What is the recommended progesterone (medroxyprogesterone acetate) dosing for a patient with menorrhagia (heavy periods) who wants to avoid birth control?

Progesterone Dosing for Heavy Menstrual Bleeding (Non-Contraceptive Use)

For a patient with menorrhagia who wants to avoid birth control, oral progestogen therapy is generally inferior to other medical options, but if chosen, medroxyprogesterone acetate (MPA) 10 mg daily for 12-14 days per month (days 15-26 or 5-26 of cycle) or norethisterone can be used, though you should strongly consider tranexamic acid or the levonorgestrel-IUS as superior first-line alternatives. 1, 2

Evidence-Based Treatment Hierarchy

Most Effective Options (Consider These First)

• Tranexamic acid is superior to cyclical progestogen therapy for reducing menstrual blood loss 1, 3
• Levonorgestrel-releasing intrauterine system (LNG-IUS) demonstrates significantly better efficacy than oral progestogens, with higher satisfaction rates (OR 5.19) and lower treatment failure rates (9.2% vs 31.0%) 2
• Tranexamic acid at 2 g/day achieved 60.3% reduction in blood loss compared to 57.7% with MPA, with fewer treatment failures (6.1% vs 28.9%) 3

If Oral Progestogen Is Still Preferred

Two regimen options exist, both with limited efficacy:

Long-Cycle Regimen (More Effective of the Two)

• Medroxyprogesterone acetate 10 mg daily for 21 days per cycle (typically days 5-26) 4
• Alternative: Norethisterone for similar duration 1
• This regimen is inferior to LNG-IUS, tranexamic acid, and ormeloxifene for reducing menstrual blood loss 1

Short-Cycle Regimen (Least Effective)

• Medroxyprogesterone acetate 10 mg daily for 7-10 days (typically days 15-19 or during luteal phase) 4, 1
• This regimen is significantly inferior to other medical therapies, with mean difference in blood loss of 37.29 mL favoring alternative treatments 1
• Results in more bleeding days compared to other medical treatments 1

Critical Clinical Considerations

Why Progestogens Underperform

• Cyclical oral progestogens show inferior efficacy across multiple comparisons with tranexamic acid, danazol, and intrauterine systems 1
• The evidence quality is low to very low, but consistently demonstrates this inferiority 1
• Higher discontinuation rates (28.9% vs 14.6% with LNG-IUS) and treatment failures occur with oral progestogens 2

Practical Dosing Details

• MPA 10 mg daily is the standard dose for endometrial protection when used cyclically 4
• The 10 mg dose reliably inhibits ovulation, while 5 mg may not be sufficient in all women 5
• For long-cycle continuous regimens (if avoiding withdrawal bleeding), minimum dose is 2.5 mg MPA daily 4

Common Pitfalls to Avoid

• Do not use short-cycle progestogen (luteal phase only) as first-line—it has the poorest efficacy profile 1
• Avoid monthly injectable MPA in patients with any tendency toward fluid retention 4
• Recurrence rates are high after stopping treatment: 66.7% with tranexamic acid and 50% with MPA within 3 months 3
• More hysterectomies were ultimately required in the MPA group (17.8%) compared to tranexamic acid (4%) 3

Recommended Clinical Approach

If the patient absolutely refuses IUD or tranexamic acid:

1. Prescribe MPA 10 mg daily for days 5-26 of the menstrual cycle (long-cycle regimen) 4
2. Continue for at least 3 cycles to assess response 3
3. Monitor for treatment failure and be prepared to transition to more effective therapy 1, 2

However, strongly counsel the patient that:

• The LNG-IUS is not "birth control" in the traditional sense for this indication—it's a superior medical treatment for menorrhagia 2
• Tranexamic acid (non-hormonal) offers better efficacy with fewer side effects than oral progestogens 1, 3
• Quality of life improvements favor LNG-IUS over conventional medical treatment including progestogens 2