Cyclogest 200mg pessaries

Cyclogest is indicated for the

1) Treatment of premenstrual syndrome, including premenstrual tension and depression.

2) Treatment of puerperal depression.

3) Prevention of preterm birth in high-risk pregnant women with a singleton pregnancy who have a history of spontaneous preterm birth and/or a short cervix of 25 mm or less measured between 16 and 24 weeks of pregnancy (see Section 4.4).

For the treatment of premenstrual syndrome and puerperal depression:

200mg daily to 400mg twice a day, by vaginal or rectal insertion. For premenstrual syndrome commence treatment on day 14 of menstrual cycle and continue treatment until onset of menstruation. If symptoms are present at ovulation commence treatment on day 12.

For the prevention of preterm birth in high-risk pregnant women with a singleton pregnancy:

200mg administered vaginally once a day at bedtime, starting between 16 and 24 weeks and continued until at least 34 weeks of pregnancy for women with either:

a) A history of spontaneous preterm birth (up to 34⁺⁰ weeks of pregnancy) or mid-trimester loss (from 16⁺⁰ weeks of pregnancy onwards); or

b) Results from a transvaginal ultrasound scan carried out between 16⁺⁰ and 24⁺⁰ weeks of pregnancy that show a cervical length of 25 mm or less.

For information on shared decision making, see Section 4.4.

Use in special populations: There is no experience with use of Cyclogest in patients with impaired liver or renal function.

Paediatric population: There is no relevant use of Cyclogest in the paediatric population.

Elderly: No clinical data have been collected in patients over age 65.

- Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

- Undiagnosed vaginal bleeding (see Section 4.4.).

- Known or suspected progesterone sensitive malignant tumours.

- Porphyria.

- Severe hepatic dysfunction or disease

- Known missed abortion or ectopic pregnancy.

- Active arterial or venous thromboembolism or severe thrombophlebitis, or a history of these events.

- Preterm premature rupture of membranes (PPROM) (see Section 4.4.).

Precautions specific for prevention of preterm birth in high-risk pregnant women with a singleton pregnancy who have a history of spontaneous preterm birth and/or a short cervix:

Before treatment with Cyclogest is initiated:

- The risks and benefits of all options available which have the potential to prevent preterm birth, should be discussed with the patient. Medical practitioner and the patient should then make a shared decision on which treatment is most suitable based on individual circumstances (see section 5.1).

After starting the treatment with Cyclogest during pregnancy:

- Any kind of vaginal bleeding should always be investigated.

- Preterm premature rupture of membranes (PPROM) should be excluded. Should rupture of membranes occur during treatment with Cyclogest 200mg Pessaries, further treatment should be discontinued (see section 4.3).

Cyclogest is not indicated in threatened miscarriage. Treatment should be discontinued in the event of a missed miscarriage.

Cyclogest should be discontinued if any of the following conditions are suspected:

myocardial infarction, cerebrovascular disorders, arterial or venous thromboembolism (venous thromboembolism or pulmonary embolism), thrombophlebitis or retinal thrombosis.

Although risk of thromboembolism has been associated with estrogens, a link with progestins remains questionable. Therefore, in women with generally recognised risk factors for thromboembolic events, such as personal or family history, treatment with Cyclogest may further increase the risk. In these women, the benefits of Cyclogest administration need to be weighed against the risks. It should be noted however, that pregnancy itself carries an increased risk of thrombo-embolic events.

Patients with a history of depression need to be closely observed. Consider discontinuation if symptoms worsen.

Because progesterone may cause some degree of fluid retention, conditions that might be influenced by this factor (e.g. epilepsy, migraine, asthma, cardiac or renal dysfunction) require careful observation.

A decrease in glucose tolerance has been observed in a small number of patients on estrogen-progestin combination drugs. The mechanism of this decrease is not known. For this reason, diabetic patients should be carefully observed while receiving progestin therapy.

Progesterone is metabolised in the liver and should be used with caution in patients with hepatic dysfunction.

Cyclogest contains the hormone progesterone which is present in significant concentrations in women during the second half of the menstrual cycle and during pregnancy. This should be borne in mind when treating patients with conditions that may be hormone-sensitive.

Abrupt discontinuation of progesterone dosing may cause increased anxiety, moodiness, and increased sensibility to seizures.

Treatment of premenstrual syndrome and puerperal depression:

Use rectally if barrier methods of contraception are used.

Use rectally if patients suffer from vaginal infection (especially moniliasis) or recurrent cystitis or have recently given birth.

Use vaginally if patients suffer from colitis or faecal incontinence.

Drugs known to induce the hepatic cytochrome-P450-3A4 system (e.g. rifampicin, carbamazepine or phenytoin) may increase the elimination rate and thereby decrease the bioavailability of progesterone.

The effect of concomitant vaginal products on the exposure of progesterone from Cyclogest has not been assessed and is therefore not recommended.

Pregnancy

Cyclogest should not be used during pregnancy except as indicated during the second and third trimesters of pregnancy in order to prevent preterm birth in high-risk pregnant women with a singleton pregnancy (see section 4.1 for full details). There is limited and inconclusive data on the risk of congenital anomalies, including genital abnormalities in male or female infants, following intrauterine exposure during pregnancy. The rates of congenital anomalies, spontaneous abortion and ectopic pregnancies observed during the clinical trial were comparable with the event rate described in the general population although the total exposure is too low to allow conclusions to be drawn.

Lactation

Progesterone is excreted in human milk and Cyclogest should not be used during breast-feeding.

None known.

Very common (≥ 1/10), Common (≥ 1/100 to < 1/10), Uncommon (≥ 1/1,000 to < 1/100), Rare (≥ 1/10,000 to < 1/1,000), Very rare (< 1/10,000), Not known (cannot be estimated from the available data)

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard or via the Yellow Card app, which can be downloaded from the Apple App Store, or Google Play Store.

There is a wide margin of safety with Cyclogest pessaries, but overdosage may produce euphoria or dysmenorrhoea

Pharmacotherapeutic group: Sex hormones and modulators of the genital system; Progestogens; Pregnen-(4) derivatives. ATC code: G03DA04.

Progesterone is a naturally occurring steroid that is secreted by the ovary, placenta, and adrenal gland. In the presence of adequate estrogen, progesterone transforms a proliferative endometrium into a secretory endometrium. Progesterone is necessary to increase endometrial receptivity for implantation of an embryo. Once an embryo is implanted, progesterone acts to maintain the pregnancy and ensures uterine quiescence by limiting the production of stimulatory prostaglandins responsible for uterine contractions. Progesterone also limits the release of matrix metalloproteinases which can cause cervical shortening and softening by inhibiting the expression of contraction-associated protein genes (ion channels, oxytocin and prostaglandin receptors, and gap junctions) within the myometrium.

Even though the levels of progesterone measured in maternal circulation do not change significantly in the weeks preceding labour, the onset of uterine contractions at term and preterm is associated with a functional withdrawal of progesterone activity at the level of the uterus.

Clinical efficacy / safety studies

The “Stitch, Pessary, or Progesterone Randomised Trial” (SuPPoRT); a multicentre, open label 3-arm randomised controlled trial, funded by the National Institute of Health Research, was designed to compare the rate of preterm birth before 37 weeks between each intervention in women who develop a short cervix in pregnancy. The SuPPoRT group (2024) confirmed that cervical cerclage, cervical pessary, and vaginal progesterone (Cyclogest 200mg pessary once daily) were equally efficacious at preventing preterm birth in high-risk pregnant women with a singleton pregnancy.

Therefore, medical practitioner and the patient should discuss which treatment option is most suitable based on individual's circumstances, benefits, risks and practicalities of each intervention and then make a shared decision.

In a large-scale review of individual participant data from 31 randomised controlled trials in 11,644 women, the EPPPIC study group (2021) concluded that vaginal progesterone reduced birth before 34 week of pregnancy in high-risk singleton pregnancies. Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0.78, 95% CI 0.68– 0.90). Absolute risk reduction was greater for women with a short cervix, hence progesterone treatment might be most useful for these women given the increased underlying risk.

Absorption

Vaginal administration of Cyclogest 200 mg every 12 h in healthy women has been shown effective in rapidly achieving and maintaining serum progesterone concentrations at physiological levels appropriate to the midluteal phase of the ovarian cycle and early pregnancy.

The mean Cmax after 10 days of multiple dosing was 13.1 [ng/mL] and Ctrough was 3.58 [ng/mL].

Distribution

Progesterone is approximately 96 % to 99 % bound to serum proteins, primarily to serum albumin and corticosteroid binding globulin.

Biotransformation

Progesterone is metabolized primarily by the liver largely to pregnanediols and pregnanolones. Pregnanediols and pregnanolones are conjugated in the liver to glucuronide and sulfate metabolites. Progesterone metabolites that are excreted in the bile may be deconjugated and may be further metabolized in the gut via reduction, dehydroxylation, and epimerization.

Elimination

When micronised progesterone is administered vaginally, the hepatic first-pass metabolism can be avoided, which enables the plasma concentrations to remain higher for longer. Progesterone undergoes renal and biliary elimination.

There are no preclinical data of relevance to the prescriber which are additional to those already included in other sections of the SmPC.

Hard fat

None known

Shelf-life

4 years.

Shelf-life after dilution/reconstitution

Not applicable.

Shelf-life after first opening

Not applicable.

Do not store above 30°C.

The product may be supplied in strip packs contained in cartons:

Carton: White backed folding box board printed on white.

Strip pack: Aluminium foil lacquer-laminated to 20µm polypropylene foil and coated on the reverse with polythene (20mg/m²). The alternative is thermoplastic film and laminated PVC to 95µm and polyethylene to 27-33µm.

Pack sizes: 5s, 12s, 15s

Do not throw away any medicines via wastewater or household waste. These measures will help protect the environment