What is the recommended dose of progesterone (progestin) for treating dysfunctional uterine bleeding?

Progesterone Dosing for Dysfunctional Uterine Bleeding

For dysfunctional uterine bleeding, medroxyprogesterone acetate should be administered at 10 mg daily for 10 days each month for at least 3 months, with close monitoring thereafter.

Understanding Dysfunctional Uterine Bleeding (DUB)

Dysfunctional uterine bleeding is abnormal uterine bleeding related to ovulatory dysfunction (oligo-ovulation and anovulation), often associated with heavy, irregular bleeding. It falls under the "O" category (ovulatory dysfunction) in the PALM-COEIN classification system used to describe uterine bleeding abnormalities 1.

Treatment Approach Based on Patient Type

For Adolescents

• Medroxyprogesterone acetate 10 mg orally once daily for 10 days each month for ≥3 months
• Close monitoring after the initial treatment period 2

For Women of Reproductive Age

1. For anovulatory bleeding without need for contraception:

   • Medroxyprogesterone acetate 10 mg orally daily for 10 days each month for 6 months 2
   • Alternative: Norethisterone 5-10 mg three times daily from days 5-25 of the cycle (for ovulatory DUB) or days 12-25 (for anovulatory DUB) 3

2. For women requiring contraception:

   • Combined hormonal contraceptives are preferred 1

For Perimenopausal Women

• Cyclic progestin: Medroxyprogesterone acetate 10 mg for days 16-25 of the cycle
• This 10-day protocol in the luteal phase has been shown to be more effective than longer protocols 4

Dosing Considerations

The FDA-approved dosing for secondary amenorrhea (which often presents with similar hormonal patterns as DUB) is:

• 400 mg progesterone capsules at bedtime for 10 days 5

For anovulatory bleeding specifically:

• The 10-day administration protocol (days 16-25) has demonstrated better outcomes in regulating menstrual cycles and stopping abnormal uterine bleeding compared to longer protocols 4

Monitoring and Follow-up

• Evaluate response after 3 cycles of treatment
• If bleeding persists despite 3 cycles of treatment, further investigation with imaging (transvaginal ultrasound) or hysteroscopy is indicated 1
• Endometrial biopsy should be considered in women with risk factors for endometrial cancer who have persistent bleeding 2

Treatment Failure Considerations

If medical treatment fails, is contraindicated, or not tolerated, or if the patient has significant intracavitary lesions, surgical options may be considered:

• Endometrial ablation
• Hysterectomy 1

Important Cautions

• Progesterone therapy should only be initiated after confirming the diagnosis of DUB and ruling out endometrial and structural pathologies 1
• High-dose estrogen therapy is generally reserved for acute bleeding episodes, while progestins are the mainstay for chronic management 2
• For women with profuse bleeding unresponsive to progestin treatment, additional interventions may be necessary 6

The evidence strongly supports the use of progestin therapy for dysfunctional uterine bleeding, with medroxyprogesterone acetate 10 mg daily for 10 days each month being the most well-established regimen.