Table 3.

Progestin Therapy

Progestin therapy
In most cases, use a cyclic progestin, usually medroxyprogesterone (Provera) because of its low cost. If PMS-like side effects are unacceptable, consider micronized progesterone (Prometrium), norethindrone (Aygestin), or megestrol (Megace).
Cyclic progestins
Start medroxyprogesterone 10 mg daily for 14 days, then off 14 days, then on 14 days, and so on without regard to bleeding pattern. If bleeding occurs before completing the 14-day course, the patient can double the dose (20 mg) and ‘reset the clock’ (count the first day of bleeding as day 1 and start medroxyprogesterone on day 14) or not reset the clock and continue the schedule without regard to bleeding pattern.
If the patient is bleeding at the time of the visit, start medroxyprogesterone 10 mg daily and increase every 2 days as needed to stop the bleeding (20 mg, 30 mg, 40 mg, 60 mg, 80 mg) until bleeding stops. However, the patient should be warned that intolerable PMS-like side effects may develop with high doses. Continue for 14 days and then cycle 14 days on, 14 days off, and so on.
Continuous progestins
Continuous progestins may be indicated if the goal is to achieve amenorrhea (eg, busy professional or athlete, intractable menstrual migraine, catamenial seizures, severe mental retardation). Maintaining amenorrhea is often more difficult than cycling a progestin (ie, there may be unpredictable spotting). Options include:
— Oral progestin: medroxyprogesterone Provera 10 to 20 mg daily or ‘Minipill’ (eg, 0.35 mg of norethindrone daily)
— Depo-medroxyprogesterone (Depo-Provera) 150 mg IM every 13 weeks. Often used in adolescents to improve compliance. Less often used in ages >40 years due to risk of osteoporosis.
— Levonorgestrel IUD (Mirena).