Women's Health: Period Delay, Contraception & Menopause

Women's health and online pharmacy

A wide range of women's health conditions can now be safely and conveniently managed through a GPhC-registered online pharmacy, without the need for a face-to-face GP appointment. Medicinex provides clinician-reviewed consultations for several women's health areas, with prescriptions dispensed by our registered pharmacist team and delivered discreetly across the UK.

Period delay: norethisterone explained

Norethisterone is a synthetic progestogen licensed in the UK for the postponement of menstruation. The BNF lists norethisterone 5 mg tablets for this indication, taken three times daily beginning three days before the expected start of the period.

According to the Electronic Medicines Compendium (EMC) Summary of Product Characteristics for norethisterone 5 mg:

• Menstruation is typically delayed for as long as the tablets are taken, up to a maximum of 14–17 days
• Withdrawal bleeding usually occurs within 2–3 days of stopping treatment
• Norethisterone maintains elevated progesterone levels, preventing the hormonal drop that triggers endometrial shedding

An alternative for women already taking the combined oral contraceptive pill is running two or three packs consecutively (tricycling) without a pill-free break. NICE CKS advises that this is acceptable and does not increase health risks, though it should be discussed with a prescriber.

Contraception: finding the right option

NICE CKS on contraception outlines that all long-acting reversible contraceptive (LARC) methods are more effective than user-dependent methods when used in real-world conditions. For women seeking the convenience of an oral contraceptive, the choice between the combined pill and the progestogen-only pill (POP) depends on medical history, lifestyle, and personal preference.

NICE CKS and the Faculty of Sexual and Reproductive Healthcare (FSRH) both provide UK Medical Eligibility Criteria (UKMEC) categories that guide prescribers in identifying which methods are safe for individual patients based on their medical history. Medicinex consultations follow these criteria to ensure safe prescribing.

The combined oral contraceptive pill

The combined oral contraceptive pill (COCP) contains synthetic oestrogen (ethinylestradiol) and a progestogen. NICE CKS states that when taken correctly, the COCP is over 99% effective at preventing pregnancy. It primarily works by suppressing ovulation, thickening cervical mucus, and thinning the uterine lining.

Beyond contraception, the FSRH guideline confirms that the COCP has recognised non-contraceptive benefits, including:

• Regulation and reduction of menstrual blood loss (dysmenorrhoea and menorrhagia)
• Management of symptoms in endometriosis and polycystic ovary syndrome (PCOS)
• Improvement of acne (particularly pills containing anti-androgenic progestogens such as drospirenone or cyproterone acetate)
• Reduction in risk of ovarian and endometrial cancer with long-term use

Vaginal thrush: when to treat

Vulvovaginal candidiasis (thrush) is caused by an overgrowth of Candida albicans and is one of the most common gynaecological conditions in the UK. NICE CKS reports that approximately 75% of women will experience at least one episode during their lifetime. Characteristic symptoms include:

• Vulval and vaginal itching or soreness
• White, thick, cottage cheese-like vaginal discharge with no offensive odour
• Superficial dyspareunia (pain during intercourse)
• External dysuria (stinging when urine contacts inflamed vulval skin)

Treatment options (BNF-listed)

NICE CKS recommends either oral or intravaginal antifungal treatment for uncomplicated acute thrush. The BNF lists the following licensed options:

• Fluconazole 150 mg oral capsule (single dose) — first-line oral treatment; fast, convenient, and highly effective for acute episodes. Available through Medicinex. Contraindicated in pregnancy — the BNF advises avoiding fluconazole in women who are pregnant or trying to conceive
• Clotrimazole 500 mg pessary (single dose) — intravaginal alternative; suitable in pregnancy under medical supervision
• Clotrimazole 1% or 2% cream — applied externally to relieve vulval symptoms; can be used alongside pessary or oral treatment

Menopause and perimenopause

Menopause is defined as 12 consecutive months without a menstrual period following the natural cessation of ovarian function. The average age of menopause in the UK is 51 years, though perimenopause — the transitional phase characterised by fluctuating oestrogen and irregular periods — may begin several years earlier.

NICE NG23 (2024 update) identifies the following as common symptoms associated with menopause that may warrant treatment:

• Vasomotor symptoms — hot flushes and night sweats, affecting approximately 75% of women; the most common reason for seeking treatment
• Sleep disturbance and fatigue
• Low mood, anxiety, and irritability
• Difficulty concentrating ("brain fog")
• Genitourinary symptoms — vaginal dryness, urinary frequency, and discomfort during intercourse (genitourinary syndrome of menopause, GSM)
• Reduced libido
• Joint and musculoskeletal aches

HRT: NICE 2024 guidance on benefits and risks

NICE NG23 (updated 2024) recommends that HRT should be offered to women with menopausal symptoms after an individualised discussion of the benefits and risks. The updated guideline emphasises that HRT is the most effective treatment for vasomotor symptoms and significantly improves quality of life.

Key points from the 2024 NICE NG23 guideline relevant to clinical decision-making:

• Cardiovascular disease: Transdermal oestrogen started in women under 60 or within 10 years of menopause is associated with reduced cardiovascular risk. Oral HRT in older women may carry a small increased risk
• Bone health: HRT reduces the risk of osteoporotic fractures and is acknowledged as having a bone-protective effect
• Breast cancer: NICE NG23 notes a small increased risk associated with combined (oestrogen + progestogen) HRT; oestrogen-only HRT (for women post-hysterectomy) is associated with little or no increased risk. The absolute risk is small and must be contextualised against benefits
• VTE risk: Transdermal oestrogen carries a lower VTE risk than oral preparations — the BNF and NICE both recommend transdermal routes for women with risk factors for thrombosis

Forms of HRT listed in the BNF

• Combined HRT (oestrogen + progestogen) — for women with an intact uterus; progestogen protects the endometrium from hyperplasia
• Oestrogen-only HRT — for women who have had a hysterectomy; the BNF notes this does not carry the same breast cancer risk as combined HRT
• Transdermal preparations (patches, gels, sprays) — preferred route per NICE NG23 for women with VTE risk factors or cardiovascular concerns, as first-pass hepatic metabolism is avoided
• Local (vaginal) oestrogen — creams, pessaries, or rings for genitourinary symptoms only; NICE NG23 notes minimal systemic absorption and a favourable safety profile, including in women with a history of breast cancer (with specialist guidance)