From the Guidelines
For breakthrough bleeding on OCPs, the most effective treatment option is to continue taking the pills as scheduled and consider adding a short-term NSAID, such as ibuprofen 800mg three times daily for 5-7 days, as needed. According to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1, this approach can help manage bleeding irregularities while using contraception. The guidelines suggest that if the patient wants treatment, NSAIDs, 5–7 days, may be considered, depending on the patient’s preferences, treatment goals, and medical history. It's essential to explore patient goals, including continued method use or method discontinuation, and provide reassurance and advice on managing bleeding irregularities.
- Key considerations for managing breakthrough bleeding on OCPs include:
- Continuing to take the pills as scheduled, even during bleeding episodes
- Adding a short-term NSAID, such as ibuprofen, as needed
- Considering switching to a pill with higher estrogen content or different progestin component if bleeding persists
- Ruling out other causes of bleeding, such as missed pills, medication interactions, or structural abnormalities, if bleeding persists despite treatment. As noted in the guidelines, it's crucial to consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, and treat the condition or refer for care if necessary 1.
From the Research
Breakthrough Bleeding on OCPs
- Breakthrough bleeding is a common side effect of hormonal contraception, including oral contraceptive pills (OCPs) 2.
- The incidence of breakthrough bleeding in women using OCPs can be as high as 24.9% in the first month, 17.5% in the second month, and 15.3% in the third month 3.
- Breakthrough bleeding can occur at any time during the menstrual cycle, but it is more common late in the cycle 3.
Management of Breakthrough Bleeding
- Counseling and reassurance are often adequate for managing breakthrough bleeding, especially during the first three months of OCP use 2.
- Supplemental estrogen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to treat breakthrough bleeding 2, 3.
- Changing to an OCP with a higher estrogen content or a different formulation can also be effective in managing breakthrough bleeding 2, 3.
Comparison of Estrogen Components
- Estradiol valerate and ethinylestradiol are two different estrogen components used in OCPs 4, 5, 6.
- Estradiol valerate has a more natural estrogenic effect and may have a better metabolic and vascular profile compared to ethinylestradiol 4, 6.
- A study comparing the effects of combined oral contraceptives containing estradiol valerate and ethinylestradiol on coagulation biomarkers found that estradiol valerate may be associated with less enhancement of coagulation potential 6.
Treatment of Heavy Menstrual Bleeding
- The estradiol valerate and dienogest oral contraceptive pill has been shown to be effective in reducing heavy menstrual bleeding in women without diagnosed uterine conditions 5.
- This pill can decrease blood loss volume by a median of 81% and lead to shorter and lighter periods among women with normal periods 5.