How can we induce a withdrawal bleed?

From the Guidelines

A withdrawal bleed can be induced by using a combined hormonal contraceptive method, such as the vaginal ring, which releases a combination of estrogen and progestin, and then removing it for 1 week to induce withdrawal bleeding, as stated in the study published in Pediatrics in 2014 1. To induce a withdrawal bleed, the following methods can be used:

• Administering a short course of progestin followed by discontinuation, which causes endometrial shedding
• Using a combined hormonal contraceptive method, such as the vaginal ring, which releases a combination of estrogen and progestin, and then removing it for 1 week to induce withdrawal bleeding The most common regimen for progestin administration is medroxyprogesterone acetate (Provera) 10mg daily for 5-10 days, as mentioned in the example. Alternative options include norethindrone acetate 5mg daily or micronized progesterone 200mg daily for the same duration. It's essential to first rule out pregnancy with a test before starting any hormonal medication, as stated in the example. The physiological mechanism involves progestin stabilizing the endometrial lining during administration, and when withdrawn, the sudden drop in hormone levels triggers endometrial shedding similar to a natural menstrual period. This approach is commonly used for women with amenorrhea, irregular cycles, or to time a period for personal reasons, but should not be used frequently without addressing the underlying cause of menstrual irregularity. The study published in American Family Physician in 2015 1 provides information on postpregnancy risk classifications for select contraceptive methods, but it does not directly relate to inducing a withdrawal bleed. Therefore, the recommendation is based on the study published in Pediatrics in 2014 1, which provides guidance on the use of combined hormonal contraceptive methods, including the vaginal ring.

From the FDA Drug Label

Medroxyprogesterone acetate, administered parenterally in the recommended doses to women with adequate endogenous estrogen, transforms proliferative endometrium into secretory endometrium. Because of its prolonged action and the resulting difficulty in predicting the time of withdrawal bleeding following injection, medroxyprogesterone acetate is not recommended in secondary amenorrhea or dysfunctional uterine bleeding.

To induce a withdrawal bleed, oral therapy is recommended, rather than using medroxyprogesterone acetate, due to its prolonged action and the resulting difficulty in predicting the time of withdrawal bleeding 2.

From the Research

Inducing a Withdrawal Bleed

To induce a withdrawal bleed, several factors and methods can be considered based on available research:

• The use of oral micronized progesterone has been shown to induce withdrawal bleeding in women with secondary amenorrhea, with a higher dose of 300 mg being more effective than a lower dose of 200 mg or placebo 3.
• The administration of progestogens in association with continuous estradiol can lead to regular monthly bleeding in postmenopausal women, with different progestogens having varying effects on bleeding patterns 4.
• In women using low-dose combined oral contraceptives, postponement of withdrawal bleeding for up to 20 extra days can be effective, although the occurrence of bleeding is related to the duration of postponement and the contraceptive regimen used 5.
• Women's attitudes and knowledge about withdrawal bleeding and oral contraceptives can influence their experiences, with some women preferring to bleed at intervals of three months or greater if possible 6.

Factors Influencing Withdrawal Bleeding

Several factors can influence the occurrence and regularity of withdrawal bleeding, including:

• The type and dose of progestogen used, with some progestogens being more effective at inducing regular bleeding than others 4.
• The duration of treatment and the timing of progestogen administration, with longer durations and specific timing regimens potentially leading to more regular bleeding 7, 5.
• Individual factors, such as endogenous estradiol concentrations and treatment progestogen concentrations, which may have limited predictive value for withdrawal bleeding 3.