Management of Amenorrhea in a Patient on Noriday (Norethisterone)
Amenorrhea while taking Noriday requires no medical treatment—only reassurance, as this is a common and benign side effect of progestin-only contraceptives. 1, 2
Immediate Assessment
Rule out pregnancy first, especially since her regular bleeding pattern changed abruptly to amenorrhea after previously having consistent monthly periods. 3, 1, 2 This is critical even though she reports no sexual activity in the past 12 months, as the FDA label specifically advises ruling out suspected pregnancy before continuing any hormonal contraceptive. 2
- Perform a urine pregnancy test today
- Document her report of no sexual activity in the past year
- The HPV screen performed today does not assess pregnancy status
Understanding Norethisterone-Induced Amenorrhea
This amenorrhea is physiologically different from pathological amenorrhea and carries no health risks. 1, 4
- Norethisterone suppresses ovulation in approximately half of users, thickens cervical mucus, lowers mid-cycle LH and FSH peaks, and alters the endometrium 2
- Unlike hypothalamic amenorrhea, contraceptive-induced amenorrhea does not cause bone mineral density loss 1, 4
- The bleeding changes are generally not harmful and do not require intervention 3, 1
- Small amounts of progestin pass into breast milk (1-6% of maternal plasma levels), but this is not relevant for this non-lactating patient 2
Clinical Management Algorithm
If Pregnancy Test is Negative:
Provide reassurance and continue current contraceptive. 3, 1
- Explain that amenorrhea occurs commonly with progestin-only pills and does not indicate a problem 3, 1
- Counsel that this does not require any medical treatment 3, 1, 2
- Emphasize the importance of taking pills at the same time every day to maintain contraceptive effectiveness 2
- Advise her to use backup contraception (condoms/spermicides) for 48 hours if she takes a pill 3+ hours late 2
If She Finds Amenorrhea Unacceptable:
Counsel on alternative contraceptive methods and offer to switch. 3, 1, 5
- Combined hormonal contraceptives may restore regular withdrawal bleeding 5, 6
- Levonorgestrel IUD is another option, though it also commonly causes amenorrhea 5
- Copper IUD would restore natural menstrual cycles but provides no hormonal benefits 3
If Pregnancy Test is Positive:
- Discontinue Noriday immediately
- Counsel on pregnancy options
- Note that studies have found no effects on fetal development from contraceptive doses of oral progestins, though it is prudent to discontinue 2
Red Flags Requiring Further Evaluation
Consider underlying pathology only if additional concerning features are present: 2, 7
- Severe or persistent abdominal pain (patient should be instructed to report this) 2
- New onset headache or worsening migraine with new pattern—this requires discontinuation and evaluation 2
- Signs of pregnancy (nausea, breast tenderness, fatigue)
- Symptoms suggesting thyroid dysfunction, hyperprolactinemia, or PCOS 5, 7
Common Pitfalls to Avoid
- Do not treat amenorrhea as pathological when it is contraceptive-induced. This is a benign side effect, not a disease state. 3, 1
- Do not order extensive hormonal workup (FSH, LH, prolactin, TSH) unless pregnancy is confirmed or other symptoms suggest endocrine pathology. 7
- Do not assume she needs to "have a period" for health reasons. The withdrawal bleeding on combined contraceptives is not physiologically necessary. 1, 4
- Do not fail to document the pregnancy test result and her report of no sexual activity. 2
Patient Education Points
Counsel her on what to expect going forward: 3, 2
- Amenorrhea may persist as long as she continues Noriday
- If she desires return of menses, switching contraceptive methods is the solution
- Fertility returns rapidly after discontinuation (normal ovulation typically resumes quickly) 2
- She should contact you if she develops prolonged or severe abdominal pain 2
- Diarrhea and/or vomiting may reduce hormone absorption and contraceptive effectiveness 2