What is the recommended treatment for a patient with irregular periods using progesterone (a progestin)?

Progesterone Treatment for Irregular Periods

For patients with irregular periods, medroxyprogesterone acetate 10 mg daily for 12-14 days per month is the recommended treatment to induce withdrawal bleeding. 1

Dosage and Administration

• Medroxyprogesterone acetate (MPA) 10 mg daily for 12-14 days per month is recommended by the American College of Obstetricians and Gynecologists to induce withdrawal bleeding in patients with amenorrhea or irregular periods 1
• For secondary amenorrhea, progesterone capsules may be given as a single daily dose of 400 mg at bedtime for 10 days 2
• When used as part of sequential hormone therapy with estradiol, MPA is administered during the last 12-14 days of a 28-day cycle 1
• For continuous regimens, a lower dose of 2.5-5 mg MPA daily can be used 1

Mechanism and Effectiveness

• When patients do not produce enough progesterone, menstrual irregularities can occur; progesterone supplementation provides the hormone needed to regulate the cycle 2
• Sequential regimens with MPA induce regular withdrawal bleeding, with a reported success rate of 80-93% of women experiencing withdrawal bleeding 1
• Continuous combined regimens (daily estrogen plus daily MPA 2.5-5 mg) can be used when amenorrhea is preferred 1
• Progesterone capsules should be taken at bedtime as some women become very drowsy and/or dizzy after taking them 2

Side Effects and Management

• Unscheduled spotting or light bleeding is common with progestin use, especially during the first 3-6 months 3
• These bleeding irregularities are generally not harmful and usually improve with persistent use of the hormonal method 3
• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful has been shown to reduce method discontinuation 3
• If irregular bleeding persists and the woman finds it unacceptable, consider the following treatment options:
  • NSAIDs for short-term treatment (5-7 days) during days of bleeding 3
  • Hormonal treatment with low-dose combined oral contraceptives or estrogen for short-term treatment (10-20 days) if medically eligible 3

Clinical Considerations

• Before starting treatment, rule out underlying gynecological problems, such as interactions with other medications, STDs, pregnancy, or pathologic uterine conditions (e.g., polyps or fibroids) 3
• Absence of withdrawal bleeding after progestin challenge may indicate insufficient endogenous estrogen or endometrial pathology 1
• Micronized progesterone (200 mg daily for 12-14 days per month) is a preferred alternative if MPA is not tolerated, particularly for women with cardiovascular risk factors 4, 1
• Oral micronized progesterone has been shown to reproduce the anti-estrogenic effect of natural progesterone on the endometrium at the dose of 200 mg daily 5
• For patients requiring contraception alongside treatment for irregular periods, combined hormonal contraceptives may be preferable to MPA alone 1

Important Cautions

• Irregular menstruation is considered an important health indicator among women and has been associated with various conditions including metabolic syndrome, coronary heart disease, type 2 diabetes mellitus, and infertility 6
• Progestins with estrogens should not be used to prevent heart disease, heart attacks, strokes, or dementia 2
• If symptoms such as blurred vision, difficulty speaking, difficulty walking, or feeling abnormal occur after taking progesterone, discuss them with your healthcare provider right away 2
• For patients who experience difficulty swallowing progesterone capsules, it is recommended to take the daily dose at bedtime with a glass of water while in the standing position 2