From the Guidelines
Primolut (norethisterone) is not recommended as a first-line treatment for managing prolonged bleeding after Depot Provera (medroxyprogesterone acetate) injection, according to the most recent guidelines. The 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1 suggest that for injectable (DMPA) users, treatment options may include a hormone-free interval for 3–4 consecutive days, but do not mention the use of norethisterone.
Instead, the guidelines recommend considering an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids), and treating the condition or referring for care if necessary 1.
Some key points to consider when managing prolonged bleeding after Depot Provera injection include:
- Exploring patient goals, including continued method use or method discontinuation
- Providing reassurance and advising the patient to contact their provider to discuss bleeding irregularities or other side effects
- Considering alternative contraceptive methods if the patient desires removal or discontinuation of the method
- Using nonsteroidal anti-inflammatory drugs (NSAIDs) or other treatments as needed, depending on the patient’s preferences, treatment goals, and medical history 1.
It's essential to note that the treatment approach should be individualized, and medical evaluation is recommended to rule out other causes of prolonged bleeding. Side effects of any treatment should be considered, and hormonal interactions need to be taken into account when combining progestins or other hormonal contraceptives.
From the Research
Management of Prolonged Bleeding after Depot Provera
- Prolonged bleeding is a common side effect of Depot Provera (medroxyprogesterone acetate) injection, especially during the initial months of use 2, 3.
- Studies have shown that irregular and/or excessive menstrual bleeding diminishes with long-term use of Depot Provera, and a high percentage of users become amenorrheic 2.
- However, for women experiencing prolonged bleeding after Depot Provera, Primolut (norethisterone) may be considered as a management option.
Efficacy of Primolut in Managing Prolonged Bleeding
- A study comparing cyclical progestogens, including norethisterone, found that short-cycle progestogen therapy was inferior to other medical therapies, such as tranexamic acid and the progestogen-releasing intrauterine system, in reducing menstrual blood loss 4.
- Another study found that prior use of oral contraceptive pills, which contain progestogens like norethisterone, before switching to Depot Provera resulted in a decrease in the duration of bleeding 5.
- However, the evidence supporting the use of Primolut for managing prolonged bleeding after Depot Provera is limited, and more research is needed to determine its effectiveness.
Potential Side Effects of Primolut
- Norethisterone, the active ingredient in Primolut, has been shown to decrease HDL-lipid levels, which may increase the risk of atherosclerosis and cardiovascular disease 6.
- Other potential side effects of Primolut include weight gain, breast tenderness, and intermenstrual bleeding 4, 5.
- Women using Primolut to manage prolonged bleeding after Depot Provera should be monitored for these potential side effects and advised to report any concerns to their healthcare provider.