Trisequens Tablets

Trisequens Tablets is a brand of medicine containing the active ingredients estradiol / estradiol - norethisterone acetate / estradiol.

Find out more about active ingredients.

Consumer medicine information (CMI) leaflet

Developed by the pharmaceutical company responsible for this medicine in Australia, according to TGA regulations.

Trisequens®

Oestradiol/Norethisterone acetate


Consumer Medicine Information

What is in this leaflet

  • What Trisequens® is used for
  • Before you take Trisequens®
  • How to take Trisequens®
  • While you are taking Trisequens®
  • Side effects
  • Storage
  • Product description
  • Further information
  • User instructions

This leaflet answers some common questions about Trisequens®. It does not contain all the available information. It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using Trisequens® against the benefits they expect it will have for you.

Ask your doctor or pharmacist if you have any concerns about using this medicine.

Keep this leaflet with the medicine. You may need to read it again.

Trisequens® is available only by prescription at pharmacies.

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What Trisequens® is used for

Trisequens® is a type of hormone replacement therapy (HRT) that relieves the symptoms of oestrogen deficiency associated with the menopause. It is a short term symptomatic treatment, also used where these symptoms arise from medical or surgical procedures affecting the ovaries.

The menopause, a woman's last menstrual period, usually occurs between the ages of 45 and 55 years. During this natural life transition, a woman slowly stops producing two female hormones called oestrogen and progesterone. Menstrual periods become less frequent until they finally stop.

The falling hormone levels may cause you to experience uncomfortable symptoms such as hot flushes or night sweats.

Trisequens® contains two hormones, an oestrogen (oestradiol) and a progestagen (norethisterone acetate). The oestradiol in Trisequens® is identical to the oestradiol 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.

The oestrogen in Trisequens® relieves the symptoms caused by a lack of oestrogen. The progestagen protects the lining of your womb from overstimulation by oestrogen.

Your doctor may have prescribed Trisequens® for another reason.

Ask your doctor if you have any questions about why Trisequens® has been prescribed for you.

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Before you take Trisequens®

When you must not take it

Do not take Trisequens® if any of the following applies to you. Talk to your doctor before taking Trisequens® if you are not sure about any of the points below.

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
  • 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 (e.g. deep vein 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 blood test results have not returned to normal
  • if you have a rare blood problem called ‘porphyria’ which is passed down in families (inherited)
  • if you are allergic (hypersensitive) to oestradiol, norethisterone acetate or any of the other ingredients of Trisequens® (listed in the Ingredients section of this leaflet)
  • if you are pregnant or suspect you may be pregnant, or you are breast-feeding
  • it is after the expiry date (‘Expiry’) printed on the pack
  • the packaging is torn or shows signs of tampering.

Stop taking Trisequens® at once and consult your doctor immediately if any of the above conditions appear for the first time while taking this medicine.

Before you start to take it

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.

Talk to your doctor if you have a premature menopause. 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.

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 check-ups, discuss with your doctor the benefits and risks of continuing with Trisequens®.

Go for regular breast screening as recommended by your doctor.

The experience of treating women older than 65 years’ is limited.

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:

  • heart disease
  • fibroids inside your womb
  • growth of the 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

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 When you must not take it 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, dizziness).
  • migraine-like headaches which happen for the first time.
  • if you become pregnant.
  • sudden development of visual problems.
  • 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® reduces 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.

Irregular bleeding
You may have irregular bleeding or drops of blood (spotting) during the first 3-6 months of taking Trisequens®.

However, see your doctor as soon as possible if the irregular bleeding:

  • carries on for more than the first 6 months
  • starts after you have been taking Trisequens® for more than 6 months
  • carries on after you have stopped taking Trisequens®.

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 HRT, 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. A slightly increased risk of ovarian cancer has been reported in women taking HRT for at least 5 to 10 years.

Women aged 50 to 69 who are not taking HRT, on average, about 2 women in 1,000 will be diagnosed with ovarian cancer over a 5-year period. For women who have been taking HRT for 5 years, there will be between 2 and 3 cases per 1,000 users (i.e. up to 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 also If you need to have surgery, below)
  • 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, above.

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.

Tell your doctor or the laboratory staff that you are taking Trisequens® if you need a blood test. This is because this medicine can affect the results of some tests.

Taking other medicines

Tell your doctor if you are taking or plan to take other medicines, including:

  • other oestrogen medicines
  • medicines to help you sleep, including barbiturates
  • medicines for epilepsy e.g. phenytoin, carbamazepine, lamotrigine
  • some antibiotics and other anti-infective medicines e.g. rifampicin, penicillin, cyclosporin, rifabutin, nevirapine, efavirenz, ritonavir, nelfinavir, ketoconazole
  • medicines for hepatitis C infections (such as telaprevir)
  • St. John’s Wort - used to treat depression
  • antihistamines - used to treat allergies
  • anticoagulants and antifibrinolytics - used to manage blood clotting processes
  • antidiabetic drugs - used to treat diabetes
  • medicines which decrease serum folate
  • thyroid hormones - used to treat malfunction of the thyroid gland
  • corticosteroids - used to treat inflammatory conditions.

Or other specific medicines including:

  • imipramine
  • pethidine.

Tell your doctor or pharmacist if you are taking any other medicines, including any that you buy without a prescription from your pharmacy, supermarket or health food shop. The effect of Trisequens® can be reduced by other medicines, and may affect your vaginal bleeding pattern.

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How to take Trisequens®

How to take it

Read carefully the instructions included in this leaflet, in order to correctly use the calendar pack.

Your doctor will tell you when to start taking the tablets. If you are still having periods, you would usually take the first tablet on the fifth day after the start of your period. If your periods have stopped or have become infrequent, the first tablet can be taken as soon as you get the product.

Take one tablet a day, preferably at the same time each day, until all 28 tablets have been taken. Swallow each tablet with a glass of water. When you have finished each pack, start the next pack immediately.

How long to take it

HRT should be prescribed at the lowest effective dose and for the shortest duration necessary (see Before you start to take it). The continuation of the treatment should be re-evaluated annually. Women who have undergone a premature menopause (e.g. hysterectomy) may require longer term treatment.

If you forget to take it

You can always see if you have taken your tablet by looking at the day on the calendar pack.

If you forget to take a tablet at the usual time, take it as soon as you remember. If it is almost time for your next dose, throw away the tablet you missed and take your next dose when you are meant to.

You may have vaginal bleeding or spotting if you forget to take more than 1 tablet. Ask your doctor for advice.

Do not take a double dose to make up for a forgotten tablet.

If you take too much (overdose)

If you take more tablets than you have been prescribed, contact your doctor for advice.

Overdose may cause nausea and vomiting, headache, dizziness, swelling due to fluid retention (oedema), breast enlargement and build up of the lining of the womb.

If you need to have surgery

Tell the surgeon that you are taking Trisequens® if you are going to have surgery. You may need to stop taking Trisequens® about 4 to 6 weeks before the operation to reduce the risk of a blood clot (see Blood clots in a vein (venous thromboembolism)).

Ask your doctor when you can start taking Trisequens® again.

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While you are taking Trisequens®

You can expect your symptoms to improve within a few months of starting Trisequens®. You will normally have a period while taking the red tablets or the last few white tablets. This is because Trisequens® mimics the natural menstrual cycle.

Trisequens® can be stopped at any time. You should discuss this with your doctor.

At your routine check-up, your doctor may reassess your continued need for Trisequens®.

Stop taking Trisequens® and contact your doctor if you become pregnant.

Do not take Trisequens® if you are breast-feeding.

If you have any concerns about taking Trisequens®, ask your doctor or pharmacist.

If your doctor tells you to stop taking Trisequens®, return any unused medicine to your pharmacist.

Things you must not do

This medicine is for you only. Do not give it to someone else even if they seem to have the same symptoms as you.

Do not take Trisequens® to treat any other complaints unless your doctor tells you to.

Do not change the way you take Trisequens® or lower the dosage, without checking with your doctor.

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Side Effects

All medicines can have side effects. Sometimes they are serious, most of the time they are not.

Tell your doctor or pharmacist if you experience any side effects while you are taking Trisequens® (whether or not they are mentioned below). You may need medical treatment if you experience some of the side effects.

When you start taking Trisequens® your body has to adjust to new hormone levels. You may experience the following side effects:

  • breast tenderness, pain or enlargement
  • irregular periods or excessive bleeding during your periods
  • period pain
  • abdominal (stomach) pain, indigestion, feeling sick (nausea), vomiting, diarrhoea, bloating, flatulence
  • skin rash or itching, skin reactions, acne, changes in hair growth, hair loss
  • inflammation of a vein
  • headache, migraine, dizziness
  • changes in sexual appetite, problems getting to sleep, nervousness
  • gall bladder problems, gallstones
  • leg cramps
  • back pain
  • weight change
  • swelling due to fluid retention (oedema)
  • visual disturbances
  • aggravation, occurrence or recurrence of uterine fibroids (benign tumours)
  • fungal infection of the vagina (thrush), vaginal inflammation or itching
  • Trisequens® does not treat your symptoms effectively.

These side effects are usually temporary and disappear.

Tell your doctor if:

  • you think you may be suffering from depression
  • you are not feeling well or find any side effect too uncomfortable or unacceptable
  • any side effect becomes worse
  • vaginal bleeding or spotting suddenly becomes heavier.

Tell your doctor immediately if any of the following conditions occur (because you may be told to stop taking Trisequens®):

  • severe pain or swelling in your legs
  • any type of blood clots
  • yellow colouring of the skin and eyes (jaundice)
  • migraine or sudden severe headache, and you have not previously had migraines
  • problems with your eyesight which develop suddenly
  • marked rise in blood pressure
  • you can see or feel a lump in your breast, or you notice dimpling of the skin or changes in the nipple
  • you know or suspect you are pregnant.

Tell your doctor immediately or go to Accident and Emergency at your nearest hospital if you notice any of the following:

  • skin rashes over a large part of the body
  • shortness of breath, wheezing
  • swelling of the face, lips or tongue
  • fast pulse
  • sweating.

This list includes very serious side effects. You may need urgent medical attention or hospitalisation. These side effects are very rare.

Effects on your heart or circulation

Heart disease
Talk to your doctor to see if you should be taking HRT if you have ever had heart disease.

HRT is not recommended for women who have heart disease, or have had heart disease recently. If you have ever had heart disease, HRT will not help to prevent heart disease.

Studies with one type of HRT (containing conjugated oestrogen plus the progestagen MPA) have shown that women may be slightly more likely to get heart disease during the first year of taking the medication. For other types of HRT, the risk is likely to be similar, although this is not yet certain.

See a doctor as soon as possible and do not take any more HRT until your doctor says you can if you get:

  • a pain in your chest that spreads to your arm or neck.

This pain could be a sign of heart disease.

Stroke
Recent research suggests that HRT slightly increases the risk of having a stroke. Other things that can increase the risk of stroke include:

  • getting older
  • high blood pressure
  • smoking
  • drinking too much alcohol
  • an irregular heartbeat.

Talk to your doctor to see if you should take HRT if you are worried about any of these things, or if you have had a stroke in the past.

See a doctor as soon as possible and do not take any more HRT until your doctor says you can if you get:

  • unexplained migraine-type headaches, with or without disturbed vision. These headaches may be an early warning sign of a stroke.

Blood clots
HRT may increase the risk of blood clots in the veins (also called deep vein thrombosis, or DVT), especially during the first year of taking it.

These blood clots are not always serious, but if one travels to the lungs, it can cause chest pain, breathlessness, collapse or even death. This condition is called pulmonary embolism, or PE.

DVT and PE are examples of a condition called venous thromboembolism, or VTE.

You are more likely to get a blood clot if:

  • you are seriously overweight
  • you have had a blood clot before
  • any of your close family have had blood clots
  • you have had one or more miscarriages
  • you have any blood clotting problem that needs treatment with a medicine such as warfarin
  • you’re off your feet for a long time because of major surgery, injury or illness
  • you have a rare condition called systemic lupus erythematosus (SLE - an autoimmune disease).

If any of these things apply to you, talk to your doctor to see if you should take HRT.

See a doctor as soon as possible and do not take any more HRT until your doctor says you can if you get:

  • painful swelling in your leg
  • sudden chest pain
  • difficulty breathing.

These may be signs of a blood clot.

Effects on your risk of developing cancer

Breast cancer
Women who have breast cancer, or have had breast cancer in the past, should not take HRT.

Taking HRT slightly increases the risk of breast cancer; so does having a later menopause. The risk for a post-menopausal woman taking oestrogen-only HRT for 5 years is about the same as for a woman of the same age who’s still having periods over that time and not taking HRT. The risk for a woman who is taking oestrogen plus progestagen HRT is higher than for oestrogen-only HRT (but oestrogen plus progestagen HRT is beneficial for the endometrium, see ‘Endometrial cancer’ below).

For all kinds of HRT, the extra risk of breast cancer goes up the longer you take it, but seems to return to normal after stopping HRT.

Your risk of breast cancer is also higher if:

  • you have a close relative (mother, sister or grandmother) who has had breast cancer
  • you are seriously overweight.

Make an appointment to see your doctor as soon as possible if you notice any changes in your breast, such as:

  • dimpling of the skin
  • changes in the nipple
  • any lumps you can see or feel.

Endometrial cancer (cancer of the lining of the womb)
Taking oestrogen-only HRT for a long time can increase the risk of cancer of the lining of the womb (the endometrium). Taking a progestagen as well as the oestrogen helps to lower the extra risk.

If you still have your womb, your doctor may prescribe a progestagen as well as oestrogen. If so, these may be prescribed separately, or as a combined HRT product.

If you have had your womb removed (a hysterectomy), your doctor will discuss with you whether you can safely take oestrogen without a progestagen.

If you have had your womb removed because of endometriosis, any endometrium left in your body may be at risk. So your doctor may prescribe HRT that includes a progestagen as well as an oestrogen.

Your product, Trisequens®, contains a progestagen.

If you get breakthrough bleeding or spotting, it’s usually nothing to worry about, especially during the first few months of taking HRT.

Make an appointment to see your doctor if the bleeding or spotting:

  • carries on for more than the first few months
  • starts after you’ve been on HRT for a while
  • carries on even after you’ve stopped taking HRT.

It could be a sign that your endometrium has become thicker.

Ovarian cancer
Long-term (at least 5 - 10 years’) use of oestrogen-only HRTs and oestrogen plus progestagen HRTs has been associated with an increased risk of ovarian cancer in some epidemiological studies.

In addition to the possible side effects listed above, dementia has been reported with HRT.

Do not be alarmed by these lists of possible side effects. You may not experience any of them.

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Storage

Keep all medicines out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the carton and label. The expiry date refers to the last day of that month.

Keep Trisequens® in a cool dry place where the temperature stays below 25°C. Do not put Trisequens® in the refrigerator.

Keep the calendar pack in the outer carton in order to protect from light.

Do not throw away any medicines down the sink or in your household rubbish. Ask your pharmacist how to throw away medicines you no longer use.

These measures will help to preserve the environment.

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Product description

What Trisequens® looks like

Trisequens® comes in a calendar pack. Each pack holds 28 round tablets.

Trisequens® contains:

  • 12 blue tablets marked ‘NOVO 280’ on one side.
  • 10 white tablets marked ‘NOVO 281’ on one side.
  • 6 red tablets marked ‘NOVO 282’ on one side.

Ingredients

  • Each blue tablet contains 2mg oestradiol (as hemihydrate) as the active ingredient and indigo carmine CI73015 (E132) as a colouring agent.
  • Each white tablet contains 2mg oestradiol (as hemihydrate) and 1mg norethisterone acetate as the active ingredients.
  • Each red tablet contains 1mg oestradiol (as hemihydrate) as the active ingredient and iron oxide red CI77491 (E172) as a colouring agent.

The tablets also contain

  • lactose,
  • maize starch,
  • talc, magnesium stearate,
  • hydroxypropylcellulose,
  • hypromellose,
  • titanium dioxide (E171) (red and blue tablets only),
  • glycerol triacetate (white tablets only),
  • macrogol 400 (blue tablets only) and
  • propylene glycol (red tablets only).

Trisequens® is gluten-free.

Manufacturer

Trisequens® is made in Denmark and supplied in Australia by:
Novo Nordisk Pharmaceuticals Pty Ltd
Level 3
21 Solent Circuit
Baulkham Hills NSW 2153

This leaflet was prepared on 28 April 2015.

Australian Registration Number:
AUST R 192476

Trisequens® is a trademark owned by Novo Nordisk FemCare AG, Switzerland.

NovoCare® is a trademark owned by Novo Nordisk A/S.

© 2015
Novo Nordisk A/S

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Further information

For further information call the NovoCare® Customer Care Centre on 1800 668 626.

www.novonordisk.com.au.

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User instructions

How to use the calendar pack

  1. Set the day reminder
    Turn the inner disc to set the day of the week opposite the little plastic tab.

  1. Take the first day’s tablet
    Break the plastic tab and tip out the first tablet.

  1. Move the dial every day
    On the next day simply move the transparent dial clockwise one space as indicated by the arrow. Tip out the next tablet. Remember to take only one tablet once a day.
    You can only turn the transparent dial after the tablet in the opening has been removed.

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CMI provided by MIMS Australia, September 2016  

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