From the Guidelines
Breakthrough bleeding in patients on hormonal birth control (BC) medication should be managed by first exploring patient goals and considering an underlying health condition, with treatment options including NSAIDs, hormonal treatment, and alternative contraceptive methods.
Management Options
- NSAIDs (e.g., ibuprofen, mefenamic acid) for short-term treatment (5–7 days) can be used for spotting, light bleeding, or heavy/prolonged bleeding in patients using implant, injectable (DMPA), or combined hormonal contraceptives (CHC) 1.
- Hormonal treatment (e.g., low-dose COCs or estrogen) for short-term treatment (10–20 days) can be used for heavy or prolonged bleeding in patients using implant or CHC 1.
- Antifibrinolytic agents (e.g., tranexamic acid) for 5 days can be used for heavy or prolonged bleeding in patients using implant 1.
- Alternative contraceptive methods should be considered if bleeding persists and the patient finds it unacceptable, with counseling and offering another method if desired 1.
Important Considerations
- Underlying health conditions should be considered and treated or referred for care if identified, such as interactions with other medications, STDs, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids) 1.
- Patient goals should be explored, including continued method use or method discontinuation, and reassurance provided that bleeding irregularities are generally not harmful and usually improve with persistent use of the hormonal method 1.
From the Research
Management of Breakthrough Bleeding
The management of breakthrough bleeding in patients on hormonal birth control (BC) medication involves several strategies, including:
- Counseling and reassurance, as breakthrough bleeding is common during the first three months of use 2, 3, 4
- Administration of supplemental estrogen and/or a nonsteroidal anti-inflammatory drug (NSAID) during bleeding episodes 2, 3
- Changing to an oral contraceptive pill (OCP) with a higher estrogen content or to a different formulation, such as a low-dose OCP containing a different progestin 2
- Evaluation for other causes of bleeding, such as pregnancy or organic causes, if bleeding persists beyond three months 2, 5
Treatment Options
Treatment options for breakthrough bleeding may include:
- Supplemental estrogen to help regulate the menstrual cycle 2, 3
- NSAIDs to reduce bleeding and alleviate symptoms 2, 3
- Changing to a different hormonal contraceptive method, such as a progestin-only pill or an intrauterine device (IUD) 5
Factors Influencing Breakthrough Bleeding
Several factors can influence the incidence and duration of breakthrough bleeding, including: