Medical Postponement of Menstruation
For short-term menstrual delay, norethisterone 5 mg three times daily starting 3-4 days before expected menstruation is the most effective option, with only 8% breakthrough bleeding compared to 43% with combined oral contraceptives. 1, 2
Primary Recommendation: Norethisterone
Norethisterone (norethindrone) 5 mg three times daily is superior to combined hormonal contraceptives for menstrual postponement, particularly when initiated late in the cycle or when breakthrough bleeding cannot be tolerated. 1, 2
Dosing Protocol
- Start 3-4 days before expected menstruation 1
- Take 5 mg three times daily (total 15 mg/day) 1, 2
- Continue until the desired end date when menstruation can occur (e.g., after travel) 1
- Discontinuing abruptly may cause breakthrough bleeding—maintain therapy until the planned end date 1
Critical Contraindications to Screen For
Before prescribing, verify absence of: 1, 3
- Pregnancy or suspected pregnancy
- History of thromboembolism or deep vein thrombosis
- Undiagnosed vaginal bleeding
- Active liver disease
- Breast cancer or hormone-sensitive cancers
- Uncontrolled hypertension
- Cerebrovascular or coronary artery disease
Important Counseling Points
- This dose does NOT provide contraception—additional contraceptive methods are required if pregnancy prevention is needed 1
- Expected side effects: Weight gain (resolves after cessation) and heavier withdrawal bleeding when stopped 2
- Patient satisfaction is high: 80% would choose this method again 2
- Fertility is maintained: Time to conceive after discontinuation is actually shorter compared to combined oral contraceptives 2
Alternative Option: Combined Oral Contraceptives
Combined oral contraceptives can delay menstruation by skipping the hormone-free interval, but have significantly higher breakthrough bleeding rates (43%) compared to norethisterone. 4, 2
When to Consider COCs Instead
- Patient has contraindications to progestin-only methods 4
- Starting earlier in the cycle (before day 12) when breakthrough bleeding risk is lower 4, 2
- Patient already using COCs for contraception 5
Extended/Continuous COC Regimen
- Start immediately if reasonably certain patient is not pregnant 5, 4
- Continue active pills without hormone-free interval to delay menstruation 5, 4
- If starting >5 days after menstrual bleeding began: Use backup contraception for 7 days 5, 4
- Unscheduled spotting/bleeding is common during first 3-6 months but generally not harmful 5
Managing Breakthrough Bleeding with COCs
If breakthrough bleeding occurs during extended use: 5
- Rule out underlying gynecological problems, medication interactions, pregnancy, or STDs
- If no pathology found and patient desires treatment: Discontinue for 3-4 consecutive days (hormone-free interval)
- Do NOT recommend hormone-free interval during first 21 days of continuous use
- Do NOT use hormone-free interval more than once per month as contraceptive effectiveness may be reduced
Common Pitfalls to Avoid
Do NOT use low-dose progestin-only pills (0.35 mg norethindrone) for menstrual delay—this contraceptive dose provides inadequate ovulation suppression for reliable menstrual postponement. 4
Do NOT confuse norethindrone doses: 1, 3, 6
- 0.35 mg = contraceptive dose (ineffective for menstrual delay)
- 5 mg three times daily = menstrual delay dose
Screen for medication interactions, particularly enzyme-inducing drugs that may reduce effectiveness. 4
Verify absence of pregnancy and underlying gynecological pathology before prescribing. 4
Evidence Quality Note
The recommendation for norethisterone is based on a 2019 randomized controlled trial demonstrating clear superiority over COCs (8% vs 43% breakthrough bleeding, p<0.01), combined with consistent guideline support. 2 This represents the highest quality evidence available for this specific clinical question, prioritizing the outcome of successful menstrual postponement without breakthrough bleeding—which directly impacts quality of life for the patient's intended purpose.