How can menstruation be postponed?

Medical Postponement of Menstruation

For short-term menstrual delay, prescribe norethisterone 5 mg three times daily starting 3 days before the expected period, which has only an 8% breakthrough bleeding rate compared to 43% with combined oral contraceptives. 1

Primary Method: Norethisterone

Norethisterone is the superior first-line option for menstrual postponement, particularly when initiated late in the cycle or when breakthrough bleeding cannot be tolerated. 1

Dosing Protocol

• Start norethisterone 5 mg three times daily approximately 3 days before the expected menstrual period 1
• Continue throughout the period when menstruation needs to be avoided 1
• Menstruation typically occurs 2-3 days after discontinuation 2

Contraindications to Screen For

Before prescribing, verify absence of: 1

• 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

Alternative Method: Combined Oral Contraceptives

If norethisterone is contraindicated or unavailable, combined oral contraceptives can delay menstruation by skipping the hormone-free interval, though this carries significantly higher breakthrough bleeding rates (43%). 1

Protocol for COCs

• Start combined oral contraceptives immediately if reasonably certain the patient is not pregnant 1
• Continue active pills without taking the hormone-free interval (skip the placebo pills) 1
• This method works best when the patient is already established on COCs rather than starting them specifically for menstrual delay 1

Managing Breakthrough Bleeding with COCs

If breakthrough bleeding occurs during extended COC use: 1

• Rule out pregnancy, STDs, medication interactions, and underlying gynecological pathology
• If no pathology is found, consider discontinuing COCs for 3-4 consecutive days (hormone-free interval) to allow withdrawal bleeding, then resume active pills 1

Clinical Pearls

The key advantage of norethisterone over COCs is the dramatically lower breakthrough bleeding rate (8% vs 43%), making it the preferred option when menstrual postponement must be reliable. 1 This is particularly important for situations like travel, athletic competitions, religious observances, or special events where any bleeding would be problematic.

Norethisterone can be initiated even late in the menstrual cycle (just 3 days before expected menses), whereas COC-based postponement requires the patient to already be taking COCs or to start them earlier in the cycle for optimal effectiveness. 1

Common Pitfalls to Avoid

• Do not prescribe norethisterone without screening for contraindications, particularly thromboembolism history and pregnancy, as these carry significant morbidity risks 1
• Do not expect COCs to reliably prevent breakthrough bleeding when used for menstrual postponement—counsel patients that nearly half will experience some bleeding 1
• Do not continue norethisterone beyond the necessary postponement period—it is intended for short-term use only 1, 2