What is the best prescription for a healthy female patient to postpone her periods?

Prescription for Menstrual Postponement

For a healthy woman seeking to postpone her period, prescribe combined hormonal contraceptives (pills, patch, or ring) in an extended or continuous regimen, which is the most evidence-based and widely recommended approach for menstrual suppression. 1, 2

Primary Recommendation: Combined Hormonal Contraceptives (CHCs)

Combined oral contraceptives taken continuously (skipping the hormone-free interval) are the first-line option for menstrual postponement in healthy women. 2 This approach involves:

• Taking active hormone pills continuously without the typical 7-day hormone-free interval 1
• Using any monophasic combined oral contraceptive formulation
• Alternatively, using the contraceptive patch or vaginal ring continuously 2

Important Counseling Points

• Complete amenorrhea may be difficult to achieve initially—patients should expect breakthrough bleeding, especially in the first few months 2
• Breakthrough bleeding is not dangerous and typically decreases over time with continued use 1
• If breakthrough bleeding becomes bothersome, a 3-4 day hormone-free interval can be taken, then resume continuous dosing 1

Contraindications to Screen For

Before prescribing CHCs, ensure the patient does NOT have 1:

• History of venous thromboembolism (VTE)
• Current or history of cardiovascular disease
• Migraine with aura
• Uncontrolled hypertension
• Age ≥35 years with smoking
• Postpartum <3 weeks (absolute contraindication due to VTE risk) 1

Alternative Options When CHCs Are Contraindicated

Progestin-Only Methods

If combined hormonal contraceptives are contraindicated, several progestin-only options can suppress menstruation 2:

1. Norethindrone Acetate (Non-Contraceptive Dose)

• Prescribe 5 mg daily, can increase to 15 mg daily if needed 3
• This is FDA-approved specifically for endometriosis but effectively suppresses menstruation 3
• Does not carry the VTE risk of estrogen-containing methods 2

2. Depot Medroxyprogesterone Acetate (DMPA)

• 150 mg intramuscular injection every 12-13 weeks 1, 2
• Highly effective for amenorrhea (most women become amenorrheic after 1 year of use) 2
• Can be given immediately if reasonably certain patient is not pregnant 1

3. Levonorgestrel Intrauterine Device (LNG-IUD)

• Most effective long-term option for menstrual suppression, reducing menstrual blood loss by 71-95% 4, 2
• Many users achieve complete amenorrhea over time 5, 6
• Provides contraception for 5-8 years depending on formulation 2

4. Etonogestrel Implant

• Single-rod subdermal implant providing 3 years of contraception 2
• Variable bleeding patterns—some achieve amenorrhea, others experience irregular bleeding 2
• Less predictable for menstrual suppression compared to other options 2

5. Progestin-Only Pills (POPs)

• Continuous daily dosing 2
• Less effective for menstrual suppression than other progestin methods 2
• Bleeding patterns are unpredictable 2

Clinical Algorithm for Selection

Step 1: Assess Medical Eligibility

• Screen for CHC contraindications (VTE history, cardiovascular disease, migraine with aura, smoking age ≥35) 1
• Measure blood pressure if considering CHCs 1

Step 2: If CHCs Are Appropriate

• Prescribe continuous/extended regimen combined oral contraceptives as first-line 2
• Counsel about expected breakthrough bleeding initially 2
• Advise that breakthrough bleeding management includes brief hormone-free intervals if needed 1

Step 3: If CHCs Are Contraindicated

• Consider LNG-IUD as most effective alternative (71-95% reduction in bleeding) 4, 5, 6
• Consider DMPA injection if long-acting method desired and patient accepts injection route 2
• Consider norethindrone acetate 5-15 mg daily if oral medication preferred 3

Step 4: Set Realistic Expectations

• Emphasize that complete amenorrhea may take several months to achieve 2
• Explain that breakthrough bleeding does not indicate method failure 1
• Schedule follow-up to assess satisfaction and manage side effects 1

Common Pitfalls to Avoid

• Do not withhold menstrual suppression based on misconceptions about "needing" monthly periods—there is no medical necessity for monthly menstruation 2, 7
• Do not prescribe cyclic progestins (10-14 days per month)—this induces withdrawal bleeding rather than suppressing it 3
• Do not discontinue method prematurely for breakthrough bleeding—this typically improves with continued use 1, 2
• Do not assume all patients know about menstrual suppression options—78% of women have never heard of this approach and providers must initiate the discussion 7