Norethindrone for Menstrual Delay
Norethindrone is an effective progestin-only option for delaying menstruation when started on or before cycle day 12, with superior efficacy compared to combined oral contraceptives in preventing breakthrough bleeding. 1
Dosing Regimen
- Standard dose: 5 mg three times daily starting on or before cycle day 12 of the menstrual cycle 1
- Continue daily until menstruation is desired, then discontinue 1
- The medication should ideally be initiated early in the cycle (before day 12) for optimal effectiveness 1
Efficacy and Outcomes
Breakthrough bleeding rates:
- Only 8% of women experience spotting with norethindrone compared to 43% with combined oral contraceptives (p < 0.01) 1
- This makes norethindrone particularly valuable when even minimal breakthrough bleeding cannot be tolerated 1
Patient satisfaction:
- 80% of women report willingness to use this method again 1
- Significantly higher satisfaction compared to combined hormonal contraceptive alternatives 1
Expected Side Effects
Common adverse effects include:
- Significant weight gain during treatment, which resolves after cessation 1
- Heavier withdrawal bleeding when the medication is stopped compared to typical menstruation (p < 0.04) 1
- Irregular bleeding is the most common reason for discontinuation in ongoing use scenarios 2
Important safety note:
- No serious adverse events have been reported in clinical studies 2
Clinical Advantages Over Combined Hormonal Contraceptives
Norethindrone is superior when:
- The patient presents late in the menstrual cycle (after typical combined oral contraceptive initiation would be effective) 1
- Absolute prevention of breakthrough bleeding is required 1
- The patient has contraindications to estrogen-containing preparations 2
- Fertility preservation is a concern, as time to conception is significantly shorter after norethindrone use (p < 0.03) 1
Contraindications and Precautions
Based on progestin-only contraceptive guidelines, avoid in:
- Current breast cancer 3
- Active hepatic disease with abnormal liver function 3
- Hypersensitivity to norethindrone 3
- Pregnancy (though this is not the indication here) 3
Practical Implementation
Timing considerations:
- Can be started at any point in the cycle if reasonably certain the patient is not pregnant 3
- Optimal timing: initiation on or before cycle day 12 for best efficacy 1
- Later initiation may still provide benefit but with higher breakthrough bleeding rates 1
Counseling points:
- Inform patients about expected weight gain during treatment 1
- Warn about heavier withdrawal bleeding when stopping 1
- Reassure that fertility returns quickly after discontinuation 1
- Emphasize the high success rate in preventing breakthrough bleeding compared to alternatives 1
Common Pitfall to Avoid
Do not use combined oral contraceptives as first-line for menstrual delay in women presenting late in their cycle (after day 5-7), as norethindrone demonstrates superior efficacy with 43% breakthrough bleeding rate for combined pills versus only 8% for norethindrone 1. This is particularly critical when the clinical scenario demands absolute prevention of bleeding (e.g., religious observances, athletic competitions, special events).