Trisequens
Package leaflet: Information for the user Trisequens® Tablets
(estradiol hemihydrate and norethisterone acetate)
Read this entire leaflet carefully before you start taking this medicine because it contains important information for you.
Keep this leaflet. You may need to read it again.
If you have any further questions, ask your doctor or pharmacist. This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.
What is in this leaflet
1. What Trisequens® is and what it is used for
2. What you need to know before you take Trisequens®
3. How to take Trisequens®
4. Possible side effects
5. Howto store Trisequens®
6. Contents of the pack and other information 1 2
• if you have excessive thickening of the womb lining (endometrial hyperplasia) that is not being treated
• if you have or have ever had a blood clot in a vein (venous thromboembolism), such as in the legs (deep venous thrombosis) or the lungs (pulmonary embolism)
• if you have a blood clotting disorder (such as protein C, protein S or antithrombin deficiency)
• if you have or previously have had a disease caused by blood clots in the arteries, such as a heart attack, stroke or angina
• if you have or have ever had a liver disease and your liver function tests have not returned to normal
• if you are allergic (hypersensitive) to estradiol, norethisterone acetate or any of the other ingredients of Trisequens® (listed in section 6 Contents of the pack and other information)
• if you have a rare blood problem called ‘porphyria’ which is passed down in families (inherited).
If any of the above conditions appear for the first time while taking Trisequens®, stop taking it at once and consult your doctor immediately.
Warnings and precautions
Tell your doctor if you have ever had any of the following problems, before you start the treatment, as these may return or become worse during treatment with Trisequens®.
If so, you should see your doctor more often for check-ups:
• fibroids inside your womb
• growth of womb lining outside your womb (endometriosis) or a history of excessive growth of the womb lining (endometrial hyperplasia)
• increased risk of developing blood clots (see Blood clots in a vein (venous thromboembolism))
• increased risk of getting an oestrogen-sensitive cancer (such as having a mother, sister or grandmother who has had breast cancer)
• high blood pressure
• a liver disorder, such as a benign liver tumour
• diabetes
• gallstones
• migraine or severe headaches
• a disease of the immune system that affects many organs of the body (systemic lupus erythematosus, SLE)
• epilepsy
• asthma
• a disease affecting the eardrum and hearing (otosclerosis)
• a very high level of fat in your blood (triglycerides)
• fluid retention due to cardiac or kidney problems
• lactose intolerance.
Stop taking Trisequens® and see a doctor immediately
If you notice any of the following when taking HRT:
• any of the conditions mentioned in the Do not take Trisequens® section
• yellowing of your skin or the whites of your eyes (jaundice).
These may be signs of a liver disease
• a large rise in your blood pressure (symptoms may be headache, tiredness and dizziness)
• migraine-like headaches which happen for the first time
• if you become pregnant
• if you notice signs of a blood clot, such as:
painful swelling and redness of the legs sudden chest pain difficulty in breathing.
For more information, see Blood clots in a vein (venous thromboembolism).
Note: Trisequens® is not a contraceptive.
If it is less than 12 months since your last menstrual period or you are under 50 years old, you may still need to use additional contraception to prevent pregnancy.
Speak to your doctor for advice.
HRT and cancer
Excessive thickening of the lining of the womb (endometrial hyperplasia) and cancer of the lining of the womb (endometrial cancer)
Taking oestrogen-only HRT will increase the risk of excessive thickening of the lining of the womb (endometrial hyperplasia) and cancer of the womb lining (endometrial cancer).
The progestagen in Trisequens® protects you from this extra risk.
Compare
In women who still have a womb and who are not taking HRT, on average, 5 in 1,000 will be diagnosed with endometrial cancer between the ages of 50 and 65.
For women aged 50 to 65 who still have a womb and who take oestrogen-only HRT, between 10 and 60 women in 1,000 will be diagnosed with endometrial cancer (i.e. between 5 and 55 extra cases), depending on the dose and for how long it is taken.
Unexpected bleeding
You will have a bleed once a month (so-called withdrawal bleed) while taking Trisequens®. But if you have unexpected bleeding or drops of blood (spotting) besides your monthly bleeding which:
• carries on for more than the first 6 months
• starts after you have been taking Trisequens® more than 6 months
• carries on after you have stopped taking Trisequens® see your doctor as soon as possible.
Breast cancer
Evidence suggests that taking combined oestrogen-progestagen and possibly also oestrogen-only HRT increases the risk of breast cancer.
The extra risk depends on how long you take HRT. The additional risk becomes clear within a few years. However, it returns to normal within a few years (at most 5) after stopping treatment.
Compare
Women aged 50 to 79 who are not taking HRT, on average, 9 to 17 in 1,000 will be diagnosed with breast cancer over a 5-year period.
For women aged 50 to 79 who are taking oestrogen-progestagen HRT over 5 years, there will be 13 to 23 cases in 1,000 users (i.e. an extra 4 to 6 cases).
Regularly check your breasts.
See your doctor if you notice any changes such as:
• dimpling of the skin
• changes in the nipple
• any lumps you can see or feel.
Additionally, you are advised to join mammography screening programs when offered to you. For mammogram screening, it is important that you inform the nurse/healthcare professional who is actually taking the x-ray that you use H RT, as this medication may increase the density of your breasts which may affect the outcome of the mammogram.
Where the density of the breast is increased, mammography may not detect all lumps.
Ovarian cancer
Ovarian cancer is rare - much rarer than breast cancer. The use of oestrogen-only or combined oestrogen-progestagen HRT has been associated with a slightly increased risk of ovarian cancer.
The risk of ovarian cancer varies with age. For example, in women aged 50 to 54 who are not taking HRT, about 2 women in 2,000 will be diagnosed with ovarian cancer over a 5-year period. For women who have been taking HRT for 5 years, there will be about 3 cases per 2,000 users (i.e. about 1 extra case).
Effect of HRT on heart and circulation
Blood clots in a vein (venous thromboembolism)
The risk of blood clots in the veins is about 1.3 to 3 times higher in HRT users than in non-users, especially during the first year of taking it.
Blood clots can be serious, and if one travels to the lungs, it can cause chest pain, breathlessness, fainting or even death.
You are more likely to get a blood clot in your veins as you get older and if any of the following applies to you. Inform your doctor if any of these situations applies to you:
• you are unable to walk for a long time because of major surgery, injury or illness (see section 3, If you need to have surgery)
• you are seriously overweight (BMI > 30 kg/m2)
• you have any blood clotting problem that needs long-term treatment with a medicine used to prevent blood clots
• if any of your close relatives has ever had a blood clot in the leg, lung or another organ
• you have systemic lupus erythematosus (SLE)
• you have cancer.
For signs of a blood clot, see Stop taking Trisequens® and see a doctor immediately.
Compare
Looking at women in their 50s who are not taking HRT, on average, over a 5-year period, 4 to 7 in 1,000 would be expected to get a blood clot in a vein.
For women in their 50s who have been taking oestrogen-progestagen HRT for over 5 years, there will be 9 to 12 cases in 1,000 users (i.e. an extra 5 cases).
Heart disease (heart attack)
There is no evidence that HRT will prevent a heart attack.
Women over the age of 60 years who use oestrogen-progestagen HRT are slightly more likely to develop heart disease than those not taking any HRT.
Stroke
The risk of getting stroke is about 1.5 times higher in HRT users than in non-users. The number of extra cases of stroke due to use of HRT will increase with age.
Compare
Looking at women in their 50s who are not taking HRT, on average, 8 in
1.000 would be expected to have a stroke over a 5-year period.
For women in their 50s who are taking HRT, there will be 11 cases in
1.000 users over 5 years (i.e. an extra 3 cases).
Other conditions
HRT will not prevent memory loss.
There is some evidence of a higher risk of memory loss in women who start using HRT after the age of 65.
Speak to your doctor for advice.
Using other medicines
Some medicines may interfere with the effect of Trisequens®. This might lead to irregular bleeding. This applies to the following medicines:
• Medicines for epilepsy (such as phenobarbital, phenytoin and carbamazepine)
• Medicines for tuberculosis (such as rifampicin and rifabutin)
• Medicines for HIV infection (such as nevirapine, efavirenz, ritonavir and nelfinavir)
• Medicines for hepatitis C infections (such as telaprevir)
• Herbal remedies containing St John’s Wort (Hypericum perforatum).
Other medicines may increase the effects of Trisequens®:
• Medicines containing ketoconazole (a fungicide).
Trisequens® may have an impact on a concomitant treatment with ciclosporin.
Please tell your doctor or pharmacist if you are taking or have recently taken any other medicines including medicines obtained without a prescription, herbal medicines or other natural products.
Laboratory tests
If you need a blood test, tell your doctor or the laboratory staff that you are taking Trisequens®, because this medicine can affect the results of some tests.
Taking Trisequens® with food and drink
The tablets can be taken with or without food and drink.
Pregnancy and breast-feeding
Pregnancy: Trisequens® is for use in postmenopausal women only. If you become pregnant, stop taking Trisequens® and contact your doctor.
Breast-feeding:
You should not take Trisequens® if you are breast-feeding.
Driving and using machines
Trisequens® has no known effect on the ability to drive or use machines.
Important information about some of the ingredients in Trisequens®
Trisequens® contains lactose monohydrate. If you have an intolerance to some sugars, contact your doctor before taking Trisequens®.
3. How to take Trisequens®
Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are unsure.
If you are not switching from another hormone replacement therapy, you can start treatment with Trisequens® on any convenient day. If you are switching from another hormone replacement therapy, ask your doctor when you should start treatment with Trisequens®.
Take one tablet once a day, at about the same time each day.
Each pack contains 3 x 28 tablets.
Days 1-12 Take one blue tablet every day for 12 days Days 13-22 Take one white tablet every day for 10 days Days 23 - 28 Take one red tablet every day for 6 days.
Take the tablets with a glass of water.
Once you have finished the pack, start a new pack continuing the treatment without interruption. A menstruation- like bleeding (period) usually occurs at the beginning of a new pack.
For further information on the use of the calendar pack, see USER INSTRUCTIONS at the end of the package leaflet.
Your doctor will aim to prescribe the lowest dose to treat your symptom for as short as necessary. Speak to your doctor if you think this dose is too strong or not strong enough.
Talk to your doctor if you do not experience symptom relief after 3 months of treatment. You should only continue treatment as long as the benefit outweighs the risk.
If you take more Trisequens® than you should
If you have taken more Trisequens® than you should, talk to a doctor or pharmacist. An overdose of Trisequens® could make you feel sick or vomit.
If you forget to take Trisequens®
If you forget to take your tablet at the usual time, take it within the next 12 hours. If more than 12 hours have gone by, start again as normal the next day. Do not take a double dose to make up for a forgotten tablet. Forgetting a dose may increase the likelihood of breakthrough bleeding and spotting.
If you stop taking Trisequens®
If you would like to stop taking Trisequens®, talk to your doctor first. Your doctor will explain the effects of stopping treatment and discuss other possibilities with you.
If you have any further questions on the use ofthis medicine, ask your doctor or pharmacist.
If you need to have surgery
If you are going to have surgery, tell the surgeon that you are taking Trisequens®. You may need to stop taking Trisequens® about 4 to 6 weeks before the operation to reduce the risk of a blood clot (see section 2, Blood clots in a vein (venous thromboembolism)). Ask your doctor when you can start taking Trisequens® again.
4. Possible side effects
Like all medicines, this medicine can have side effects, although not everybody gets them.
The following diseases are reported more often in women using FIRT compared to women not using HRT:
• breast cancer
• abnormal growth or cancer of the lining of the womb (endometrial hyperplasia or cancer)
• ovarian cancer
• blood clots in the veins of the legs or lungs (venous thromboembolism)
• heart disease
• stroke
• probable memory loss if HRT is started over the age of 65.
For more information about these side effects, see section 2 What you need to know before you take Trisequens®.
Hypersensitivity/allergy
(uncommon side effect - affects 1 to 10 users in 1,000)
Though it is an uncommon event, hypersensitivity/allergy may occur.
Signs of hypersensitivity/allergy may include one or more of the following symptoms: hives, itching, swelling, difficulty in breathing, low blood pressure (paleness and coldness of skin, rapid heartbeat), feeling dizzy, sweating, which could be signs of anaphylactic reaction/shock.
If one of the mentioned symptoms appears, stop taking Trisequens® and seek immediate medical help.
Very common side effects
• Breast pain or breast tenderness
• Irregular periods or excessive bleeding during your periods.
Common side effects
• Headache
• Weight gain caused by fluid retention
• Vaginal inflammation
• Vaginal infection with a fungus
• Migraine, new or worse than before
• Depression, new or worse than before
• Nausea
• Abdominal pain, swelling or discomfort
• Enlargement or swelling of the breasts (breast oedema)
• Back pain
• Leg cramps
• Uterine fibroid (benign tumour), aggravation, occurrence or recurrence
• Swelling of arms and legs (peripheral oedema)
• Weight increase.
Uncommon side effects
• Bloating or flatulence
• Acne
• Hair loss (alopecia)
• Abnormal (male pattern) hair growth
• Itching or hives (urticaria)
• Inflammation of a vein (superficial thrombophlebitis)
• Drug ineffective
• Allergic reaction
• Endometrial hyperplasia (excessive growth of the lining of the womb)
• Painful periods
• Nervousness.
Rare side effects
• Pulmonary embolism (blood clot) (see Blood clots in a vein in section 2 What you need to know before you take Trisequens®)
• Deep inflammation of a vein associated with thrombosis (blood clot).
Very rare side effects
• Cancer of the lining of the womb (endometrial cancer)
• Increase in blood pressure or worsening of high blood pressure
• Gall bladder disease, gallstones occurrence/recurrence or aggravated
• Excessive secretion of sebum, skin eruption
• Acute or recurring attack of oedema (angioneurotic oedema)
• Insomnia, dizziness, anxiety
• Change in sexual desire
• Visual disturbances
• Weight decreased
• Vomiting
• Heartburn
• Vaginal and genital itching
• Heart attack and stroke.
The frequency of possible side effects listed above is defined using the following convention:
Very common (affects more than 1 user in 10)
Common (affects 1 to 10 users in 100)
Uncommon (affects 1 to 10 users in 1,000)
Rare (affects 1 to 10 users in 10,000)
Very rare (affects less than 1 user in 10,000)
Not known (frequency cannot be estimated from the available data).
1. Set the day reminder
Turn the inner disc to set the day of the week opposite the little plastic tab.
2. Take the first day’s tablet
Break the plastic tab and tip out the first
tablet.
Other side effects of combined HRT
The following side effects have been reported with other HRTs:
• various skin disorders:
discolouration of the skin, especially of the face or neck, known
as ‘pregnancy patches’ (chloasma)
painful reddish skin nodules (erythema nodosum)
rash with target-shaped reddening or sores (erythema
multiforme).
Reporting of side effects
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via Yellow Card Scheme Website: www.mhra.aov.uk/vellowcard.
By reporting side effects you can help provide more information on the safety of this medicine.
5. How to store Trisequens®
Do not store above 25°C. Protect from light and moisture. Do not refrigerate.
Keep out of the sight and reach of children
Do not remove the tablets from the calendar dial pack except when taking them.
Do not use this medicine after the expiry date on the carton, or if the product shows signs of deterioration or discolouration.
If your doctor decides to stop treatment return any remaining tablets you have left to the pharmacist for safe disposal. Only keep them if your doctor tells you to.
Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. These measures will help to protect the environment.
6. Contents of the pack and other Information
Trisequens® 12 blue round film coated tablets marked ‘NOVO 280’ on one side and plain on reverse, each containing 2 milligrams of estradiol (as hemihydrate) which is an oestrogen as active ingredient.
Trisequens® 10 white round film coated tablets marked ‘ NOVO 281’ on one side and plain on reverse, each containing 2 milligrams of estradiol (as hemihydrate) and 1 mg of norethisterone acetate as active ingredients.
Trisequens® 6 red film coated tablets marked ‘NOVO 282’ on one side and plain on reverse, each containing 1 milligram of estradiol (as hemihydrate) as active ingredient.
Each tablet also contains lactose monohydrate, maize starch, hydroxypropyl cellulose, talc, hypromellose and magnesium stearate.
The blue tablets also contain: titanium dioxide (E171), indigo carmine
(E132) and macrogol 400
The white tablets also contain: triacetin
The red pills also contain: titanium dioxide (E171), red iron oxide and propylene glycol
Trisequens® Tablets come in 3 calendar dial packs of 28 tablets (a total of 84 Tablets).
USER INSTRUCTIONS
How to use the calendar pack
A translation of the days of the week is as follows:
LU MA ME JE VE SA Dl
MON TUE WED THUR FRI SAT SUN
3. Move the dial every day
On the next day, simply move the transparent dial clockwise 1 space as indicated by the arrow. Tip out the next tablet. Remember to take only 1 tablet once a day.
You can only turn the transparent dial after the tablet in the opening has been removed.
This medicine is manufactured by Novo Nordisk A/S, 2880 Bagsvaerd, Denmark. Procured from within the EU: Product Licence holder: Quadrant Pharmaceuticals Ltd, Lynstock House, Lynstock Way, Lostock, Bolton BL6 4SA. Repackaged by Maxearn Ltd, Bolton BL6 4SA.
POM
Trisequens® Tablets PL 20774/0640 Date of preparation: 17th August 2016
Trisequens is a registered trade mark of Novo Nordisk FemCare AG.
PP5/0640/V3
What Trisequens® is and what it is used for
Trisequens® is a sequential combined Hormone Replacement Therapy (HRT) which is taken every day without interruption. Trisequens® is used in postmenopausal women with at least 6 months since their last natural period.
Trisequens® contains 2 hormones, an oestrogen (estradiol) and a progestogen (norethisterone acetate).
The estradiol in Trisequens® is identical to the estradiol produced in the ovaries of women, and is classified as a natural oestrogen.
Norethisterone acetate is a synthetic progestagen, which acts in a similar manner as progesterone, another important female sex hormone.
Trisequens® is used for:
Relief of symptoms occurring after menopause
During the menopause, the amount of the oestrogen produced by a woman’s body drops. This can cause symptoms such as hot face, neck and chest (‘hot flushes’).
Trisequens® alleviates these symptoms after menopause. You will only be prescribed Trisequens® if your symptoms seriously hinder your daily life.
Prevention of osteoporosis
After the menopause some women may develop fragile bones (osteoporosis).
You should discuss all available options with your doctor.
If you are at an increased risk of fractures due to osteoporosis and other medicines are not suitable for you, you can use Trisequens® to prevent osteoporosis after menopause.
The experience of treating women older than 65 years is limited.
What you need to know before you take Trisequens®
Medical history and regular check-ups
The use of HRT carries risks which need to be considered when deciding whether to start taking it, or whether to carry on taking it.
The experience in treating women with a premature menopause (due to ovarian failure or surgery) is limited. If you have a premature menopause, the risks of using HRT may be different.
Please talk to your doctor.
Before you start (or restart) HRT, your doctor will ask about your own and your family’s medical history.
Your doctor may decide to perform a physical examination.
This may include an examination of your breasts and/or an internal examination, if necessary.
Once you have started on Trisequens®, you should see your doctor for regular check-ups (at least once a year). At these checkups, discuss with your doctor the benefits and risks of continuing with Trisequens®.
Go for regular breast screening, as recommended by your doctor.
Do not take Trisequens®
If any of the following applies to you. If you are not sure about any of the points below, talk to your doctor before taking Trisequens®.
Do not take Trisequens®:
• if you have, have had or suspect having breast cancer
• if you have, have had or suspect having cancer of the womb lining (endometrial cancer) or any other oestrogen dependent cancer
• if you have any unexplained vaginal bleeding