Can I prescribe norethindrone (progestin) to a 17-year-old?

Prescribing Norethindrone for a 17-Year-Old

Yes, norethindrone (progestin) can be prescribed to a 17-year-old patient, as FDA labeling approves progestin-only pills for postpubertal adolescents, and safety and efficacy are expected to be the same for users under 16 and those 16 years and older. 1

Indications and Considerations

Norethindrone may be prescribed to adolescents for various indications:

• Contraception
• Management of abnormal uterine bleeding 2
• Treatment of dysmenorrhea
• Management of endometriosis-associated pain 3
• Alternative for patients with contraindications to estrogen-containing contraceptives

Dosing Information

• Standard dose: 0.35 mg daily
• Must be taken at the same time every day for maximum effectiveness
• Can be started at any time if reasonably certain the patient is not pregnant 4
• If started >5 days after menses began, advise using backup contraception (e.g., condoms) for 2 days 4

Efficacy

• Typical use effectiveness rate: <90% for contraception 4
• Highly effective for managing abnormal uterine bleeding (78.9% of adolescents experienced complete cessation of heavy bleeding within 7 days when used as a taper) 5

Safety Profile for Adolescents

Norethindrone has several advantages for adolescent patients:

• No increased risk of stroke (unlike combined hormonal contraceptives) 4
• Safe for patients with contraindications to estrogen (e.g., history of migraines with aura, cardiovascular risk factors) 4
• No significant impact on bone mineral density (unlike DMPA)
• No serious adverse events reported in adolescent studies 5

Common Side Effects in Adolescents

• Menstrual irregularities (most common reason for discontinuation - 54.5%) 5
• Breakthrough bleeding
• Headache
• Breast tenderness
• Nausea
• Mood changes

Important Counseling Points

1. Emphasize the importance of taking the pill at the same time every day
2. Explain that irregular bleeding is common, especially in the first few months
3. Advise using backup contraception for 48 hours if a pill is taken 3+ hours late 1
4. Discuss that small amounts of progestin pass into breast milk (1-6% of maternal plasma levels) if relevant 1
5. Warn that certain medications may reduce effectiveness:
   • Rifampin
   • Griseofulvin
   • Anticonvulsants (phenytoin, carbamazepine, topiramate)
   • St. John's Wort 4, 1

Monitoring Requirements

• No routine laboratory monitoring required
• No requirement for pelvic examination before initiation
• Blood pressure measurement at baseline is recommended

Contraindications

• Pregnancy
• Breast cancer
• Abnormal uterine bleeding of unknown cause
• Severe liver disease

Clinical Decision Algorithm

1. Assess medical history:

   • Check for contraindications to hormonal contraception
   • Determine if estrogen-containing methods are contraindicated
   • Evaluate for conditions that might benefit from progestin therapy

2. Consider patient preferences:

   • Ability to adhere to daily medication schedule
   • Tolerance for potential irregular bleeding
   • Desire for contraception vs. medical management

3. Initiate therapy:

   • Start with 0.35 mg daily
   • Provide clear instructions on timing and missed pills
   • Recommend backup contraception for first 2 days if starting >5 days after menses

4. Follow-up plan:

   • Schedule follow-up at 3 months to assess tolerance and side effects
   • Address any breakthrough bleeding issues
   • Reinforce importance of daily adherence

Special Considerations for Adolescents

• Discontinuation rates are relatively high (48.5%) primarily due to irregular bleeding 5
• Counseling about expected bleeding patterns may improve adherence
• Consider alternative methods if adherence is likely to be poor
• Progestin-only pills may be particularly suitable for adolescents with certain medical conditions (e.g., neurologic or cardiovascular diseases) 5

Norethindrone is a safe and effective option for 17-year-old patients who need contraception or management of gynecologic conditions, particularly when estrogen-containing methods are contraindicated.