What is the recommended dosage of Provera (medroxyprogesterone acetate) for managing heavy menses?

Provera for Heavy Menses: Dosing Recommendations

Primary Recommendation

Oral medroxyprogesterone acetate (Provera) at 10 mg daily for 10-14 days per cycle (days 16-25 or days 14-28) is the standard cyclic regimen for heavy menstrual bleeding, though it is significantly less effective than the levonorgestrel-releasing intrauterine system and should be considered a second-line option. 1

Evidence-Based Dosing Protocols

Cyclic Regimen (Standard Approach)

• 10 mg daily for 10 days starting on day 16 of each cycle is the most commonly studied regimen for heavy menstrual bleeding 1
• This cyclic approach reduces menstrual blood loss by approximately 87% according to cardiovascular guidelines 2
• However, this regimen resulted in only 22.2% treatment success (defined as menstrual blood loss <80 mL with ≥50% reduction) compared to 84.8% with levonorgestrel IUD 1
• The median reduction in menstrual blood loss was only 17.8 mL with cyclic oral medroxyprogesterone versus 128.8 mL with levonorgestrel IUD 1

Continuous Regimen (For Amenorrhea)

• 10 mg daily administered continuously can be used when avoidance of withdrawal bleeding is desired 3
• Continuous medroxyprogesterone 10 mg daily with estrogen induces endometrial atrophy and reduces bleeding frequency 3
• This approach is mentioned in cardiovascular guidelines as reducing menses to light bleeding when used cyclically, with higher doses for acute bleeding control 2

Acute Heavy Bleeding (Short-Term Only)

• High-dose oral or injectable progestin-only medications may be considered short-term for hemodynamically unstable women with uncontrolled bleeding 2
• Injectable depot medroxyprogesterone acetate (DMPA) 150 mg intramuscularly every 12 weeks can be used, with NSAIDs for 5-7 days if heavy bleeding occurs 2, 4

Critical Limitations and Caveats

Efficacy Concerns

• Oral medroxyprogesterone is substantially inferior to levonorgestrel IUD for heavy menstrual bleeding management 1
• Long-term use (21 days per cycle for 3 cycles) showed similar efficacy to tranexamic acid but with more drug complications and less patient satisfaction 5
• Treatment failure rates are high, with only about 1 in 5 women achieving adequate bleeding control 1

Side Effect Profile

• More drug complications and lower satisfaction compared to alternative treatments 5
• Menstrual irregularity and breakthrough bleeding are common side effects that may limit use 5
• Injectable DMPA causes fluid retention and is inappropriate for patients with heart failure 2
• Weight gain is a common concern with DMPA 6

Contraindications in Specific Populations

• Monthly injectables containing medroxyprogesterone are contraindicated in heart failure due to fluid retention 2
• Careful clinical judgment required in women with cardiovascular disease, as hormonal therapy is relatively contraindicated after spontaneous coronary artery dissection 2

Superior Alternative: Levonorgestrel IUD

The levonorgestrel-releasing intrauterine device (20 μg/day) is the most effective medical treatment for heavy menstrual bleeding and should be offered as first-line therapy before oral medroxyprogesterone 2, 4

• Results in 71-95% reduction in menstrual blood loss, comparable to endometrial ablation 2
• Reduces menstrual blood loss by a median of 128.8 mL versus only 17.8 mL with oral medroxyprogesterone 1
• Treatment success rate of 84.8% versus 22.2% with oral medroxyprogesterone 1
• Main effect is local at the endometrial level with minimal systemic progesterone absorption 2
• Backup contraception needed only if inserted >7 days after menses starts 2, 4

Practical Management Algorithm

Step 1: First-Line Treatment

• Offer levonorgestrel IUD 20 μg/day as initial therapy 2, 1
• Requires bimanual examination and cervical inspection before placement 2

Step 2: If IUD Declined or Contraindicated

• Prescribe oral medroxyprogesterone acetate 10 mg daily for 10-14 days per cycle (starting day 16) 1, 5
• Counsel extensively about expected irregular bleeding patterns and lower efficacy 4
• Consider 3-month trial before switching to alternative 5

Step 3: Managing Breakthrough Bleeding

• Add NSAIDs for 5-7 days if heavy bleeding persists 2, 4
• Rule out pregnancy, STIs, or new pathologic conditions before treating breakthrough bleeding 4
• Consider switching to continuous regimen (10 mg daily) if cyclic bleeding unacceptable 3

Step 4: Treatment Failure

• If inadequate response after 3 cycles, transition to levonorgestrel IUD or consider endometrial ablation 2, 1
• Counsel about alternative contraceptive methods with better bleeding control 4

Adolescent-Specific Considerations

Combined oral contraceptives with 30-35 μg ethinyl estradiol are preferred over progestin-only methods as first-line treatment in adolescents with heavy menstrual bleeding 4

• Monophasic COCs provide better cycle control and additional benefits (acne improvement, cancer risk reduction) 4
• Depot medroxyprogesterone is considered second-line in adolescents 4
• Blood pressure monitoring required at follow-up for COC users 4