How can a healthy, non‑pregnant woman safely delay her menstrual period with norethindrone, including appropriate dosing and contraindications?

Norethindrone for Menstrual Delay

For a healthy woman seeking to delay her period, norethindrone 5 mg three times daily started on or before cycle day 12 is the most effective approach, providing superior breakthrough bleeding prevention compared to combined oral contraceptives. 1

Dosing Protocol

Standard regimen for menstrual delay:

• Norethindrone 5 mg orally three times daily 1
• Begin on or before cycle day 12 for optimal efficacy 1
• Continue throughout the period you wish to avoid menstruation 1
• Expect withdrawal bleeding within days of discontinuation 1

Efficacy and Advantages

Norethindrone demonstrates superior performance over combined oral contraceptives:

• Only 8% of norethindrone users experience breakthrough spotting versus 43% with COCs (p < 0.01) 1
• 80% of users report willingness to use this method again 1
• Particularly valuable when even minimal breakthrough bleeding cannot be tolerated (e.g., weddings, athletic competitions, religious observances) 1

Absolute Contraindications

Do not prescribe norethindrone if the patient has: 2

• Active or history of arterial thromboembolic disease (stroke, myocardial infarction) 2
• Active deep vein thrombosis, pulmonary embolism, or thromboembolic disease 2
• Known or suspected breast cancer or other estrogen/progestin-sensitive malignancy 2
• Undiagnosed abnormal genital bleeding 2
• Active hepatic disease with abnormal liver function 2
• Hepatic adenomas or carcinomas 2
• Pregnancy (Category X) 2
• Hypersensitivity to norethindrone 2

Important Clinical Considerations

Expected side effects:

• Transient weight gain (resolves after cessation) 1
• Heavier withdrawal bleeding compared to typical menses 1
• Potential mood changes, headache, or breast tenderness 2

Critical safety points:

• This is not a contraceptive method when used for menstrual delay—additional contraception is required if sexually active 3
• No baseline laboratory testing is required in healthy women 4
• Confirm the patient is not pregnant before initiating 2
• Monitor blood pressure at baseline 2

Drug Interactions

Exercise caution with concurrent use of: 2

• Anticonvulsants (carbamazepine, phenytoin, topiramate, barbiturates) 2
• Rifampin and rifabutin 2
• HIV protease inhibitors (ritonavir, nelfinavir) 2
• St. John's wort 2
• Lamotrigine (norethindrone may decrease lamotrigine levels) 2

Alternative Approach: Combined Oral Contraceptives

If norethindrone is contraindicated or unavailable:

• Continue active COC pills without taking the placebo/hormone-free interval 3
• Skip directly to a new pack of active pills 3
• Expect higher rates of breakthrough bleeding (43% vs 8%) 1
• Requires 7 days of backup contraception if starting >5 days after menses onset 4

Managing breakthrough bleeding with COCs:

• Allow a 3-4 day hormone-free interval if breakthrough bleeding becomes problematic 3
• Do not take this break during the first 21 days of continuous use 3
• Limit hormone-free intervals to no more than once per month 3

Common Pitfalls to Avoid

• Starting too late in the cycle: Norethindrone should ideally begin on or before cycle day 12 for maximum efficacy 1
• Assuming contraceptive protection: Norethindrone for menstrual delay does not provide reliable contraception—counsel patients to use barrier methods if sexually active 3
• Inadequate counseling about withdrawal bleeding: Patients should expect heavier-than-usual bleeding after stopping norethindrone 1
• Missing drug interactions: Always review current medications, particularly anticonvulsants and antibiotics 2