Maintenance Progesterone for Anovulatory Bleeding

Primary Recommended Regimen

The American Academy of Family Physicians recommends medroxyprogesterone acetate 10 mg orally daily for 12-14 days every 28 days for the maintenance management of anovulatory bleeding, which effectively transforms proliferative endometrium into secretory endometrium and prevents endometrial hyperplasia 1
A cyclic progestin regimen provides complete endometrial protection when used at appropriate doses and duration, with the 12-14 day duration being critical to adequately protect against endometrial hyperplasia and cancer 4
Expect withdrawal bleeding after each progestin cycle, which is a normal and expected outcome 2

Oral micronized progesterone 200 mg daily for 12-14 days every 28 days is a preferred alternative to medroxyprogesterone acetate, with a more favorable cardiovascular and metabolic profile 2
Norethindrone acetate 1 mg daily offers superior cardiovascular and metabolic outcomes compared to medroxyprogesterone acetate while maintaining excellent endometrial protection 4

For reproductive-age women who require contraception, combined oral contraceptives are an appropriate option for managing anovulatory bleeding 1

Perform baseline transvaginal ultrasound before starting progestin to confirm appropriate endometrial thickness and rule out structural pathology 2
The sequential dosing approach is most evidence-based if the patient tolerates withdrawal bleeding 2

Consider the levonorgestrel intrauterine system, which delivers progestogen directly to the uterus with fewer systemic side effects, if progestin therapy fails or is contraindicated 4
Surgical options, including endometrial ablation or hysterectomy, may be considered if the patient has concomitant significant intracavitary lesions or no longer desires fertility 1