What is the recommended maintenance progesterone (progestin) regimen for managing anovulatory bleeding?

Maintenance Progesterone for Anovulatory Bleeding

For maintenance management of anovulatory bleeding, prescribe oral medroxyprogesterone acetate 10 mg daily for 12-14 days each month (cyclic regimen), which effectively transforms proliferative endometrium into secretory endometrium and prevents endometrial hyperplasia. 1, 2, 3, 4

Primary Recommended Regimen

• Medroxyprogesterone acetate (MPA) 10 mg orally daily for 12-14 days every 28 days is the standard maintenance approach for anovulatory bleeding 2, 3, 4
• This cyclic progestin regimen provides complete endometrial protection when used at appropriate doses and duration 3
• Expect withdrawal bleeding after each progestin cycle, which is a normal and expected outcome 2
• The 12-14 day duration is critical because progestogen must be delivered for at least the same duration as the luteal phase to adequately protect against endometrial hyperplasia and cancer 5

Alternative Progestin Options

If MPA is not tolerated or contraindicated, consider these evidence-based alternatives:

• Oral micronized progesterone 200 mg daily for 12-14 days every 28 days is the preferred alternative with a more favorable cardiovascular and metabolic profile compared to synthetic progestogens 2, 5, 3
• Norethindrone acetate 1 mg daily (either cyclically for 12-14 days or continuously) offers superior cardiovascular and metabolic outcomes compared to MPA while maintaining excellent endometrial protection 5
• Norethindrone acetate is particularly advantageous because it converts partially to ethinyl estradiol, making it especially useful for patients with low estrogen states 6

Clinical Considerations for Specific Populations

For adolescents with anovulatory bleeding:

• Administer MPA orally once daily for 10 days each month for at least 3 months, with close monitoring thereafter 4

For reproductive-age women:

• If contraception is also needed, combined oral contraceptives are appropriate 1, 4
• If contraception is not needed, cyclic progestin (MPA 10 mg for 10 days each month for 6 months) is recommended 4

For perimenopausal women:

• Cyclic progestin remains effective, or consider low-dose combination oral contraceptives if the patient is a nonsmoker without vascular disease 4

Important Caveats and Monitoring

• Perform baseline transvaginal ultrasound before starting progestin to confirm appropriate endometrial thickness and rule out structural pathology 2
• Injectable medroxyprogesterone acetate (DMPA) is not recommended for anovulatory bleeding or dysfunctional uterine bleeding due to its prolonged action and difficulty predicting withdrawal bleeding timing 7
• Estrogen therapy is generally contraindicated in chronic anovulatory bleeding because it increases the risk of endometrial hyperplasia and cancer, except in cases of profuse bleeding unresponsive to progestin 8
• The sequential dosing approach is most evidence-based if the patient tolerates withdrawal bleeding 2

When Medical Management Fails

If progestin therapy fails, is contraindicated, or is not tolerated:

• Consider the levonorgestrel intrauterine system, which delivers progestogen directly to the uterus with fewer systemic side effects 5
• Surgical options including endometrial ablation or hysterectomy may be considered if the patient has concomitant significant intracavitary lesions or no longer desires fertility 1, 4