Considerations when choosing a medicine

Some individuals may want to delay their period (menstruation) for a holiday, during exams or for a special event. Menstrual suppression may also be used in transgender and gender-diverse individuals who experience negative association with having periods. The choice of medicine will depend on various factors.

When the delay is needed

Ensure you are aware of when the onset of the delay is required to allow enough time for the medicine to take effect. For example, norethisterone needs to be started 3 days before the effects can be seen.

Patients should be advised that the efficacy of treatment can vary between individuals, as can the onset of the period after stopping the chosen medicine.

Preferred route of administration

The patient’s preferred route of administration should be taken into account before choosing a medicine.

Potential options include tablets, transdermal patches, intramuscular injection and vaginal implant. Some non-oral options require weekly, monthly or 12-weekly administration which may improve compliance.

Contraceptive use

Individuals using the combined oral contraceptives may be able to delay a period by taking their active pill daily without a break. For some brands of oral contraceptives, this method is off-label.

If an individual is taking a progestogen only contraceptive pill, consider switching to a combined oral contraceptive pill if there are no contraindications. NICE Clinical Knowledge Summaries (CKS) provide advice on switching from progesterone only contraceptive pill to combined contraceptive pill.

The use of a contraceptive barrier method, such as a condom, may be required for the first 7 days after some switches.

Medical history

Previous venous thromboembolism (VTE), migraines and uncontrolled hypertension are contraindications to certain oestrogens and progestogens. Check the product Summary of Product Characteristics (SmPC) for further information.

Body Mass Index (BMI)

Severe obesity, defined as BMI more than 30kg/m², is a risk factor for VTE. Some oestrogens and progestogens are cautioned or contraindicated in patients at high risk of VTE or in obese individuals.

Review the potential risk factors for developing a VTE such as smoking, varicose veins or family history of VTE.

Restoration of fertility

Some of the medicines listed below are contraceptives, so they affect fertility. The time taken for fertility potential to be restored after stopping the medicine will vary.

Progestogens

The progestogen only pill (POP) is taken every day with no break between packs. Taking the POP may cause periods to become irregular, so it cannot be reliably used to prevent periods.

Norethisterone and medroxyprogesterone are alternative progestogens that can be used to for this purpose.

Norethisterone is the only progestogen licensed in the UK to delay periods. Prescribing any other medicine for this indication would be considered off-label. Refer to this off-label or unlicensed use of medicines page for further information.

Norethisterone

Norethisterone 5mg three times a day is licensed to delay periods. To be effective, norethisterone should be started at least 3 days before the expected period.

Norethisterone can be taken for up to 3 to 4 weeks if necessary. Periods usually resume within 3 days of discontinuing norethisterone.

The individual should be advised that norethisterone is not a contraceptive and so another form of contraceptive should be used to avoid pregnancy.

Medroxyprogesterone

Medroxyprogesterone is an option if an individual has contraindications to oestrogens, such as migraines.

Depot medroxyprogesterone

Depot medroxyprogesterone acetate (DPMA) is injected every 12 weeks and it takes time to start delaying periods. Previous VTE history is not a contraindication to DPMA.

The efficacy of DPMA in delaying a period improves with time. No periods are seen in 30% of people during the first 3 months of treatment with DPMA. This increases to 55% after a year of DPMA treatment.

DPMA is licensed as a contraceptive in the UK; its use to delay periods is off-label.

DPMA provides contraception for at least 12 weeks and it can take up to a year for fertility to return after stopping it.

Medroxyprogesterone tablets

Medroxyprogesterone tablets at a dose of 10mg three times a day have been used off-label to delay periods. This dose has been shown to reduce heavy bleeding, although breakthrough bleeding can occur.

Periods usually resume within 3 days of discontinuing medroxyprogesterone tablets.

The individual should be advised that oral medroxyprogesterone is not a contraceptive and so another form of contraceptive, such as condoms, should be used to avoid pregnancy.

Oral medroxyprogesterone may inhibit ovulation so fertility can be affected. The time taken for fertility to return to normal varies.

Combined oral contraceptive pill

Individuals already taking a combined oral contraceptive pill have a withdrawal bleed as opposed to a menstrual period. They can delay their withdrawal bleed by taking their packets back-to-back depending on the type of pill. Breakthrough bleeding is more common in the first few months.

The individual can expect their withdrawal bleed to start approximately 3 days after stopping the pill.

Monophasic 21-day pills

Take the pill for 21 days and start a new packet of pills straight away without a 7-day break.

Monophasic pills can be taken continuously for as long as the individual wants, but the risk of breakthrough bleeding increases with prolonged continuous use.

Everyday pills

Take the active pill for 21 days and then miss out the 7 inactive pills. Start a new packet of active pills straight away.

Advise individuals to dispose of the 7 inactive pills safely.

Phasic pills

If the individual is using a biphasic or triphasic contraceptive pill, they should finish the first pack and then start the last phase of pills from the next pack immediately.

Advise individuals to dispose of the unused pills safely.

Vaginal ring

The vaginal ring can delay a withdrawal bleed. The delivery system can be used continuously or as an extended cycle. This use is off-label.

Extended cycling involves individuals inserting a new ring every 4 weeks to avoid any hormone- or ring-free interval. Spotting or breakthrough bleeding can occur. The American College of Obstetricians and Gynaecologists (ACOG) state that 89% of women who completed 6 months of extended cycling had no to minimal bleeding. 

Transdermal patches

Transdermal patches are usually applied for 3 weeks, followed by a 1 week “off” period to mimic the menstrual cycle. These can be applied continuously to delay a withdrawal bleed. This use is off-label.

Using the contraceptive patch in an extended regimen has been shown to be equally as effective at delaying a withdrawal bleed as continuous use of the combined oral contraceptive pill.

Skin reactions can occur with patches.

Patient counselling

Advice should be tailored to the chosen medicine used to delay the period. Information should include:

• whether the chosen medicine is off-label
• how to take the medicine
• when to expect a period or withdrawal bleed
• if there is a need for additional barrier contraceptive methods
• how to manage any side effects or drug interactions
• the expected time taken to return to fertility potential

Patients can be directed to the NHS periods page for further information.

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