BNF for Children 2011-2012

378 6.4.1 Female sex hormones BNFC 2011–20126 Endocrine system[unlicensed indication] (see section 7.3.1) or as a combinedoestrogen and progestogen hormone replacementtherapy preparation [unlicensed indication] (see BNFsection 6.4.1.1). There is limited experience in the useof transdermal patches or gels in children; complianceand skin irritation are sometimes a problem.Ethinylestradiol is occasionally used, under specialistsupervision, for the management of hereditary haemorrhagictelangiectasia (but evidence of benefit is limited),for the prevention of tall stature, and in tests of growthhormone secretion (see below). Side-effects includenausea and fluid retention.Topical oestrogen creams are used in the treatment oflabial adhesions (see section 7.2.1)ETHINYLESTRADIOL(Ethinyloestradiol)Cautions see Combined Hormonal Contraceptives(section 7.3.1); interactions: Appendix 1 (Oestrogens)Contra-indications cardiovascular disease (sodiumretention with oedema), personal or family history ofthromboembolism, acute porphyria; see also CombinedHormonal Contraceptives (section 7.3.1)Hepatic impairment avoid in liver disease includingdisorders of hepatic excretion (e.g. Dubin-Johnson orRotor syndromes), infective hepatitis (until liverfunction returns to normal), and jaundicePregnancy avoidBreast-feeding avoidSide-effects nausea, vomiting, headache, breast tenderness,changes in body weight, fluid retention,depression, chorea, skin reactions, chloasma, hypertension,may irritate contact lenses, impairment ofliver function, hepatic tumours, rarely photosensitivity;see also Combined Hormonal Contraceptives(section 7.3.1)Licensed use unlicensed for use in childrenIndication and doseSee notes aboveInduction of sexual maturation in girls. By mouthInitially 2 micrograms daily, increasing every 6months to 5 micrograms, then to 10 micrograms,and then to 20 micrograms dailyNote after 12–18 months of treatment give progestogenfor 7 days of each 28-day cycleMaintenance of sexual maturation in girls. By mouth20 micrograms daily with cyclical progestogen for7 days of each 28-day cyclePrevention of tall stature in girls. By mouthGirls 2–12 years 20–50 micrograms dailyPituitary priming before growth hormonesecretion test in girls. By mouthGirls with bone age above 10 years 100 microgramsdaily for 3 days before testEthinylestradiol (Non-proprietary) ATablets, ethinylestradiol (unlicensed) 10 micrograms,net price 21-tab pack = £29.95; 50 micrograms, 21-tabpack = £38.20; 1 mg, 28-tab pack = £49.50Note 2 microgram tablets available from ‘special-order’manufacturers or specialist-importing companies, see p. 8096.4.1.2 ProgestogensThere are two main groups of progestogen, progesteroneand its analogues (dydrogesterone and medroxyprogesterone)and testosterone analogues (norethisteroneand norgestrel). The newer progestogens(desogestrel, norgestimate, and gestodene) are all derivativesof norgestrel; levonorgestrel is the active isomerof norgestrel and has twice its potency. Progesteroneand its analogues are less androgenic than the testosteronederivatives and neither progesterone nor dydrogesteronecauses virilisation.In delayed puberty cyclical progestogen is added after12–18 months of oestrogen therapy (section 6.4.1.1) toestablish a menstrual cycle; usually levonorgestrel30 micrograms or norethisterone 5 mg daily are usedfor the last 7 days of each 28 day cycle.Norethisterone is also used to postpone menstruationduring a cycle; treatment is started 3 days before theexpected onset of menstruation.NORETHISTERONECautions conditions that may worsen with fluidretention e.g. epilepsy, hypertension, migraine,asthma, cardiac dysfunction; susceptibility to thromboembolism(particular caution with high dose); historyof depression; diabetes (monitor closely); interactions:Appendix 1 (progestogens)Contra-indications history of liver tumours, severeliver impairment; severe arterial disease, undiagnosedvaginal bleeding; acute porphyria (section 9.8.2); historyduring pregnancy of idiopathic jaundice, severepruritus, or pemphigoid gestationisHepatic impairment caution; avoid if severeRenal impairment use with cautionPregnancy avoidBreast-feeding higher doses may suppress lactationand alter milk composition; use lowest effective doseSide-effects menstrual disturbances, premenstruallikesyndrome (including bloating, fluid retention,breast tenderness), weight gain, nausea, headache,dizziness, insomnia, drowsiness, depression; skinreactions (including urticaria, pruritus, rash, andacne), hirsutism and alopecia; jaundice and anaphylactoidreactions also reportedLicensed use not licensed for use in childrenIndication and doseSee notes aboveInduction and maintenance of sexual maturationin females (combined with an oestrogenafter 12–24 months oestrogen therapy). By mouth5 mg once daily for the last 7 days of a 28-day cycle