What is the best approach to adjust Birth Control Pills (BCPs) when a patient experiences spotting and is measuring hormone levels necessary?

From the Guidelines

When a patient experiences spotting while on birth control pills (BCPs), the best approach is to first consider an underlying gynecological problem, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions, and treat or refer for care if found, as recommended by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1. The most recent and highest quality study, U.S. Selected Practice Recommendations for Contraceptive Use, 2013, adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd edition, published in MMWR Recommendations and Reports, provides guidance on managing unscheduled bleeding with extended or continuous use of combined hormonal contraceptives 1. Key points to consider when adjusting BCPs for spotting include:

• Counseling patients about potential changes in bleeding patterns during extended or continuous combined hormonal contraceptive use
• Considering an underlying gynecological problem if unscheduled spotting or bleeding occurs
• Treating the underlying condition or referring for care if found
• Advising patients to discontinue combined hormonal contraceptive use for 3-4 consecutive days if no underlying gynecological problem is found and the woman wants treatment
• Counseling patients on alternative contraceptive methods if unscheduled spotting or bleeding persists and is unacceptable Measuring hormone levels may not be necessary in all cases, as the U.S. Selected Practice Recommendations for Contraceptive Use, 2013, suggest considering an underlying gynecological problem and treating or referring for care if found, rather than relying solely on hormone level testing 1. In terms of specific adjustments to BCPs, the evidence suggests that NSAIDs can be used for short-term treatment (5-7 days) of unscheduled spotting or light bleeding, and hormonal treatment with low-dose COCs or estrogen can be considered for short-term treatment (10-20 days) if medically eligible 1. The most important consideration is to prioritize the patient's health and well-being, and to adjust the BCP regimen accordingly, rather than relying solely on hormone level testing or other factors 1.

From the FDA Drug Label

Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use The type and dose of progestogen may be important. Nonhormonal 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

The best approach to adjust Birth Control Pills (BCPs) when a patient experiences spotting is to:

• Consider nonhormonal causes of the spotting
• Rule out malignancy or pregnancy
• If pathology has been excluded, time or a change to another formulation may solve the problem There is no indication in the label that measuring hormone levels is necessary when adjusting BCPs due to spotting 2 2.

From the Research

Adjusting Birth Control Pills (BCPs) for Spotting

• The best approach to adjust BCPs when a patient experiences spotting is not directly addressed in the provided studies 3, 4, 5, 6, 7.
• However, studies suggest that the formulation and dosage of BCPs can affect cycle control and bleeding patterns 3, 6.
• For example, a study on a new contraceptive pill containing 17β-estradiol and nomegestrol acetate found that it had less influence on hemostasis, fibrinolysis markers, lipids, and carbohydrate metabolism compared to other combined oral contraceptives 3.
• Another study on extended-cycle pills with levonorgestrel and ethinyl estradiol found that the new formulation reduced the number of days of unscheduled spotting and bleeding 6.

Measuring Hormone Levels

• Measuring hormone levels may not be necessary for adjusting BCPs for spotting, as the provided studies do not suggest a direct correlation between hormone levels and spotting 5, 7.
• However, a study on the effect of monophasic combinations of ethinyl estradiol and norethindrone on gonadotropins, androgens, and sex hormone binding globulin found that oral contraceptive-induced changes in these hormones can be predicted by considering the relative amounts of estrogen and progestin in the pill 5.
• Another study on the estrogen potency of oral contraceptive pills found that the estrogen potencies of different pills varied, and that the effect of progestins on estrogen potency was additive, antagonistic, or a combination of both 7.