What is the recommended dosing of norethindrone (a progestin) for a female patient of reproductive age with no significant medical history to delay menstruation?

Norethindrone Dosing for Menstrual Delay

For delaying menstruation in a healthy reproductive-age woman, norethindrone should be dosed at 5 mg orally two to three times daily (10-15 mg total daily), starting 3 days before the expected period and continuing until menstruation is desired. 1

Dosing Protocol

• Start timing: Begin norethindrone 5 mg orally 2-3 times daily exactly 3 days before the anticipated menstrual period 1
• Duration: Continue daily dosing without interruption until you want menstruation to occur 1
• Expected withdrawal bleeding: Menstruation typically occurs 2-3 days after discontinuation 1

The 5 mg dose administered 2-3 times daily (total 10-15 mg/day) is necessary for reliable menstrual suppression—lower doses are insufficient for this indication 1. This differs substantially from the 0.35 mg daily dose used for contraception or the 5 mg daily dose used for other conditions 2.

Critical Safety Screening

Before prescribing, you must exclude the following contraindications 1:

• Thrombotic history: Any history of deep vein thrombosis, pulmonary embolism, or thromboembolic disease 1
• Cardiovascular disease: Uncontrolled hypertension, cerebrovascular disease, coronary artery disease, or hypercoagulopathies 1
• Malignancy: Breast cancer or other hormone-sensitive cancers 1
• Hepatic disease: Active liver disease or hepatic tumors 1
• Undiagnosed vaginal bleeding 1
• Pregnancy (must be reasonably certain patient is not pregnant) 1

Essential Patient Counseling

Norethindrone at this dose is NOT contraceptive—patients must use barrier methods if sexually active during treatment 1. This is a critical counseling point that is frequently overlooked.

Warn patients about expected side effects 3:

• Significant weight gain during treatment (resolves after cessation) 3
• Heavier withdrawal bleeding compared to normal menses 3
• Possible breakthrough spotting (occurs in approximately 8% of patients when started appropriately) 3

Clinical Evidence Supporting This Regimen

A randomized controlled trial demonstrated norethindrone 5 mg three times daily is superior to combined oral contraceptives for menstrual delay, with only 8% experiencing breakthrough bleeding versus 43% with OCPs 3. Patient satisfaction was significantly higher (80% willing to repeat), and importantly, time to conceive after discontinuation was shorter with norethindrone compared to OCPs 3.

Important Limitations

• Duration of use: This regimen is intended for short-term, occasional use only 1
• Repeated use: For patients requiring frequent or prolonged menstrual suppression, alternative hormonal management should be considered rather than repeated courses of norethindrone 1
• Timing matters: Starting on or before cycle day 12 provides optimal efficacy; patients presenting later in their cycle can still use this regimen but should be counseled about slightly higher breakthrough bleeding risk 3

Common Pitfalls to Avoid

• Underdosing: Using the 0.35 mg contraceptive dose or 5 mg daily dose will not reliably suppress menstruation 1, 2
• Starting too late: Beginning less than 3 days before expected menses reduces efficacy 1
• Assuming contraceptive effect: Patients must be explicitly told this is not birth control at any dose when used for menstrual delay 1
• Ignoring thrombotic risk: Even short-term use at therapeutic doses (5-15 mg daily) carries thrombotic risk in susceptible patients 4