Medications for Menstrual Suppression

First-Line Options

Depot medroxyprogesterone acetate (DMPA) 150 mg intramuscularly or 104 mg subcutaneously every 13 weeks provides effective long-term suppression, with menstrual irregularities initially that typically improve over time, often resulting in amenorrhea, as recommended by the American Academy of Pediatrics 1, 2
Levonorgestrel-releasing intrauterine device (LNG-IUS) is the single most effective option for long-term menstrual suppression, achieving 71-95% reduction in menstrual blood loss with 22% of users experiencing complete amenorrhea, according to the American College of Obstetricians and Gynecologists 3
The LNG-IUS is particularly useful for adolescents with medical conditions requiring long-term menstrual suppression where estrogen is contraindicated, as stated by the American Academy of Pediatrics 1

Combined oral contraceptives can be used continuously to suppress menses, though they are less effective than norethindrone for short-term delay when started late in the cycle, as reported by the American Academy of Family Physicians 4
Cyclic oral progestins reduce bleeding by 87% and typically result in eventual reduction to light bleeding only, according to the American College of Obstetricians and Gynecologists 3

Rule out pregnancy before initiating any hormonal therapy, as recommended by the American Academy of Family Physicians 4
In women with spontaneous coronary artery dissection, hormonal therapy including progesterone is relatively contraindicated, as stated by the American Heart Association 3
Hormone replacement therapy should not be used for secondary prevention in women with established coronary artery disease, according to the American College of Cardiology 3

Enhanced counseling about expected bleeding patterns reduces discontinuation rates, as reported by the American College of Obstetricians and Gynecologists 3
With DMPA: nearly all patients experience menstrual irregularities initially, which improve over time, as stated by the American Academy of Pediatrics 1, 2
With LNG-IUS: irregular bleeding is common initially but 22% achieve complete amenorrhea, according to the American College of Obstetricians and Gynecologists 3

The Centers for Disease Control and Prevention recommends Depot Medroxyprogesterone Acetate (DMPA) as a highly effective option for long-term menstrual suppression, available in two formulations (150 mg IM or 104 mg SC) with the only difference being route of administration 5, 6
The Centers for Disease Control and Prevention suggests that the Etonogestrel Implant is associated with 22% of users experiencing amenorrhea and 34% experiencing infrequent spotting, while 7% report frequent bleeding and 18% report prolonged bleeding 5, 6

The Centers for Disease Control and Prevention recommends that for implant users with irregular bleeding, celecoxib 200 mg daily for 5 days or mefenamic acid 500 mg three times daily for 5 days can achieve bleeding cessation within 7 days, and estrogen, daily COCs, or tranexamic acid can reduce bleeding days during treatment 5, 6
The American College of Obstetricians and Gynecologists advises that for COC users with breakthrough bleeding, ruling out underlying gynecological problems, medication interactions, STDs, pregnancy, or new pathologic uterine conditions is essential, and if no underlying problem is found, NSAIDs for 5-7 days or hormonal treatment with low-dose COCs or estrogen for 10-20 days can be used 5, 6

The Journal of Clinical Oncology notes that cessation of menses alone is not an adequate indicator of ovarian suppression, and patients should be alert to physiologic changes suggesting recovery of ovarian function 7
The Journal of Clinical Oncology also states that menstrual cycles do not indicate fertility, and many patients erroneously assume this 8

The Centers for Disease Control and Prevention recommends that amenorrhea during hormonal contraceptive use is generally not harmful and does not require medical treatment 6
The Journal of Clinical Oncology advises that patients should be counseled about realistic expectations regarding menstrual suppression, and complete amenorrhea may be difficult to achieve 7