What 7-day course of progesterone (e.g. medroxyprogesterone acetate) can be ordered to induce a withdrawal bleed and start a period in individuals with amenorrhea?

Medroxyprogesterone Acetate 10 mg Daily for 7-10 Days is the Optimal Regimen to Induce Withdrawal Bleeding

For individuals with amenorrhea who need to induce a withdrawal bleed, medroxyprogesterone acetate 10 mg daily for 7-10 days is the recommended regimen. This approach effectively transforms proliferative endometrium into secretory endometrium and reliably induces withdrawal bleeding upon discontinuation 1.

Evidence-Based Rationale

The FDA-approved drug information for medroxyprogesterone acetate confirms that it transforms proliferative endometrium into secretory endometrium when administered in recommended doses to women with adequate endogenous estrogen 1. This pharmacological action is precisely what's needed to induce a withdrawal bleed in amenorrheic patients.

Dosing Options

Several progesterone options exist for inducing withdrawal bleeding:

1. Medroxyprogesterone acetate (MPA):

   • Dose: 10 mg daily
   • Duration: 7-10 days
   • Advantages: Widely available, cost-effective, reliable withdrawal bleeding

2. Micronized progesterone:

   • Dose: 300 mg daily
   • Duration: 10 days
   • Efficacy: 90% withdrawal bleeding rate (compared to 58% with 200 mg) 2
   • Disadvantages: Higher cost, may cause sedation when taken orally

Clinical Considerations

Expected Outcomes

• Withdrawal bleeding typically occurs within 7 days after completing the progesterone course 3
• In clinical studies, 80% of women experienced withdrawal bleeding within 7 days following a 10-day course of progesterone therapy 3

Patient Selection

This approach is most effective in patients who:

• Have adequate endogenous estrogen (indicating endometrial proliferation has occurred)
• Have secondary amenorrhea without underlying pathology
• Are not pregnant (pregnancy test should be performed before initiating therapy) 4

Monitoring and Follow-up

• If withdrawal bleeding does not occur after the first course, consider:
  • Checking estradiol levels to confirm adequate endogenous estrogen
  • Increasing the dose or duration of progesterone in subsequent cycles
  • Evaluating for other causes of amenorrhea

Important Caveats

1. Rule out pregnancy before initiating therapy, as this is a critical first step in evaluating amenorrhea 4

2. Laboratory evaluation should include luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and thyroid-stimulating hormone (TSH) to identify underlying causes of amenorrhea 4

3. Long-term management: For patients requiring ongoing menstrual cycle regulation, combined hormonal contraceptives may be more appropriate than repeated progesterone challenges 4

4. Avoid in dysfunctional uterine bleeding: The FDA label specifically notes that medroxyprogesterone acetate is not recommended for secondary amenorrhea or dysfunctional uterine bleeding due to difficulty predicting the time of withdrawal bleeding 1

By following this evidence-based approach, clinicians can effectively induce withdrawal bleeding in patients with amenorrhea while minimizing potential complications and optimizing patient outcomes.