How to Administer Medroxyprogesterone for Abnormal Uterine Bleeding
For abnormal uterine bleeding, medroxyprogesterone acetate should be administered at 5-10 mg orally daily for 5-10 days, with 10 mg for 10 days being the optimal dose for adequate secretory transformation of the endometrium. 1
Dosing Protocols Based on Clinical Scenario
For Acute Heavy Bleeding
- Combination therapy: Administer depo-medroxyprogesterone acetate 150 mg intramuscularly as a single injection, combined with oral medroxyprogesterone acetate 20 mg every 8 hours for 3 days (9 doses total) 2
- This regimen stops bleeding in 100% of patients within 5 days, with mean cessation time of 2.6 days 2
- This approach is highly effective for outpatient management of acute bleeding episodes 2
For Chronic Anovulatory Bleeding (Most Common Scenario)
- Standard cyclic regimen: Give medroxyprogesterone acetate 10 mg orally daily for 10 days each month 1, 3
- Timing options: Start on either day 16 or day 21 of the menstrual cycle 1
- Duration: Continue for at least 3-6 months with close monitoring 3
- Withdrawal bleeding typically occurs 3-7 days after stopping each cycle 1
Optimal Timing Protocol
- 10-day protocol (days 16-25) is superior to 15-day protocol (days 11-25) for regulating menstrual cycles and stopping abnormal bleeding 4
- The 10-day protocol achieves bleeding cessation more frequently and requires only 3 cycles of treatment to achieve results 4
Important Clinical Considerations
When Medroxyprogesterone is NOT First-Line
- Levonorgestrel-releasing IUD is the most effective first-line treatment, reducing menstrual blood loss by 71-95% compared to only 20% reduction with oral progestogens like medroxyprogesterone 5
- Medroxyprogesterone should be considered when IUD is not acceptable to the patient or contraindicated 5
Special Populations Requiring Caution
- Cardiovascular disease patients: Avoid medroxyprogesterone and instead use levonorgestrel-releasing IUD due to minimal systemic absorption 6, 5
- Patients on anticoagulation: Prefer levonorgestrel-releasing IUD over oral progestogens 5
Before Starting Treatment
- Rule out pregnancy with β-hCG testing in all reproductive-age women 7, 6
- Perform transvaginal ultrasound to exclude structural causes (polyps, fibroids, adenomyosis, malignancy) 7
- Check thyroid-stimulating hormone and prolactin levels 7
- Consider endometrial sampling in women with risk factors for endometrial cancer (postmenopausal status, obesity, diabetes, unopposed estrogen exposure) 7
When to Escalate Care
Treatment Failure Indicators
- Bleeding persists after 2-3 treatment cycles 5
- Bleeding saturates a large pad or tampon hourly for ≥4 hours 7, 5
- Patient develops hemodynamic instability 7
Next Steps After Failure
- Perform hysteroscopy to exclude focal lesions that may have been missed by endometrial sampling 6, 5
- Consider referral to gynecology for endometrial ablation or hysterectomy 7, 6
Common Pitfalls to Avoid
- Do not use medroxyprogesterone for acute profuse bleeding unresponsive to initial therapy: High-dose estrogen is more appropriate for acute hemorrhagic episodes 3
- Do not rely on endometrial biopsy alone to rule out focal lesions, as it has variable sensitivity 6
- Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to MI and thrombosis risk 7, 6