What is the appropriate dosing regimen of medroxyprogesterone acetate (Provera) for an adult woman with dysfunctional uterine bleeding and no contraindications?

Medroxyprogesterone Acetate Dosing for Dysfunctional Uterine Bleeding

For dysfunctional uterine bleeding in adult women, medroxyprogesterone acetate (Provera) 10 mg daily for 12-14 days per month is the standard cyclic regimen, while acute hemorrhagic episodes require higher doses of 20 mg orally every 8 hours for 3 days combined with depot medroxyprogesterone acetate 150 mg intramuscularly. 1, 2, 3, 4

Acute Hemorrhagic Episodes (Hemodynamically Unstable)

For women presenting with acute, heavy bleeding:

• Administer depot medroxyprogesterone acetate 150 mg intramuscularly as a single injection, combined with oral medroxyprogesterone acetate 20 mg every 8 hours for 9 doses (3 days total). 4
• This regimen stops bleeding in 100% of women within 5 days, with mean cessation time of 2.6 days. 4
• After acute bleeding control, transition to maintenance cyclic therapy (see below). 2

Chronic Anovulatory Dysfunctional Uterine Bleeding

For ongoing management of anovulatory bleeding:

Standard Cyclic Regimen (First-Line)

• Medroxyprogesterone acetate 10 mg orally once daily for 12-14 days per month (typically days 12-25 or days 16-25 of the menstrual cycle). 1, 2, 3
• This regimen reduces menstrual blood loss by approximately 87% and provides proven endometrial protection. 2, 5
• Continue for at least 3-6 months with close monitoring. 3

Alternative Timing Protocol

• For better cycle regulation, consider administering medroxyprogesterone acetate 10 mg daily from days 16-25 (10-day protocol) rather than days 11-25 (15-day protocol). 6
• The 10-day protocol more effectively regulates menstrual cycles and stops abnormal bleeding, with 3 cycles typically sufficient to achieve bleeding cessation. 6

Higher-Dose Cyclic Regimen (Refractory Cases)

• For women who fail standard dosing, escalate to medroxyprogesterone acetate 5-10 mg orally three times daily from day 5-25 of the cycle. 5
• This higher-dose regimen effectively reduces measured menstrual blood loss from baseline (control 110-131 mL to treatment 64-80 mL). 5

Continuous Combined Regimen (Alternative Approach)

For women preferring amenorrhea over cyclic bleeding:

• Medroxyprogesterone acetate 2.5-5 mg orally once daily continuously (without interruption). 1, 7
• The 5 mg daily dose provides better endometrial protection and higher rates of amenorrhea compared to 2.5 mg. 8
• Expect breakthrough bleeding in 58% of women during the first 3 months, declining to 10% by 12 months and complete amenorrhea by 24 months with 5-10 mg doses. 8

Critical Clinical Considerations

When to Choose Each Regimen

• Acute hemorrhage: Use high-dose combination protocol (depot injection + oral 20 mg TID). 4
• Adolescents with anovulatory bleeding: Use cyclic 10 mg daily for 10 days monthly for ≥3 months. 3
• Reproductive-age women requiring contraception: Consider combined oral contraceptives instead of progestin-only therapy. 2, 3
• Perimenopausal women: Use cyclic 10 mg daily for 12-14 days monthly, or consider low-dose combined oral contraceptives if nonsmoker without vascular disease. 3

Important Pitfalls to Avoid

• Never use progestin for fewer than 12 days per cycle in sequential regimens—this provides inadequate endometrial protection. 1, 7
• Before treating any breakthrough bleeding, rule out pregnancy, sexually transmitted infections, thyroid disorders, and structural uterine pathology (polyps, fibroids). 2
• Medroxyprogesterone acetate has less favorable cardiovascular and metabolic effects compared to micronized progesterone, including adverse effects on lipid profiles and vasomotion. 1, 7
• Injectable depot medroxyprogesterone acetate causes fluid retention and is contraindicated in women with heart failure. 2

When Medical Therapy Fails

• If bleeding persists despite 6 months of appropriate progestin therapy, consider endometrial biopsy or hysteroscopy to exclude structural pathology or malignancy. 3
• Women with risk factors for endometrial cancer (obesity, diabetes, chronic anovulation) require endometrial sampling before initiating long-term progestin therapy. 3
• Surgical options (endometrial ablation or hysterectomy) are reserved for women who fail all medical regimens or have completed childbearing with associated pelvic pathology. 3

Monitoring and Follow-Up

• After acute bleeding control, transition to standard cyclic therapy for at least 21 consecutive days before any hormone-free interval to prevent recurrent bleeding. 2
• Assess response after 3 months of cyclic therapy; if inadequate, consider increasing duration (10-day to 14-day protocol) or dose escalation. 6
• No routine laboratory monitoring is required unless specific symptoms arise. 7