Initial Dose of Provera for Prolonged Menstrual Bleeding
For treating abnormal uterine bleeding due to hormonal imbalance, the initial dose of Provera (medroxyprogesterone acetate) is 5-10 mg daily for 5-10 days, with 10 mg daily for 10 days being the optimal dose for achieving adequate secretory transformation of the endometrium. 1
Specific Dosing Regimen
The FDA-approved dosing for abnormal uterine bleeding provides two timing options 1:
- Starting on day 16 of the menstrual cycle: Give 5-10 mg daily for 5-10 days
- Starting on day 21 of the menstrual cycle: Give 5-10 mg daily for 5-10 days
- Optimal regimen: 10 mg daily for 10 days beginning on day 16 of the cycle produces the best secretory transformation 1
Withdrawal bleeding typically occurs within 3-7 days after discontinuing therapy, which helps establish a predictable bleeding pattern 1.
Important Clinical Context
Before initiating Provera, you must rule out pregnancy, structural causes (polyps, fibroids), endometrial malignancy, and sexually transmitted infections 2. The guidelines emphasize that oral progestins like Provera are second-line treatment for chronic heavy menstrual bleeding, with the levonorgestrel IUD being first-line (reducing blood loss by 71-95% versus 87% with cyclic oral progestins) 3, 2.
When to Use Higher Doses
High-dose oral progestogens may be considered for short-term use in hemodynamically unstable women when bleeding is not controlled 2. However, the standard initial dose remains 5-10 mg daily as outlined above 1.
Managing Breakthrough Bleeding
If bleeding persists during treatment 4:
- NSAIDs (mefenamic acid 500 mg three times daily or ibuprofen) are first-line for breakthrough bleeding, used only during days of active bleeding 4
- Continue treatment for at least 3-6 months to evaluate full effectiveness 2
- If bleeding persists beyond 3-6 months, evaluate for underlying pathology 4, 2
Contraindications to Check
Do not use Provera in patients with 2:
- Known or suspected pregnancy
- Current or past thromboembolic disease
- Undiagnosed vaginal bleeding (must evaluate first)
- Severe liver disease
- History of hormone-sensitive cancers
Follow-Up Expectations
If withdrawal bleeding does not occur within 3 weeks after completing oral Provera therapy, pregnancy testing is warranted 4. For patients with recurrent episodes, planned menstrual cycling with medroxyprogesterone acetate may prevent future episodes 1.