What is an effective regimen for a female patient of reproductive age seeking to cease menses using Provera (medroxyprogesterone)?

Provera 10mg Daily for Menstrual Cessation

Direct Recommendation

For cessation of menses in reproductive-age women, use medroxyprogesterone acetate (Provera) 10 mg daily continuously without breaks, rather than cyclically, to achieve amenorrhea. 1

Dosing Regimen

Continuous daily administration is the key approach for menstrual suppression:

• Take 10 mg medroxyprogesterone acetate orally every day without interruption 1
• Do not follow the cyclic regimen (5-10 days per month) described in the FDA label for treating abnormal bleeding, as this will induce withdrawal bleeding rather than suppress menses 1
• The FDA-approved cyclic dosing (10 mg daily for 10-14 days per month) is specifically designed to produce withdrawal bleeding, not prevent it 1

Expected Timeline and Counseling

Menstrual pattern changes require patient preparation:

• Breakthrough bleeding and spotting are common during the first 3-6 months of continuous progestin use 2
• Amenorrhea typically develops after several months of continuous use 2, 3
• Counsel patients extensively before initiation that irregular bleeding is expected initially but will decrease with continued use 2
• This bleeding is not harmful and does not require treatment unless problematic 2

Managing Breakthrough Bleeding

If breakthrough bleeding becomes problematic during continuous use:

• Consider adding NSAIDs for 5-7 days 2
• Before treating, rule out pregnancy, sexually transmitted infections, medication interactions, or new pathologic uterine conditions 2
• Reassure patients that amenorrhea with progestin does not require medical treatment and is not harmful 2

Safety Considerations

Medroxyprogesterone acetate is safe for most reproductive-age women:

• No increased risk of venous thromboembolism compared to estrogen-containing methods 4
• Safe in women with contraindications to estrogen (history of VTE, stroke, cardiovascular disease, age >35 who smoke) 5, 4
• However, avoid in women with osteoporosis or at high risk for bone loss, as depot formulations cause bone density concerns 5
• The oral formulation has less data on bone effects than depot medroxyprogesterone acetate (DMPA), but caution is warranted 3

Contraception Considerations

This regimen provides contraceptive protection:

• Continuous oral medroxyprogesterone 10 mg daily should provide contraceptive efficacy, though this specific regimen is not FDA-approved for contraception 1
• If reliable contraception is a priority, consider depot medroxyprogesterone acetate (DMPA) 150 mg IM every 12 weeks instead, which has proven contraceptive efficacy and commonly causes amenorrhea after ≥1 year of use 5, 2, 3
• Alternatively, the levonorgestrel IUD (Mirena) causes amenorrhea in many users and is highly effective contraception 5, 4

Alternative Approaches for Menstrual Suppression

If oral medroxyprogesterone is ineffective or poorly tolerated:

• Extended-cycle combined oral contraceptives (30-35 mcg ethinyl estradiol with progestin taken continuously for 3-4 months) are highly effective for menstrual suppression if estrogen is not contraindicated 2
• Levonorgestrel IUD reduces menstrual blood loss by 71-95% and causes amenorrhea in many users 2, 4
• Depot medroxyprogesterone acetate 150 mg IM every 12 weeks commonly produces amenorrhea after 1 year 2, 3

Critical Pitfalls to Avoid

• Do not use cyclic dosing (10 days per month) if the goal is amenorrhea—this will cause regular withdrawal bleeding 1
• Do not discontinue prematurely due to breakthrough bleeding in the first few months; this typically resolves with continued use 2, 3
• Do not use in women with significant osteoporosis risk without careful consideration, particularly if considering long-term use 5
• Ensure this is not being used to mask underlying pathology—rule out pregnancy, thyroid disorders, or structural uterine abnormalities before initiating 2