From the Guidelines
Hormonal birth control methods, such as combined hormonal contraceptives or a levonorgestrel intrauterine device (IUD), can effectively reduce or stop menstrual bleeding, and are recommended as the first line of treatment for managing bleeding irregularities while using contraception 1.
Treatment Options
The choice of treatment depends on the patient's preferences, treatment goals, and medical history. According to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use, the following treatment options may be considered:
- For Cu-IUD users: NSAIDs, 5–7 days, for spotting or light bleeding or for heavy or prolonged bleeding 1.
- For LNG-IUD users: No interventions identified, but treatment options for implant users may be considered, such as NSAIDs, 5–7 days, or hormonal treatment (e.g., low dose COCs or estrogen), 10–20 days 1.
- For implant users: NSAIDs, 5–7 days, for spotting or light bleeding, or heavy or prolonged bleeding; hormonal treatment (e.g., low dose COCs or estrogen), 10–20 days; or antifibrinolytic agents (e.g., tranexamic acid), 5 days 1.
- For injectable (DMPA) users: Hormone-free interval for 3–4 consecutive days 1.
- For CHC users (extended or continuous regimen): Not recommended during the first 21 days of extended or continuous CHC use, and not recommended more than once per month because contraceptive effectiveness might be reduced 1.
Important Considerations
It is essential to explore patient goals, including continued method use or method discontinuation, and to consider underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids) 1. If an underlying health condition is found, treat the condition or refer for care. A healthcare provider should be consulted to determine the most appropriate option based on individual health history, bleeding patterns, and contraceptive needs.
From the FDA Drug Label
Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease
- Ethinyl estradiol may be used to stop bleeding, but caution is advised as it may not be effective for all cases of abnormal bleeding.
- The drug label suggests that changing to an oral contraceptive with a higher estrogen content may be useful in minimizing menstrual irregularity, but this should be done only if necessary due to the increased risk of thromboembolic disease.
- Before using ethinyl estradiol to stop bleeding, it is essential to rule out pregnancy and malignancy through adequate diagnostic measures 2.
From the Research
Birth Control to Stop Bleeding
- Birth control methods can be used to stop or reduce bleeding, with various options available, including oral contraceptives, patches, and rings 3, 4, 5.
- Extended- and continuous-cycle oral contraceptives have been shown to be effective in reducing the frequency of bleeding, with some regimens shortening the duration of menses or eliminating them altogether 5.
- A study comparing a 24-day regimen of norethindrone acetate 1 mg/ethinyl estradiol 20 microg (NETA/EE-24) with a 21-day regimen of the same combination (NETA/EE-21) found that NETA/EE-24 was associated with significantly fewer intracyclic bleeding days and fewer days of withdrawal bleeding 3.
- Another study comparing a low-dose transdermal contraceptive patch with a combined oral contraceptive found that the patch was associated with a comparable bleeding pattern and cycle control, with fewer bleeding/spotting episodes in the second reference period 4.
- The use of hormonal contraceptives can also affect bleeding patterns, with lower doses of estrogen and progestin being used in newer formulations to reduce the risk of breakthrough bleeding and spotting 6, 7.
- A comparative analysis of estrogenic components used in hormonal contraception found that estetrol (E4) has a lower binding affinity for estrogen receptors and may be less stimulatory of coagulant proteins than ethinyl estradiol (EE) 7.