What is the recommended dose and schedule of medroxyprogesterone acetate for a non‑pregnant woman with anovulatory dysfunctional uterine bleeding and no contraindications such as active liver disease or thrombophilia?

Medroxyprogesterone Acetate Dosing for Anovulatory Uterine Bleeding

For anovulatory dysfunctional uterine bleeding in non-pregnant women without contraindications, administer medroxyprogesterone acetate 10 mg orally once daily for 10 days each month for at least 3-6 months. 1, 2

Standard Dosing Regimen

The established dose is medroxyprogesterone acetate 10 mg daily for 10 days per month, typically given on days 16-25 of the cycle or for any consecutive 10-day period each month. 1, 2 This regimen:

• Induces withdrawal bleeding in approximately 93% of women with adequate endogenous estrogen 3
• Provides endometrial protection against hyperplasia from unopposed estrogen 4
• Should be continued for a minimum of 3 months in adolescents with close monitoring thereafter 1
• Can be extended to 6 months for reproductive-age women requiring treatment of anovulatory bleeding alone 1

Alternative Dosing for Acute Management

For acute heavy bleeding episodes requiring immediate control, higher-dose progestin regimens may be necessary:

• Medroxyprogesterone acetate 5-10 mg three times daily (15-30 mg total daily) can be used for acute bleeding control 5
• This higher dosing is typically given from day 5-25 of the cycle for ovulatory bleeding or day 12-25 for anovulatory bleeding 5
• Duration of bleeding is reduced and menstrual blood loss decreases significantly with these regimens 5

Age-Specific Considerations

Adolescents

• Use medroxyprogesterone acetate 10 mg daily for 10 days monthly for at least 3 months 1
• Close monitoring is essential after the initial treatment period 1
• Consider oral contraceptives if contraception is also needed 1

Reproductive Age Women

• Medroxyprogesterone acetate 10 mg for 10 days monthly for 6 months is appropriate for anovulatory bleeding when contraception is not needed 1
• Oral contraceptives are preferred if contraception is simultaneously required 1
• Clomiphene citrate should be used instead if fertility is desired 1

Perimenopausal Women

• Cyclic medroxyprogesterone acetate on days 18-25 of a 25-day cycle can be combined with conjugated equine estrogens 1
• Low-dose combination oral contraceptives are an alternative for non-smokers without vascular disease 1

Important Clinical Caveats

Before initiating treatment, exclude structural pathology, pregnancy, bleeding disorders (particularly von Willebrand disease, present in ~1% of the population), and endometrial cancer risk factors. 1

• Endometrial biopsy or curettage is indicated for women with risk factors for endometrial cancer who have persistent bleeding 1
• Acute bleeding causing hypovolemia requires curettage rather than medical management alone 1
• Von Willebrand disease is commonly misdiagnosed as dysfunctional uterine bleeding and requires specific treatment 1

Monitoring and Follow-Up

Patients should be monitored for:

• Breakthrough bleeding (common side effect) 3
• Return of regular cycles after treatment cessation 1
• Prompt resumption of ovulation post-treatment 6
• Need for alternative therapy if bleeding persists despite 3-6 months of treatment 1

When This Regimen Fails

If medroxyprogesterone acetate fails to control bleeding after an adequate trial:

• Consider switching to continuous oral contraceptives 1
• NSAIDs for 5-7 days during bleeding episodes can be added 7
• Evaluate for underlying pathology including thyroid disease, hyperprolactinemia, or androgen excess 2
• Surgical options (endometrial ablation or hysterectomy) are reserved for patients who fail all medical regimens or no longer desire fertility 1