What is the next step in managing a 28-year-old female who was switched from Marvelon 21 (desogestrel and ethinylestradiol) to Tri-cyclen 28 (norgestimate and ethinylestradiol) due to amenorrhea and is now experiencing prolonged withdrawal bleeding for 4 weeks?

From the Guidelines

The next step in managing this patient is to consider treatment options for prolonged withdrawal bleeding, such as NSAIDs for 5-7 days, as recommended by the most recent guidelines 1. The patient's experience of prolonged withdrawal bleeding for 4 weeks after switching from Marvelon 21 to Tri-cyclen 28 suggests that her hormonal balance may have been disrupted by the change in progestin from desogestrel to norgestimate.

• The patient's goals and preferences should be explored, including whether she wants to continue using the current contraceptive method or switch to a different one.
• If the patient wants to continue using Tri-cyclen 28, she can be advised to take NSAIDs, such as ibuprofen or mefenamic acid, for 5-7 days to help reduce bleeding, as suggested by the guidelines 1.
• Alternatively, hormonal treatment with low-dose combined oral contraceptives or estrogen for 10-20 days can be considered, but this option is not explicitly recommended for combined hormonal contraceptive users in the guidelines 1.
• If the bleeding persists and the patient finds it unacceptable, she should be counseled on alternative contraceptive methods, and another method can be offered if desired, such as a levonorgestrel IUD, which can reduce menstrual bleeding over time. It is also important to consider underlying health conditions that may be contributing to the bleeding, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, and to treat or refer for care if necessary, as recommended by the guidelines 1.

From the Research

Management of Prolonged Withdrawal Bleeding

The patient in question is experiencing prolonged withdrawal bleeding for 4 weeks after being switched from Marvelon 21 to Tri-cyclen 28. The next step in management would involve addressing the cause of the prolonged bleeding and considering alternative treatment options.

• Assessment of Bleeding: The first step would be to assess the severity of the bleeding and rule out any underlying conditions that may be contributing to the prolonged bleeding 2.
• Patient Education: Educating the patient on expected bleeding patterns with the new contraceptive method is essential to compliance and continuation 2.
• Alternative Treatment Options: If the patient is experiencing unacceptable bleeding, alternative treatment options such as extended-cycle oral contraception may be considered 3.
• Evaluation of Contraceptive Method: The effectiveness of the current contraceptive method in reducing menstrual bleeding should be evaluated, and alternative methods such as the levonorgestrel-releasing intrauterine system (LNG IUS) may be considered if the current method is not effective 4.

Considerations for Combined Hormonal Contraceptives

Combined hormonal contraceptives such as Tri-cyclen 28 have been shown to be effective in reducing menstrual bleeding, but may have varying effects on different women 4.

• Efficacy in Reducing Menstrual Bleeding: The combined oral contraceptive pill has been shown to reduce menstrual bleeding in women with heavy menstrual bleeding, with moderate-quality evidence suggesting a reduction in bleeding from 12% to 77% over six months 4.
• Comparison with Other Medical Therapies: The effectiveness of combined hormonal contraceptives in reducing menstrual bleeding compared to other medical therapies such as non-steroidal anti-inflammatory drugs (NSAIDs) and progestogens is uncertain, with limited evidence available 4.