What medication can be given to induce menstruation?

Medications to Induce Menstruation

For inducing menstruation in women with amenorrhea, norethindrone acetate at doses of 5-10 mg daily for 5-10 days is the most effective medication to produce withdrawal bleeding within 3-7 days after discontinuation. 1

Medication Options Based on Clinical Context

Primary Option: Progestins

• Norethindrone acetate: 5-10 mg daily for 5-10 days is FDA-approved specifically for inducing withdrawal bleeding in women with secondary amenorrhea 1
• Medroxyprogesterone acetate (MPA): 10 mg daily for 10-14 days can be used as an alternative to induce withdrawal bleeding 2
• Micronized progesterone (MP): 200 mg daily orally or vaginally for 12-14 days can also effectively induce withdrawal bleeding 2

Secondary Options

• Combined oral contraceptives (COCs): Effective for treating amenorrhea, particularly in women using DMPA (depot medroxyprogesterone acetate) 2, 3
• 17β-estradiol (17βE) with progestin: Can be administered in sequential regimens to induce withdrawal bleeding 2

Clinical Algorithm for Inducing Menstruation

For Secondary Amenorrhea or Hormonal Imbalance

1. First-line therapy: Norethindrone acetate 5-10 mg daily for 5-10 days 1

   • Withdrawal bleeding typically occurs within 3-7 days after discontinuation
   • Adequate endometrial priming with either endogenous or exogenous estrogen is necessary for optimal results

2. Alternative approach: Medroxyprogesterone acetate 10 mg daily for 12-14 days 2

   • Particularly useful when planning cyclic withdrawal bleeding

3. For women with amenorrhea on DMPA contraception:

   • Low-dose combined oral contraceptives can effectively re-induce menstrual bleeding 3
   • 70% of women receiving COCs experience return of menstrual bleeding compared to only 22.7% with placebo 3

For Dysfunctional Uterine Bleeding Requiring Prompt Control

• Higher doses of MPA (60-120 mg initially, followed by 20 mg daily for 10 days) can rapidly control excessive bleeding 4
• This approach is particularly effective in adolescents with dysfunctional uterine bleeding 4

Important Clinical Considerations

• Confirm absence of pregnancy before initiating any hormonal therapy to induce menstruation 2
• Rule out underlying pathology as the cause of amenorrhea before attributing it to hormonal imbalance 1
• For women with premature ovarian insufficiency (POI), sequential hormone therapy with estrogen followed by progestin is preferred over progestin-only regimens 2
• For women desiring contraception, combined hormonal contraceptives can both provide contraception and regulate menstrual cycles 2

Monitoring and Follow-up

• Withdrawal bleeding should occur within 3-7 days after discontinuing progestin therapy 1
• If no bleeding occurs after progestin challenge, consider:
  • Insufficient endometrial priming (may need estrogen priming first)
  • Outflow tract obstruction
  • Endometrial damage (Asherman's syndrome)
  • Severe hypoestrogenism 2

Potential Side Effects and Precautions

• Common side effects of progestin therapy include:
  • Headaches
  • Breast tenderness
  • Mood changes 2
• For women with recurrent episodes of abnormal uterine bleeding, planned menstrual cycling with norethindrone acetate may be beneficial 1
• Avoid progestins with anti-androgenic effects in women with iatrogenic POI, as they may worsen hypoandrogenism 2