How to prescribe norethindrone for menstrual suppression?

Prescribing Norethindrone for Menstrual Suppression

For menstrual suppression, norethindrone should be prescribed at a dose of 5 mg three times daily (15 mg total daily) when started late in the cycle, or at continuous daily doses of 5-10 mg for ongoing suppression. 1

Dosing Regimens

For Immediate Menstrual Suppression

• Start with norethindrone 5 mg three times daily (15 mg total)
• Begin on or before cycle day 12 for optimal effectiveness in preventing breakthrough bleeding 1
• Continue until menstrual suppression is no longer needed
• Expect heavier withdrawal bleeding when medication is discontinued 1

For Ongoing Menstrual Suppression

• Norethindrone 5-10 mg daily, taken continuously
• Must be taken at the same time every day for maximum effectiveness 2
• No breaks between pill packs; administration is continuous 2

Administration Guidelines

1. Timing: Take at the same time every day for maximum contraceptive and menstrual suppression effectiveness 2
2. Missed Doses:
   • If a dose is missed by >3 hours, take one pill as soon as possible
   • Continue taking pills daily at the same time
   • Use backup contraception for 2 consecutive days if also using for contraception 3
   • Consider emergency contraception if unprotected intercourse occurred 3
3. Vomiting/Diarrhea: If vomiting or severe diarrhea occurs within 3 hours of taking a pill, take another pill as soon as possible and continue regular schedule 3

Monitoring and Follow-up

• Assess for irregular bleeding patterns, which is the most common side effect and reason for discontinuation 4
• Monitor for weight changes, which may occur temporarily during therapy 1
• No routine follow-up visit is specifically required, but evaluate satisfaction with the method at regular visits 3
• Assess for any changes in health status or medications that might affect effectiveness 3

Expected Outcomes and Side Effects

Effectiveness

• Only 8% of women using norethindrone for menstrual suppression experience breakthrough spotting, compared to 43% with combined oral contraceptives 1
• 78.9% of adolescents using norethindrone taper for heavy menstrual bleeding experience complete cessation of bleeding within 7 days 4

Side Effects

• Irregular bleeding patterns (most common reason for discontinuation - 54.5%) 4
• Temporary weight gain (resolves after cessation of therapy) 1
• Heavier withdrawal bleeding when discontinued 1
• Other potential side effects: headache, fatigue, tension, nausea, depression 5

Special Considerations

• Norethindrone is superior to combined oral contraceptives for preventing breakthrough bleeding when started late in the cycle 1
• Patient satisfaction is significantly higher with norethindrone for menstrual suppression (80% willing to choose this method again) 1
• Ideal for circumstances when even minimal breakthrough bleeding cannot be tolerated 1
• Safe option for women with contraindications to estrogen, including those with cardiovascular risk factors and hypertension 3
• Does not increase risk of thromboembolism or stroke 3

Clinical Pearls

• When used for menstrual suppression before important events (e.g., weddings, travel), start at least 10 days before the event 1
• Higher doses (15 mg daily) are more effective for immediate suppression, while lower continuous doses (5-10 mg) are suitable for long-term management
• If using for both contraception and menstrual suppression, be aware that the contraceptive dose (0.35 mg) is much lower than the dose needed for effective menstrual suppression (5-15 mg) 2, 6
• Consider alternative methods if patient has difficulty with daily medication adherence 3