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Suppress Your Menstrual Cycle

This FAQ helps answer questions about three pill options (NETA, MPA, and birth control pills) to delay/suppress menstruation for social/personal reasons.

General Questions

What are my pill options for delaying my period for social reasons?
For delaying menstruation, several options are available. These include prescription medications like
  • NETA (Norethisterone Acetate)
  • MPA (Medroxyprogesterone Acetate)
  • COC pills (Combined Estrogen-Progesterone Contraceptives AKA 'birth control pills')
  • NETA Birth Control (i.e. Micronor)
These drugs manipulate hormone levels, essentially postponing the shedding of the uterine lining.
Use of NETA (5mg) and MPA (10mg) is considered 'off-label' use. 'Off-label' use means NETA and MPA aren't approved by Health Canada for suppression of your period for social purposes. This doesn't mean the medication isn't effective, but using medication off-label carries specific risks. See more about 'off-label' usage below.
What are common reasons people suppress their period?
While you can delay your period for any social reason, common requests for delaying your menstrual cycle include:
  • Going on a religious pilgrimage (i.e. Hajj)
  • Avoid bleeding on your Honeymoon
  • Going away on vacation for a week
  • Visiting a water park/recreational facility
  • Going camping or hiking for a week
Can delaying my period affect my future fertility?
Delaying your period or using birth control pills to control menstrual bleeding does not have a long-term impact on your fertility.
Are there any non-medication methods to delay my period?
There are no non-medication-based methods to delay your period. The only temporary method to control menstrual flow is the use of prescription hormonal medication.
I don't want to take birth control pills. Are there other options?
NETA and MPA are the only progesterone-only pill options that are used for short-term purposes. The doses for these hormones are much higher than provided in traditional birth control pills, and these medications do not contain estrogen which is in nearly all birth control pills.
  • The doses of NETA used to delay your periods are much higher (5-15mg) than the dose used in birth control pills (0.35mg).
  • The dose of MPA pills (5-10mg) is much higher than the dose used in injection birth control (150mg every 90 days ~ 1.7mg/day)
There are alternatives to suppression of your periods. These are discussed here.
Do these medications guarantee that I won't experience spotting or bleeding?
When progesterone-only pills like NETA and MPA are used, they're very effective in preventing you from spotting or bleeding. However, there is always a possibility that you might experience mild spotting or bleeding when on any hormonal medication. This risk is very low when using NETA/MPA for short periods of time.
What does 'off-label' use mean?
"Off-label usage" refers to the practice of prescribing a medication for a purpose or dosage that has not been officially approved by regulatory agencies, such as Health Canada. When a medication is approved (or "labelled") for use, it's based on evidence from clinical trials that supports its safety and effectiveness for a specific condition or condition.
However, once a drug is on the market, healthcare professionals might discover that it is also effective for other conditions or in different dosages or forms than what was originally approved. This can lead to off-label prescribing. It's essential to understand a few key points about off-label usage:
  1. 1.
    Common Practice: Off-label prescribing is a common and legal practice. It's often based on accumulated clinical experience, smaller studies, or anecdotal evidence.
  2. 2.
    Not Always Supported by Large Clinical Trials: Because the off-label use hasn't gone through the same rigorous testing for the specific condition, there might be less data on its effectiveness or potential side effects for that particular use.
Prescribing NETA and MPA for menstrual suppression is based on our understanding of how the medication works (i.e. stabilizes the lining of your uterus), and that it's used to suppress menstruation in individuals who have painful and prolonged periods.

NETA

What is NETA (Norethisterone Acetate)?
NETA stands for Norethisterone Acetate, which is a synthetic progesterone. It has similar actions to the natural hormone progesterone found in the body. NETA is often used in various treatments, including:
  1. 1.
    Menstrual disorders: To treat painful, heavy, or irregular periods.
  2. 2.
    Endometriosis: A condition where tissue similar to the lining of the womb starts to grow in other places, such as the ovaries and fallopian tubes.
  3. 3.
    Delaying menstruation: Women can take NETA to delay their period, for instance, when going on vacation or for other personal reasons.
When taken to delay menstruation, NETA needs to be started a 3 days before the expected start of the period and will prevent bleeding for the duration it's taken. Once the medication is stopped, the period will usually return in 2-3 days.
How does NETA work?
When taken to delay a period, NETA helps maintain the lining of the uterus. During a regular menstrual cycle, the drop in progesterone levels signals the body to shed the uterine lining, resulting in a period. By taking NETA, you effectively maintain elevated progestogen levels, thereby preventing this shedding and delaying the period. Once you stop taking the medication, progesterone levels drop, and your period starts.
What are reasons I cannot take NETA?
There are several contraindications and conditions that might make it unsafe or inadvisable to take NETA. Here are some reasons why you might not be able to take NETA:
  1. 1.
    Blood Clots: If you have a history of thrombosis (blood clots) in the veins (like deep vein thrombosis) or arteries, or if you're at a higher risk for these conditions.
  2. 2.
    Cancer: Known, suspected, or past breast cancer, or other cancers influenced by sex hormones.
  3. 3.
    Liver Issues: Any liver diseases or liver tumors, whether benign or malignant.
  4. 4.
    Undiagnosed Vaginal Bleeding: If you're experiencing vaginal bleeding and the cause hasn't been determined, it's not safe to take NETA until a diagnosis is made.
  5. 5.
    Allergic Reaction: If you've had an allergic reaction to NETA or any of its ingredients in the past.
  6. 6.
    Arterial Diseases: History of or current severe arterial disease like stroke or heart attack.
  7. 7.
    Pregnancy: NETA shouldn't be taken if you are pregnant or suspect you might be pregnant.
  8. 8.
    Porphyria: A rare hereditary disease that can be triggered by certain drugs.
  9. 9.
    Migraines: Particularly migraines with aura, as certain hormonal treatments can exacerbate them.
Is NETA converted into estrogen?
Yes, even though NETA is a progesterone, your body will convert some of it into estrogen. This carries important medical risks. Some studies reference that 1mg of NETA is converted into 6 mcg of Ethinyl Estradiol (EE). Birth control pills like Alesse contain 20 mcg EE, Yasmin contains 30 mcg EE, Diane 35 contains 35 mcg EE. Studies vary in referencing the conversion of NETA to Estrogen, but taking 10-20mg of NETA results in the equivalent of 20-30mcg of EE.
What are the risks of taking NETA?
  • NETA increases the risk of blood clots in the veins (venous thromboembolism) or arteries (arterial thromboembolism). This risk is higher if you have underlying conditions or other risk factors such as high blood pressure, smoke, migraines or have a previous history of blood clots.
    • The overall risk is low because you're only on NETA for a short period of time (typically less than 14 days).
  • Some users of NETA report mood swings, depression, or feeling down. If you have a history of depression, suicidal thoughts or previous suicide attempts, we advise against using NETA.
What are common side effects while on NETA?
Commonly reported side effects include mood swings, bloating, increased appetite, breast tenderness and in some instances nausea. In some instances, you may experience a worsening of your acne or experience an acne flare. NETA can be prescribed at a dose of 5mg once daily up to 15mg daily.
  • If you experience significant side effects by taking NETA at a prescribed dose of 5mg three times daily, your dose can be reduced to 5mg twice daily or 5mg once daily.
  • NETA remains effective at 5mg but the chance of spotting increases on lower doses.
Isn't there a birth control pill that uses NETA?
There is a birth control pill called Micronor (Movisse) that contains NETA. The dose of NETA is 0.35 mg. Prescription doses for delaying your period for NETA are 5mg (~15x)- 15mg (~40x). The significantly higher doses of progesterone are why NETA is very effective at stopping menstrual bleeding.
Can I use Micronor (Movisse) for delaying my period?
Movisse/Micronor contains NETA and is used as an estrogen free birth control pill. It can stop you from experiencing bleeding. However, because of the doses are much lower (0.35mg vs. 5mg), you are more likely to experience breakthrough bleeding on these medications.
Is using NETA (pill) for menstrual suppression considered 'off-label use'?
Yes, the use of NETA to suppress your period is considered 'off-label use. However the dose and duration permissible is up to 15mg for 6-9 months of daily use.
NETA has been approved for:
  • Triggering bleeding in women who aren't experiencing regular menstrual cycles (i.e. amenorrhea)
  • Managing Endometriosis
  • Reducing heavy menstrual bleeding in women who don't have fibroids or endometrial cancer
NETA has been approved at doses up to 15mg daily, as an example, in women for 6-9 months for endometriosis.NETA is also approved in the United Kindom to delay your period for delaying your period.
What's the lowest dose of NETA that I need to suppress my periods?
The 'lowest effective dose' to suppress periods hasn't been established, but NETA is often prescribed at the most tolerable dosing. It's often reasonable to start with a dose of 5mg 2x/day. If you experience spotting, the dose can be increased to 5mg 3x/day. If you feel you have significant side effects, you can reduce the dose to once daily.
  • 5mg once daily (total dose 5mg) (Reduced dose if you have side effects)
  • 5mg twice daily (total dose 10mg) (Starting Regimen)
  • 5mg three times daily (total dose 15mg) (Higher dose if you have spotting)

MPA

What is MPA?
MPA stands for Medroxyprogesterone Acetate. It's a synthetic form of the hormone progesterone. Traditionally, DMPA is known and widely used as an injectable contraceptive under brand names like Depo-Provera (i.e. Depo Medroxyprogesterone). As an injectable, it's administered once every three months and acts as a long-acting reversible contraceptive. Roughly 50%-70% of women stop experiencing any menstrual bleeding after 1 year on DMPA.
Oral MPA refers to a pill form of medroxyprogesterone acetate. This is not a common or standard way to receive MPA for contraceptive purposes. Instead, oral medroxyprogesterone is often used in hormone therapy to regulate menstrual periods (i.e. delay periods for social purposes).
How does MPA work?
By mimicking the natural hormone progesterone, oral DMPA can help regulate the menstrual cycle. When progesterone levels drop in the menstrual cycle, it signals the body to shed the uterine lining, leading to menstruation. By taking oral DMPA, this shedding can be controlled, leading to lighter, less painful, or more regular periods.
What are side effects on MPA?
MPA (Medroxyprogesterone Acetate) can lead to a variety of side effects, such as mood swings, lower mood or anxiety. Abdominal discomfort, bloating, nausea, breast tenderness, and headaches or migraines are other reported effects. In some instances, you may experience a worsening of your acne or experience an acne flare. Additionally, some users have described feelings of fatigue. Prolonged use of MPA can lead to weight gain, but not for the duration of therapy prescribed for delaying your menstrual cycle.
Who should not be on MPA?
MPA has certain contraindications, meaning situations or conditions where its use may be harmful or inadvisable. Here are some of the contraindications to MPA:
  1. 1.
    Pregnancy: It should not be used if you are pregnant or suspect you might be pregnant.
  2. 2.
    Unexplained Vaginal Bleeding: If you have vaginal bleeding that hasn't been diagnosed.
  3. 3.
    History of Blood Clots: Individuals with a history of blood clots, deep vein thrombosis, or pulmonary embolism should avoid MPA.
  4. 4.
    History of Stroke or Heart Attack: MPA is not suitable f if have had a stroke, transient ischemic attack (TIA), or heart attack.
  5. 5.
    Breast Cancer: It's not permitted in women with current or past breast cancer.
  6. 6.
    Liver Disease: People with acute liver disease or liver tumours should avoid MPA.
  7. 7.
    Hypersensitivity to MPA: If you've previously shown allergic reactions to MPA or any of its components, it should be avoided.
  8. 8.
    Porphyria: MPA might make this condition worse (though this condition is very rare).
  9. 9.
    Current Cerebrovascular Disease: If you have plaque build-up in the blood vessels in your brain.
  10. 10.
    Unexplained Vaginal/Urinary Bleeding: If you have vaginal/urinary bleeding that hasn't been diagnosed.
  11. 11.
    Smoking: you smoke > 15 cigarettes/day and are over the age of 35.
  12. 12.
    Migraines with aura: You have migraines with an aura (an aura is when you experience sensory symptoms before your migraine i.e. vision changes, numbness/tingling, muscle weakness)
  13. 13.
    Blood clot disorder: You have an inheritable blood clot disorder (i.e. Factor V leiden, Protein C/S deficiency)
  14. 14.
    Vision Loss: You have experienced vision loss either partially or fully in one or both eyes.
Is MPA to delay periods considered 'off-label' use?
Yes, the use of MPA to suppress your period is considered 'off-label use.
MPA has been approved for:
  • Triggering bleeding in women who aren't experiencing regular menstrual cycles (i.e. amenorrhea)
  • Hormone replacement therapy to reduce the risk of endometrial cancer
  • Reducing heavy menstrual bleeding in women who have endometrial cancer
How is MPA prescribed?
MPA is written as:
  • 10mg once - twice daily - initiate 3 days prior to the onset of the event/travel
  • May take up to 14 days
  • Approximately 2-7 days after stopping the medication, you will experience a withdrawal bleed (i.e. period)
What's the lowest dose of MPA that I need to suppress my periods?
The 'lowest effective dose' to suppress periods hasn't been established, but MPA is often prescribed at the most tolerable dosing.
It's often reasonable to start with a dose of 10mg 2x/day. If you experience side effects, the dose can be reduced to 10mg/day.
  • 10mg once daily (Reduced dose if side effects)
  • 10mg two times daily (total dose 15mg) (Starting Regimen)

COC Pills (Combined Estrogen-Progesterone Contraceptives)

What are Combined Oral Contraceptives (COC)?
COCs, commonly referred to as "birth control pills," are oral medications that contain a combination of estrogen and progestin. They are primarily used to prevent pregnancy but can also regulate menstrual cycles. Examples of COCs include:
  • Lolo
  • Linessa
  • Marvelon
  • Alesse/Alysena
  • Tri-cyclen(Tricira)/Tricyclin-Lo(Tricira-lo)
  • Yaz
  • Yasmin
  • Diane 35
How can COC pills help delay my period?
By taking the active COC pills continuously without the typical 7-day break or placebo pills, you can delay your period. Essentially, you skip the week of placebo pills and move directly to the next pack.
Will I experience side effects when using COC to delay my period?
Some women might experience spotting or breakthrough bleeding, especially when first starting the regimen. Other common side effects of COC pills include bloating, breast tenderness, mood swings, and headaches.
Will I experience spotting on COCs?
You are more likely to experience spotting on combined oral contraceptive pills when used 'continuously' (i.e. without the withdrawal bleeding that occurs when you take your placebo pills). This risk is greatest in the 1st 3 months when used continuously.
How will this affect my fertility in the future?
Using COC to delay your period should not have a long-term impact on your fertility. Once you stop taking the pills and your cycles normalize, your fertility will return to its baseline.
Can I use any COC pill to delay my period?
Most combined birth control pills can be used to delay periods. Taking lower dose estrogen pills less than 30 mcg may result in more breakthrough bleeding. There are extended pill packages (i.e. Seasonique) that are meant to suppress menstruation for 84 days, though these packages can be taken back-to-back without a need for any bleeding.
How soon can I start delaying my period after starting COC?
If you're already on COC pills, you can generally begin the continuous regimen at the start of your next pack. Instead of taking the sugar/placebo pills, start the hormone pills in your next package without interruption. You will not experience a withdrawal bleed.

Non-Pill Options

Are there alternatives to NETA (tablets) and MPA (tablets) to suppress my periods?
There are several alternatives to suppressing periods. These include:
  • DMPA Injection (Progesterone Injection)
  • Nexplanon Implant (Progesterone Implant)
  • Hormonal IUD (i.e. Mirena, Kyleena)
NETA and MPA are preferred to the above options, as they carry the lowest risk of breakthrough bleeding. If avoiding bleeding is very important to you (i.e. going on a religious pilgrimage where you cannot participate if menstruating), then we strongly advise against these other options as there don't reliably reduce menstrual bleeding risk like NETA and MPA.

Deciding between NETA, MPA and COCs

What do TeleTest physicians recommend when choosing between NETA and MPA?
Both NETA and MPA are effective at stopping you from experiencing bleeding while on medication. While both hormones are 'progesterones', some of the hormones in NETA are converted into estrogen by your body. As a result, NETA carries the same risks as if you were on estrogen-containing birth control.
Because fewer people can take NETA than can take MPA, we preferentially prescribe MPA but you can request either option from the doctor, provided you don't have a medical contraindication (a medical contraindication is when you're not permitted to take a medication because you have a medical condition that puts you at an unacceptable increased your risk of side effects from the medication).
What is the benefit of using birth control pills over NETA/MPA?
Birth control pills can:
  • Be used for long durations (i.e. continuously) for family planning
  • Have fewer side effects than progesterone pills (i.e less likely to experience bloating, breast tenderness, mood swings and acne flares)
What is the downside to birth control pills (COCs) instead of NETA/MPA when delaying your period?
You may experience spotting when starting birth control pills. You're much less likely to experience spotting on NETA/MPA. If minimizing your risk of any spotting is a priority (i.e. for some women on religious pilgrimage), then NETA/MPA is preferred over COCs.
Is there a better time to start NETA/MPA to reduce my risk of breakthrough spotting?
Starting MPA/NETA just after your period or in the 1st half of your cycle is preferable. Doing so 'captures' the thickness of the endometrial lining when it is thinnest. The thinner the lining of the endometrium, the less likely you are to experience irregular spotting. This doesn't mean starting NETA/MPA in the 2nd half of your cycle is ineffective, though the risk of spotting is theoretically higher.

Summary of Treatment Options

Method
Instructions
Considerations
MPA Pill
10mg twice daily for 14 days, starting 3 days prior to travel
Dose can be reduced to 10mg daily if higher doses produce undesirable side effects
NETA Pill
5mg orally three times per day for 14 days starting 3 days prior to travel
Dose can be reduced to 5mg per day if higher doses produce undesirable side effects
Birth Control Pills
Use hormone pills continuously (use 21 day pill package, taken back-to-back)
Can stop pills if taken for more than 21 days at any time
DMPA injection
150mg Injection (arm)
Given at any time in your cycle, effect lasts 8-12 weeks
Nexplanon Implant
Surgically implanted into arm
Requires surgical implantation and removal
IUD
Mirena or Kyleena IUD placed into uterus
Requires placement by a doctor

References

Dean, J., Kramer, K.J., Akbary, F. et al. Norethindrone is superior to combined oral contraceptive pills in short-term delay of menses and onset of breakthrough bleeding: a randomized trial. BMC Women's Health 19, 70 (2019). https://doi.org/10.1186/s12905-019-0766-6
Huvinen E, Holopainen E, Heikinheimo ONorethisterone and its acetate – what’s so special about them?BMJ Sexual & Reproductive Health 2021;47:102-109.
Product Monograph: (Norethindrone Acetate Tablets - https://pdf.hres.ca/dpd_pm/00067753.PDF
Mansour DSafer prescribing of therapeutic norethisterone for women at risk of venous thromboembolismJournal of Family Planning and Reproductive Health Care 2012;38:148-149.