What treatment options are available to induce menses (menstruation) early?

Treatment to Induce Menses Early

For women who need to bring on menstruation early, the most effective approach is using progestin therapy (norethindrone acetate 5-10 mg daily for 5-10 days), which induces withdrawal bleeding within 3-7 days after stopping the medication. 1

Primary Treatment Option: Progestin Withdrawal

Norethindrone acetate is the FDA-approved medication specifically indicated for inducing menses in women with secondary amenorrhea or delayed menstruation. 1

Dosing Protocol

• Administer 5-10 mg of norethindrone acetate daily for 5-10 days 1
• Withdrawal bleeding typically occurs within 3-7 days after discontinuing therapy 1
• This regimen produces secretory transformation of the endometrium that has been adequately primed with estrogen 1

Prerequisites Before Treatment

Before initiating progestin therapy, you must be reasonably certain the patient is not pregnant. According to CDC guidelines, this requires: 2

• No signs or symptoms of pregnancy, AND
• At least one of the following:
  • ≤7 days after start of normal menses
  • No intercourse since last normal menses
  • Correct and consistent use of reliable contraception
  • ≤7 days after abortion
  • Within 4 weeks postpartum
  • Fully breastfeeding, amenorrheic, and <6 months postpartum

Alternative Approach: Combined Hormonal Contraceptives

For women already using continuous combined hormonal contraceptives, skipping pills for 3-4 consecutive days can temporarily induce bleeding, though this should not be done more often than monthly or before the first 21 days of use. 2

This method works by:

• Causing temporary hormone withdrawal 2
• Inducing endometrial thinning 2
• Triggering breakthrough bleeding within days 2

Contraindications and Safety Concerns

Do not use norethindrone acetate if the patient has: 1

• Known or suspected pregnancy (may cause fetal harm including masculinization of female fetus or hypospadias in male fetus)
• History of blood clots (legs, lungs, eyes, brain)
• Liver impairment or disease
• Known or suspected breast cancer
• Undiagnosed vaginal bleeding
• Hypersensitivity to the medication

Progestational drugs carry risk of abnormal blood clotting, which can lead to stroke, heart attack, pulmonary embolus, or visual loss. 1

Important Clinical Caveats

When This Approach Won't Work

• The endometrium must be adequately primed with estrogen for progestin withdrawal to be effective 1
• Women with prolonged amenorrhea or hypoestrogenic states may not respond appropriately 1
• If no bleeding occurs after progestin withdrawal, further evaluation for anovulation or other causes is needed 1

Not for Emergency Contraception

This question appears to be about menstrual timing rather than emergency contraception. If the goal is preventing pregnancy after unprotected intercourse, different regimens apply (levonorgestrel, ulipristal, or copper IUD within 5 days). 2

Monitoring Requirements

• Instruct patients to discontinue immediately and contact you if they experience sudden vision changes, severe headache, chest pain, leg swelling, or other signs of thromboembolism 1
• No routine follow-up visit is required if bleeding occurs as expected 1
• If bleeding does not occur within 7-10 days after stopping medication, pregnancy testing and further evaluation are indicated 1

Patient Counseling Points

Inform patients that: 1

• Bleeding should start within 3-7 days after finishing the medication
• This is withdrawal bleeding, not a true menstrual period
• The next natural cycle may be delayed or irregular
• This treatment does not provide contraception
• Backup contraception should be used if pregnancy prevention is desired