How to manage breakthrough bleeding in a patient taking oral contraceptive pills (OCP)?

From the Guidelines

To manage breakthrough bleeding in a patient taking oral contraceptive pills (OCPs), consider treating the condition with NSAIDs for short-term treatment (5–7 days) or hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days), as recommended by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1. When managing breakthrough bleeding, it is essential to first rule out any underlying gynecological problems, such as interactions with other medications, sexually transmitted infections, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids) 1. If an underlying gynecologic problem is found, treat the condition or refer for care. If no underlying problem is identified and the woman desires treatment, the following options can be considered:

• NSAIDs for short-term treatment (5–7 days) to reduce bleeding by inhibiting prostaglandin synthesis
• Hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) If breakthrough bleeding persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods and offer another method if desired 1. It is crucial to advise the patient to continue taking their pills regularly despite the bleeding, as breakthrough bleeding is common, especially in the first 3-4 months of use, and typically resolves on its own. However, if bleeding persists beyond 3-4 months or is bothersome, further evaluation and consideration of alternative treatments or contraceptive methods may be necessary.

From the Research

Management of Breakthrough Bleeding on OCP

• Breakthrough bleeding is a common side effect of hormonal contraception, including oral contraceptive pills (OCP) 2.
• The evaluation of abnormal uterine bleeding in women using hormonal contraception includes an assessment of compliance, a thorough history and complete physical examination to exclude organic causes of bleeding, and a targeted laboratory evaluation 2.
• Bleeding is common during the first three months of OCP use; counseling and reassurance are adequate during this time period 2.
• If bleeding persists beyond three months, it can be treated with supplemental estrogen and/or a nonsteroidal anti-inflammatory drug (NSAID) 2.
• Other options are to change to an OCP with a higher estrogen content or to a different formulation (i.e., a low-dose OCP containing a different progestin) 2.

Treatment Options

• Instituting a 3-day hormone-free interval (HFI) was significantly more effective in resolving breakthrough bleeding than continuing active pills 3.
• Switching to a monophasic pill similar to the relatively estrogenic formulation of the beginning of the package may improve late-package breakthrough bleeding 4.
• Supplemental estrogen and/or an NSAID can be administered during bleeding episodes to manage breakthrough bleeding 2, 5.

Considerations for Lactating Mothers

• Breakthrough bleeding is a side effect of progesterone-only pills (POPs) in 40% of women, and is reduced to 10% with combined hormonal contraceptives (CHCs) 5.
• CHCs are considered safe during lactation, do not reduce milk production, nor impede infant development 5.
• The risk of breakthrough bleeding justifies the more routine use of CHC in lieu of POP in lactating mothers 5.