What alternative contraceptive methods can be considered for a female patient of reproductive age experiencing amenorrhea due to norethindrone, particularly a combination pill (containing estrogen and progestin)?

Switching to Combined Oral Contraceptives for Norethindrone-Induced Amenorrhea

If amenorrhea from norethindrone is unacceptable to the patient, switch to a low-dose combined oral contraceptive (COC) containing 20 μg ethinyl estradiol with 100 μg levonorgestrel, which provides effective contraception while alleviating amenorrhea. 1, 2

Primary Recommendation: Combined Hormonal Contraceptives

The CDC explicitly recommends offering alternative contraceptive methods when amenorrhea persists and the woman finds it unacceptable, with COCs being a proven option for treating progestin-induced amenorrhea. 1

Evidence Supporting COC Use for Amenorrhea

• In women using depot medroxyprogesterone acetate (DMPA) who experienced amenorrhea for 2 months, treatment with COCs alleviated amenorrhea better than placebo in clinical trials 1
• This same principle applies to norethindrone-induced amenorrhea, as both are progestin-only methods that commonly cause amenorrhea through similar mechanisms 3

Specific Formulation Guidance

Start with low-dose ethinyl estradiol formulations (20 μg) combined with 100 μg levonorgestrel as first-line therapy. 2

• This formulation demonstrates excellent contraceptive efficacy with a Pearl index of 0.88 and cumulative pregnancy rate of 1.9% over 3 years 2
• The typical use failure rate is approximately 9 per 100 women-years, which is comparable to norethindrone's typical failure rate of 5% 2, 3

Alternative COC Formulations to Consider

If the patient experiences breakthrough bleeding or spotting with the 20 μg formulation:

• Consider norethindrone acetate 1,000 μg with 20 μg ethinyl estradiol, which produces significantly more amenorrhea days and fewer spotting days compared to levonorgestrel-containing pills during continuous dosing 4
• Increasing ethinyl estradiol from 20 μg to 30 μg does not improve bleeding patterns and may increase estrogen-related side effects 4

Initiation Protocol

COCs can be started immediately if pregnancy is reasonably excluded (negative pregnancy test, no unprotected intercourse since last menses, or currently using reliable contraception like norethindrone). 1, 2

Timing and Back-Up Contraception

• If started within 5 days of menstrual bleeding onset: no additional contraceptive protection needed 1, 2
• If started >5 days after menstrual bleeding or when switching from norethindrone with amenorrhea: use back-up contraception (abstinence or barrier method) for 7 days 1, 2

Practical Switching Strategy

When transitioning from norethindrone to COCs:

• Start the COC on any day after confirming the patient is not pregnant 1, 2
• Use back-up contraception for 7 days 1, 2
• No need to wait for withdrawal bleeding before initiating COCs 1

Medical Eligibility Assessment

Before prescribing COCs, confirm the patient has no contraindications, particularly cardiovascular risk factors, thromboembolism risk, migraine with aura, or smoking status if over age 35. 2

Key Contraindications to Screen For

• Age >35 years with smoking (≥15 cigarettes/day) 2
• History of venous thromboembolism or current thrombophilia 2
• Cardiovascular disease, stroke, or ischemic heart disease 2
• Migraine with aura 2
• Uncontrolled hypertension (measure blood pressure before prescribing) 2

Expected Outcomes

Amenorrhea does not require medical treatment and is not harmful; however, if unacceptable to the patient, switching to COCs typically restores regular withdrawal bleeding patterns. 1

Bleeding Pattern Expectations

• Most women experience regular withdrawal bleeding every 21-28 days with cyclic COC use 1
• Bleeding typically lasts 3-5 days with good cycle control 5
• The interval between withdrawal bleeding is 26-30 days in 86% of cycles 5

Important Caveats

COCs do not protect against sexually transmitted diseases; recommend consistent condom use if STD risk exists. 1, 2

Common Pitfalls to Avoid

• Do not assume amenorrhea indicates a medical problem requiring treatment—it is a benign side effect of progestin-only contraception 1
• Always rule out pregnancy before switching methods if the patient's bleeding pattern changed abruptly to amenorrhea 1
• Do not prescribe COCs without assessing cardiovascular and thrombotic risk factors, especially in women over 35 2

Counseling Points

• Inform the patient that amenorrhea from norethindrone is not harmful and does not require treatment unless she finds it unacceptable 1
• Explain that COCs will likely restore regular monthly bleeding but may cause different side effects (headache 15.2%, abdominal pain 10.2%, breast pain 9.0%) 6
• Emphasize the importance of taking COCs at the same time daily for maximum effectiveness 3

Alternative Non-Estrogen Options

If the patient has contraindications to estrogen but still finds amenorrhea unacceptable:

Consider switching to a different progestin-only method (levonorgestrel IUD, etonogestrel implant) or copper IUD, though these may also cause amenorrhea or irregular bleeding. 2

• The copper IUD provides highly effective contraception without hormones and typically maintains regular menstrual bleeding 2
• Progestin-only methods remain valuable options but commonly cause amenorrhea, so they may not resolve the patient's concern 2