What is an appropriate taper schedule for discontinuing Aygestin (norethindrone acetate)?

Aygestin (Norethindrone Acetate) Tapering Protocol

There is no established evidence-based taper protocol for discontinuing Aygestin (norethindrone acetate) when used for conditions such as endometriosis or abnormal uterine bleeding, and in most clinical scenarios, abrupt discontinuation is safe and does not require gradual dose reduction.

Key Clinical Context

Unlike benzodiazepines or certain other medications, progestins such as norethindrone acetate do not cause physiologic dependence or withdrawal seizures when stopped suddenly. The primary concern with discontinuation is the return of underlying symptoms (breakthrough bleeding, endometriosis pain, or hormonal symptoms), not a dangerous withdrawal syndrome 1.

Standard Discontinuation Approach

For Most Clinical Indications

Simply stop the medication without tapering when treatment goals have been achieved or when discontinuation is desired 1.

• No gradual dose reduction is required for norethindrone acetate used at standard doses (0.35 mg daily for contraception, 5-10 mg daily for endometriosis or bleeding control) 2, 3, 4.
• Patients should be counseled that withdrawal bleeding typically occurs within 3-7 days after stopping 3, 4.
• Return of underlying symptoms (endometriosis pain, abnormal bleeding patterns) may occur within weeks to months after discontinuation 5.

Exception: Acute Heavy Menstrual Bleeding Management

When norethindrone acetate has been used at high doses (10-15 mg daily) for acute heavy bleeding control, a brief taper may be employed to prevent rebound hemorrhage 4, 6:

• Week 1: Continue current dose (typically 10-15 mg daily) until bleeding stops completely for 2 consecutive days 6.
• Week 2: Reduce to 5 mg daily for 3-5 days 4.
• Week 3: Reduce to 2.5 mg daily for 3-5 days, then discontinue 4.
• Alternative approach: Once bleeding stops, reduce by 5 mg every 3-5 days until discontinued 4.

This taper is designed to allow endometrial stabilization and prevent immediate rebound bleeding, not to prevent withdrawal symptoms 4, 6.

Monitoring After Discontinuation

• Follow-up within 4-6 weeks to assess return of symptoms and bleeding patterns 3, 4.
• Monitor for recurrence of the original indication (endometriosis pain, abnormal bleeding) 5.
• If norethindrone was used following GnRH agonist therapy (e.g., Lupron), expect return of symptoms within 2-3 months as the GnRH agonist effect wears off 5.

Special Populations

Adolescents

• Abrupt discontinuation is safe in adolescents who received norethindrone for heavy menstrual bleeding or contraindications to estrogen 4.
• Counsel patients and families that irregular bleeding may occur for 1-3 cycles after stopping 4.

Postmenopausal Women on HRT

• When norethindrone is used as the progestin component of hormone replacement therapy (sequential or continuous regimens), it can be stopped abruptly if HRT is being discontinued 1.
• If transitioning to a different progestin, direct switch without taper is appropriate 1.

Patients with Premature Ovarian Insufficiency

• For young women with iatrogenic POI receiving norethindrone as part of HRT, discontinuation should occur only when transitioning to alternative therapy or reaching the age of natural menopause (45-55 years) 1.
• No taper is required; direct switch to alternative progestin or estrogen-only therapy (if hysterectomy) is appropriate 1.

Common Pitfalls to Avoid

• Do not confuse progestin discontinuation with benzodiazepine or opioid tapering: Norethindrone does not cause physiologic dependence and does not require the gradual, prolonged tapers used for CNS depressants 7.
• Do not substitute another progestin "to make stopping easier": This simply continues therapy rather than discontinuing it 1.
• Do not taper norethindrone used for contraception: The 0.35 mg daily "minipill" dose can be stopped immediately when contraception is no longer needed 3, 4.

When to Consider Specialist Referral

• Severe rebound bleeding within days of stopping high-dose norethindrone (>10 mg daily) that does not respond to reinitiation 4, 6.
• Underlying endometriosis or bleeding disorder requiring alternative long-term management 5.
• Patients with complex hormonal needs (e.g., cancer survivors with POI) who require individualized HRT regimens 1.

Bottom Line

Norethindrone acetate can be stopped abruptly in the vast majority of clinical scenarios without a taper. The only exception is when high doses (≥10 mg daily) have been used for acute bleeding control, where a brief 1-2 week stepwise reduction may prevent rebound hemorrhage 4, 6. This is fundamentally different from medications requiring prolonged tapers to prevent dangerous withdrawal syndromes 7.