How to manage breakthrough bleeding in patients on contraception?

From the Guidelines

Breakthrough bleeding in patients on contraception can be managed with reassurance, NSAIDs, or hormonal treatment, and the most effective approach depends on the type of contraceptive method used, as outlined in the 2024 US Selected Practice Recommendations for Contraceptive Use 1. When managing breakthrough bleeding, it is essential to first rule out other causes of abnormal bleeding, such as pregnancy, infection, or anatomical abnormalities, and to consider the patient's medical history and preferences.

• For Cu-IUD users, NSAIDs for 5-7 days can be considered for spotting, light bleeding, or heavy/prolonged bleeding 1.
• For LNG-IUD users, no specific interventions are identified, but treatment options for implant users can be considered, including NSAIDs, hormonal treatment, or antifibrinolytic agents 1.
• For implant users, treatment options include NSAIDs for 5-7 days, hormonal treatment (e.g., low-dose COCs or estrogen) for 10-20 days, or antifibrinolytic agents (e.g., tranexamic acid) for 5 days 1.
• For injectable (DMPA) users, a hormone-free interval for 3-4 consecutive days can be considered, and NSAIDs for 5-7 days can be used for spotting or light bleeding 1.
• For CHC users on an extended or continuous regimen, NSAIDs are not recommended during the first 21 days, and not more than once per month to avoid reducing contraceptive effectiveness 1. The most recent guidelines from 2024 1 prioritize a patient-centered approach, exploring patient goals and preferences, and considering the underlying health condition, if any, before initiating treatment. Key considerations include:
• Exploring patient goals, including continued method use or method discontinuation
• Providing reassurance and advising patients to contact their provider for bleeding irregularities or other side effects
• Considering removal or discontinuation of the method if desired by the patient
• Offering counseling on alternative contraceptive methods and initiating another method if desired Always prioritize the patient's health, well-being, and preferences when managing breakthrough bleeding, and consider the most recent guidelines and evidence-based recommendations 1.

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 Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use Non-hormonal causes should be considered and adequate diagnostic measures taken to rule out malignancy or pregnancy in the event of breakthrough bleeding, as in the case of any abnormal vaginal bleeding. If pathology has been excluded, time or a change to another formulation may solve the problem.

To manage breakthrough bleeding in patients on contraception, the following steps should be taken:

• Rule out pregnancy or malignancy: Adequate diagnostic measures should be taken to exclude these conditions.
• Consider non-hormonal causes: Other potential causes of bleeding should be investigated.
• Wait or change formulation: If no underlying condition is found, the patient can either wait to see if the bleeding resolves on its own or switch to a different contraceptive formulation. It is essential to note that changing to an oral contraceptive with a higher estrogen content may increase the risk of thromboembolic disease, so this should only be done if necessary 2.

From the Research

Management of Breakthrough Bleeding

Breakthrough bleeding is a common issue in patients using contraception, and it can lead to discontinuation of reliable methods of contraception and unintended pregnancies 3, 4. To manage breakthrough bleeding, clinicians should first exclude other potential causes of abnormal uterine bleeding.

Treatment Options

• For patients with levonorgestrel intrauterine devices, nonsteroidal anti-inflammatory drugs can be used as a first-line treatment, and estradiol can be used if nonsteroidal anti-inflammatory drugs are ineffective 3.
• For depo-medroxyprogesterone acetate or progestin implant users, combined oral contraceptives or nonsteroidal anti-inflammatory drugs may be considered 3.
• For patients using norethindrone progestin-only pills, changing to drospirenone progesterone-only pills may help reduce the bleeding 3.
• For people using combined hormonal contraception, increasing the estrogen content, decreasing the hormone-free interval, or starting a trial of low-dose doxycycline may be helpful 3.
• Instituting a 3-day hormone-free interval can be effective in resolving breakthrough bleeding/breakthrough spotting in patients using an extended oral contraceptive regimen 5.

Considerations for Lactating Mothers

Breakthrough bleeding is a side effect of progesterone-only pills in 40% of women, and it is reduced to 10% with combined hormonal contraceptives 6. Combined hormonal contraceptives are considered safe during lactation and do not reduce milk production or impede infant development 6.

Bleeding Patterns and Management

Bleeding patterns during an extended oral contraceptive regimen can be managed with institution of a randomized protocol to manage breakthrough bleeding/breakthrough spotting 5. Patients with heavier daily flow ratings during the 21/7-day pre-extension cycle may have greater daily flow ratings and tend to have earlier occurrence of breakthrough bleeding during the extended regimen 5.