Medication to Delay Menstruation in a 40-Year-Old Patient
For a 40-year-old woman requesting menstrual delay, norethindrone (progestin-only) 5 mg three times daily is the superior choice, particularly when started late in the cycle, as it provides better suppression of breakthrough bleeding compared to combined oral contraceptives. 1
Recommended Medication and Dosing
First-Line: Norethindrone (Progestin-Only)
- Norethindrone 5 mg orally three times daily is the most effective option for menstrual delay, especially when the patient presents late in her cycle 1
- This regimen should be started on or before cycle day 12 for optimal efficacy 1
- Only 8% of women experience breakthrough spotting with norethindrone compared to 43% with combined oral contraceptives 1
- Patient satisfaction is significantly higher with norethindrone, with 80% willing to choose this method again 1
Alternative: Combined Oral Contraceptives (COCs)
- Continue active COC pills without the hormone-free interval by skipping placebo pills and immediately starting a new pack of active pills 2
- Use monophasic COCs containing 30-35 μg of ethinyl estradiol for this purpose 2
- Patients can continue active pills for 3-4 consecutive months if desired 2
Clinical Considerations and Timing
When to Start Treatment
- Norethindrone should ideally be initiated on or before cycle day 12 to minimize breakthrough bleeding risk 1
- For patients presenting late in their cycle (after day 12), norethindrone remains superior to COCs for preventing breakthrough bleeding 1
- If using COCs, they must be started within 5 days of menses to avoid need for backup contraception 2
Pre-Treatment Requirements
- Rule out pregnancy before initiating any hormonal therapy - this is a fundamental safety requirement (U.S. MEC Category 4 contraindication) 3
- No pelvic examination, ultrasound, or laboratory tests are required in healthy women beyond pregnancy exclusion 3
Managing Breakthrough Bleeding
If Breakthrough Bleeding Occurs
- NSAIDs for 5-7 days during bleeding episodes can effectively reduce blood flow 4
- With extended COC regimens, a 3-4 day hormone-free interval can temporarily induce bleeding, but not during the first 21 days of use and not more than once per month 2
- Unscheduled spotting is common during the first 3-6 months of extended use and generally decreases with continued use 2
Before Treating Breakthrough Bleeding
- Rule out pregnancy, sexually transmitted infections, medication interactions, cigarette smoking, or new pathologic uterine conditions 2
Expected Side Effects and Counseling
Norethindrone-Specific Effects
- Significant weight gain may occur but resolves after cessation of therapy 1
- Heavier withdrawal bleeding is expected when norethindrone is stopped compared to COCs 1
- Small amounts pass into breast milk (1-6% of maternal plasma levels), though this is generally not harmful 5
- Diarrhea and/or vomiting may reduce hormone absorption 5
COC-Specific Effects
- VTE risk increases three to fourfold (up to 4 per 10,000 woman-years) 2
- Common transient effects include irregular bleeding, headache, nausea, and breast pain 2
- Smoking is NOT a contraindication in women younger than 35 years 2
Important Caveats
Contraceptive Considerations
- Neither norethindrone nor COCs used for menstrual delay should be relied upon as contraception unless the patient has been using them continuously 6
- If starting hormonal contraceptives more than 5 days after menses begins, backup contraception for 7 days is required 2
Follow-Up Requirements
- No routine follow-up visit is required unless the patient experiences concerning side effects 4
- Blood pressure should be monitored at follow-up visits for patients on COCs 2
- Counsel patients that unscheduled bleeding in the first 3-6 months is expected, not harmful, and decreases over time 2