, dear, which bit of me doing this practical session where we have the placebo gel rubbing on the arm or the leg? Did you not understand? And then it was this sort of embarrassed silence at the end of the phone. And I thought, gosh, and it is easy to misunderstand when you're prescribing and you haven't seen or you haven't prescribed something before. And it's very obvious for us because we're prescribing it all the time. And, you know, sometimes I say to patients, don't get too stressed, whereabouts on the arm it goes or whereabouts on the legs. I know it's licensed for the outside of the arms and the inside of the thighs.

But actually, I say you can put it on your face. It doesn't really matter. It's just using the skin as a vehicle, isn't it, to get it into the bloodstream. That's what we're doing. Yeah, definitely. But I think also, you know, we always like to prescribe each hormone separately so you can, individualise the dose easier. But in the first appointment, there's quite a lot to take in, isn't there? And yes, you know, we do letters. Now I'm quite particular about my letters and try and make

it very specific so they know exactly and can refer back to it. But still, I always think, you know, you don't know because what they'll remember and, you know, just reinforcing that information is quite useful. So actually all the calls we've been doing, like I say, all my team have been doing all of these free of charge. We've actually, you know, been able to check in on people. and just reinforced key information, which has been really great. Yes, which is wonderful. I'm trying to find a silver lining with all these shortages. Well, you're great because you're always so happy, and I know it's very difficult.

So we've got estrogen, and at the minute, there's no problem with estrogen gel, there's no shortage. Everrell patches, and they come at different strains, there isn't a shortage. But estradot, the small ones, are still difficult to get hold of, aren't they? Yes. It's intermittent, and all the strands aren't available all of the time. So it changes. But yes, hopefully that's going to improve soon. But on the whole, estrogen is available.

Yes. On the whole, estrogen's not so bad. And the vaginal preparations of estrogen are fine as well. So the big problem that people are talking about, which is a real problem, is Uchajestan. And utchagestan is micronized progesterone, isn't it? So it's the body identical progesterone. It's called micronized because it's made into very small particles,

isn't it? It's suspended in oil just to help the absorption. But when you look down the microscope, it's the same structure as the progesterone people produce from their ovaries when they're younger. Any other progesterone is a synthetic progestogen, isn't it? So it's been chemically modified. And it depends on what type of progesterate it is as to how it's been modified, isn't it? Definitely. And having micronized progesterone is first choice, isn't it? Because then we know it's safe. It doesn't affect other things. It doesn't affect your blood pressure, your cholesterol. And that's the one women want to be on long term, don't they? Yeah, because the studies have shown that it doesn't have a clot risk,

it doesn't have a cardiovascular risk, it's probably either neutral or beneficial on blood pressure as well. And it has less side effects, actually, because you're giving the proper progesterone. Yes. The alternatives, which there are. And, you know, years ago, we used to prescribe all the time the synthetic progestogens. It's only now it can have the eutrogen.

done, it's easier. But the synthetic progestogens can come as tablets, can't they? And they do have a small risk associated with them, small risk of clot, small risk of heart disease, which sounds more scary than it is actually, because for a lot of people, their background risk is very low. So increasing a low risk is still a low risk, isn't it? Yeah, definitely. And then the whole breast cancer risk has only ever been shown with synthetic progestogens, but again, it's never been shown to statistically significant and the risk is far lower than it is with other risk factors for breast cancer, for example, not exercising or being overweight or drinking moderate amounts of alcohol. All those are still really low risk factors, but they're actually more than taking a synthetic

progestergent. And then we've also got the marina coil, haven't we? So can you explain the bit about the marina coil? So the marina coil is, you know, I would say in terms of safety and efficacy is on the same level as you're suggesting, would you say, Louise? And the great thing about that is that, you know, it can be left in place and replaced every five years, so you kind of forget about it. And it just helps to balance the effect of estrogen on the lining of the womb, keeps it nice and thin. And so in that way, yes, you don't have an additional thing to think about to take or insert into the vagina. So it's great from that perspective. And a lot of our patients quite like that, because it also has a two-in-one effect, doesn't it? Because it can act as a contraceptive

if you're perimenopausal, for example. And it often means that women don't have periods, which again is really nice. One of the problems often is people actually getting the marina coil because there's been a real restriction in their use in general practice and in the NHS, a lot of clinics will only give them for contraception. So if you're in your 50s and you're having one replaced maybe or inserted for the first time and don't need contraception can be difficult. And, you know, we do have marina coil clinics running throughout our clinic.

And people sometimes travel for miles, actually, just to come and have a marina coil. But that is actually really good. People, I was talking to a lady yesterday, and she said, oh, no, I don't fancy that. And I said, have you seen the size? They're really small. It's actually not a difficult procedure. You want, obviously, someone who's used to putting them in. And once they're in, people really don't remember, you know, they don't feel them or anything else.

And if people don't get on with them, they can be very easily removed, can they? Yeah, absolutely. But I suppose it's patient choice, isn't it? And again, so nice that we have these different options. But yes, Marina is one of my favourites, just because you can forget about it for five years and not have to think about it. Absolutely. And then the other option of there are different preparations of progesterone, which some people might not realize. So in the UK, we can only have the oral as the utergastan.

But for many years, actually, for women who don't tolerate utergustan orally, we can use the oral uterone. gestan capsules vaginally and they sort of just melt into the vagina and then you have a higher concentration actually in the womb which is where you need it and women often have less side effects so we've done that for many years anyway obviously if you can't get the utergestan it doesn't matter whether it's all or vagina you just can't use it but there are alternative progesterones aren't there we can use vaginally yes there's a two in the main that we've been using is cyclogest which comes as a pestry and also lutegest and And the great thing is that their body identical progesterine as well.

So essentially the woman is getting the same ingredient. And those are the calls we've been making to patients just to explain how to use them. If they've been used to using them eutrogen orally, it's quite a change. So with the pezzaries, they come as a 200 milligram. So they can, if people are having 100 vaginally, they can be cut in half very easily. And they're very small actually, aren't they? Yes, they're very small and very malleable and easy to cut. So this is what we explain when we call and explain what the alternatives are or what the options are.

And the vast majority of patients have chosen cyclogest or lute jess, and that's fine. At least we've got something so they don't have to interrupt their treatment. Yeah, absolutely. And using it for dyni, some people are quite scared that it's going to disappear or they're going to insert it too far. But you can't insert it too far. And it usually just melts or easy. People don't usually get a discharge or anything. And if they are using something like Vagifem or another vaginal hormonal preparation,

it's quite safe to use the two, isn't it? Yeah, absolutely. And we normally would say use the progesterone first and then the vagina and estrogen afterwards or opposite ends of the day. That's fine too. And I guess this is why it's so important. Our felt is so important to call patients and we've been doing that during the shortages just so we can answer some of these practical questions

and make sure patients understandfully. Yeah. And then the other alternatives, so there are always alternatives. And so I think it's really lovely for patients to know. I never leave, or I never want them to leave my consulting room until they know there's an alternative of anything because people, if they get side effects or whatever, it's quite nice to know. So there is a capsule called by juve, which is an oral body identical combination. And so it contains low-ish dose, one milligram of estradiol, which is equivalent-ish to about 50 microgram

hatch, isn't it, or two pumps of gel. I say ish, because it all depends how it's absorbed into the body, of course. But it also contains 100 milligram of utergestan. So it's a way of getting it. You can't split it out. It's all there as a combination. It's been around, actually in America, it's called by juva. And it's been around for quite a long time.

It's by juve over here. Quite a few NHS areas are still unable to prescribe it because it's not in the formulary, which is very frustrating. But we can prescribe it through the clinic. and in some areas they can prescribe it. And that can be quite a good combination, oral preparation, can't it, for some people? Yeah.

And it's not been shown to be associated with risk of clot like the synthetic progestogens as well. So sometimes if people are using that or taking it, they might have to reduce the dose of their estrogen a little bit, depending on the way how it's absorbed. So that's an option. And then there are combination patches that we sometimes use as well, aren't there,

which contain. estrogen and it's a synthetic progestogen, but it's through the skin. There probably is a small risk, you know, this risk of clot and heart disease, but it's very, very low, especially because it's a low dose that's absorbed. But again, those combination patches only contain 50 micrograms, don't they, of estrogen? So sometimes with people, they still need more estrogen. Yes, and if you want to titrate, it's much easier sometimes to have the products separately so that you can individualise treatment, can't you?

because then you can't have any more estrogen because the skin is a barrier and sometimes you will need more depending on how you absorb. Absolutely. So it really varies and sometimes it can take a while to get the right one and I always say to people when you change, just try and bear with it for a good two or three months because sometimes people get side effects initially and then they settle down. So there are choices, there are options, there's more information on the balance website as well and we've written some information about alternatives to Eutogestam. One of the reasons there is a shortness, obviously because there's increased demand, but they've built a new factory and it's supposed to be in full swing by the end of the year.

So I think this is going to be an intermittent problem. I must say that Bezines are trying as hard as they are. There is still stock, but obviously they've got to distribute it throughout everybody. And we really shouldn't be advising that people have estrogen on their own. it's okay for a few weeks. They might get bleeding, but certainly any more than that, it does help protect the lining of the womb, having progesterone. So it really shouldn't be having estrogen on its own, if at all possible. Yeah. There is stock and it is coming in, which is really reassuring. And also we're trying to find other pharmacies that have stock just so that we can get HRT for our

patients. But, you know, it's not as if there's no stock. It's just that for a while we might have to be careful about, you know, making sure everyone has some treatment to continue. continue with. Yeah, and at the minute, the guidelines are we should only prescribe two months of the Uttergesta at a time. So that's two months, whether it's NHS or private. Of course, if you have one of the alternatives, you can have longer. So anybody who's listening and is struggling, it would be worth probably going to see pharmacists first, find out where our stock is. They often know more actually the pharmacist than just going to your GP and then obviously read some information, empower yourself with knowledge and then decide which alternative is best for you.

you and then it's easier that way and then going pre-armed with the information so you can then have a shared decision-making consultation with your GP rather than your poor GP who might not necessarily know all the alternatives. So having information is really good. So I'm very grateful, Pfizer, for your time to do this podcast at very short notice. But before we end, just three take-home tips I always ask for. So I'm very keen to ask for three tips for people that are struggling or worried about the utergestin, shortage, what three things would you say to them? So the first one I would say is just the intention of the serious shortage

protocol of only having two months is just so everyone has treatment and no one's treatment is interrupted. So please only order what you need. You know, it is frustrating that you have to do it every two months. But hopefully this will get us out of it and the manufacturers will catch up. And then second, I would say just be organized, make sure you're allowing. enough time as well. So, you know, when you've got about two weeks of treatment left, that's the time to order some more. Just in case you have to have a phone call for an alternative and go through

that. So leave plenty of time and don't wait till the last minute to order. And just make sure you've got enough of both, you know, estrogen, progester, if you're on both treatments. And then last but not least, I would say, you know, we're here to help. The pharmacy will communicate to us if you let them know that you're close to running out of treatment, you know, you can contact us as well. So as long as you've had an annual review or being seen in the last 12 months, we're absolutely happy to help you, prescribe an alternative, or even if you'd get your prescriptions through the GP and just come and see us for annual review, that's fine. We can always recommend different options for you to discuss with your GP. That's fine too. So we're here to help. Just get in

touch. Very good. So absolutely. So if you're our patients, obviously, get in touch. But if you're not our patients, there's lots of free information available on the Balance website. And hopefully we won't be having more of these conversations. But the good thing is it means that more people are taking HRT, meaning that future health for those women will improve. So there are good points as well. So thank you again so much. And it's been great having you on the podcast today. So thanks, Pfizer. Thank you, Louise. For more information about the perimenopause and menopause, Please visit my website, balance-manopause.com, or you can download the free balance app, which is available to download from the App Store or from Google Play.