What is the most effective method to suppress or delay my menstrual cycle for one cycle, considering I have a contraindication to estrogen due to a family history of pulmonary embolism (PE)?

Norethindrone (Progestin-Only Pills) for Menstrual Suppression

For one-cycle menstrual suppression with an estrogen contraindication due to family history of PE, norethindrone (progestin-only pills) taken continuously without a hormone-free interval is the most effective and safest option.

Why Progestin-Only Methods Are Appropriate

Given your family history of pulmonary embolism from estrogen-containing medication, combined hormonal contraceptives (containing estrogen) are contraindicated. Family history of estrogen-associated VTE is classified as a higher risk factor for recurrent DVT/PE, making progestin-only methods the clear choice 1.

• Progestin-only contraceptives have substantially less thrombotic risk compared to combined oral contraceptives containing estrogen 1
• While some recent data suggest DMPA may carry a small increased VTE risk, progestin-only pills (POPs) show minimal to no increased thrombotic risk 1
• Women with higher risk for recurrent DVT/PE (including those with family history of estrogen-associated VTE) can use progestin-only pills with a Category 2 classification (benefits generally outweigh risks) 1

Recommended Regimen: Continuous Norethindrone

Take norethindrone 0.35 mg daily continuously (without any pill-free days) starting 5-7 days before your expected period and continuing through the event you need to avoid menstruation 2.

How It Works for Menstrual Suppression

• Norethindrone suppresses ovulation in approximately 50% of users and alters the endometrium to prevent bleeding 2
• Continuous dosing (without hormone-free intervals) maintains endometrial suppression and prevents withdrawal bleeding 1
• Peak plasma concentrations occur within 1-2 hours, with a half-life of approximately 8 hours, requiring daily dosing 2

Timing and Duration

• Start norethindrone at least 5-7 days before your expected period (based on your typical 28-day cycle from your LMP) 1
• Continue taking one pill daily at the same time each day through the period you need to suppress menstruation 1
• You can stop after the event, and your period should resume within 2-5 days of discontinuation 2

Alternative: Levonorgestrel IUD (If Time Permits)

If you have several weeks before needing menstrual suppression, a levonorgestrel IUD could be considered, though this is less practical for one-cycle suppression:

• The levonorgestrel IUD significantly reduces menstrual bleeding and can cause amenorrhea, but this effect typically takes 3-6 months to develop 3
• It provides effective menstrual suppression while avoiding exogenous estrogen exposure 1
• This option is more suitable for long-term menstrual management rather than single-cycle suppression 3

Why Not Other Options

DMPA (Depo-Provera) - Not Ideal for Single Cycle

• DMPA requires injection every 13 weeks and causes prolonged effects that cannot be easily reversed 1
• Recent evidence suggests DMPA may carry increased VTE risk in patients with thrombotic risk factors 1
• Menstrual irregularities are nearly universal initially, making it unpredictable for single-cycle suppression 1

Combined Hormonal Methods - Contraindicated

• All combined estrogen-progestin contraceptives significantly increase VTE risk (HR 1.88-2.11 for DVT, HR 1.98 for PE) 1
• Your family history of estrogen-associated PE makes these methods inappropriate 1
• Even transdermal estrogen increases thrombotic risk, though possibly less than oral formulations 4

Important Considerations and Pitfalls

Breakthrough Bleeding Risk

• Approximately 30-50% of women experience unscheduled spotting or bleeding when first starting continuous progestin-only pills 1
• This risk decreases with continued use, but for single-cycle suppression, breakthrough bleeding remains a possibility 1
• Starting 5-7 days before expected menses (rather than waiting until bleeding starts) improves suppression success 1

Strict Timing Requirements

• Norethindrone must be taken at the same time each day (within a 3-hour window) to maintain effectiveness 2
• Missing a pill or taking it >3 hours late can trigger breakthrough bleeding 1
• Set a daily alarm to ensure consistent timing 1

Not 100% Effective for Suppression

• While norethindrone is highly effective for contraception (0.5% perfect-use failure rate), menstrual suppression success rates are lower 2
• Some women will experience breakthrough bleeding despite perfect adherence 1
• Having backup menstrual products available is prudent 1

What to Expect

Side Effects

• Menstrual irregularities (most common) 1
• Mild headache, breast tenderness, or mood changes (less common) 2
• Nausea (uncommon with progestin-only pills) 1

After Stopping

• Expect withdrawal bleeding 2-5 days after discontinuing norethindrone 2
• Your normal menstrual cycle should resume within 1-2 cycles 2
• No long-term effects on fertility 2

Obtaining Norethindrone

• Norethindrone requires a prescription 2
• Inform your provider about your family history of estrogen-associated PE 1
• Request enough pills to cover the suppression period plus 2-3 extra days as buffer 1