What is the best treatment for breakthrough bleeding?

Management of Breakthrough Bleeding with Hormonal Contraception

For breakthrough bleeding on combined oral contraceptives (COCs), adding tranexamic acid (TXA) to the COC regimen is the best first-line treatment option. 1

First-Line Approaches for Breakthrough Bleeding

Combined Oral Contraceptive (COC) Users

• First-line treatment: Add tranexamic acid (TXA) to COC (53% of specialists recommend this approach) 1
• For extended or continuous COC regimens experiencing heavy bleeding:
  • NSAIDs for 5-7 days of treatment
  • Note: Hormone-free interval is not recommended during the first 21 days of extended/continuous COC use 1

Alternative First-Line Options

• Discontinuation of current COC and insertion of a levonorgestrel-releasing intrauterine device (LNG-IUD) (19% of specialists recommend this) 1
• TXA therapy alone (10% of specialists recommend this) 1

Second-Line Approaches if Initial Treatment Fails

1. LNG-IUD insertion (51% of specialists recommend this) 1
2. COC combined with TXA (13% of specialists recommend this) 1
3. COC with desmopressin (DDAVP) (13% of specialists recommend this) 1

Third-Line Options

• Combined DDAVP/COC/TXA (34% of specialists recommend this) 1
• DDAVP with COC (14% of specialists recommend this) 1
• DDAVP with TXA (13% of specialists recommend this) 1

Special Considerations by Contraceptive Type

Implant Users

• For unscheduled spotting, light bleeding, or heavy/prolonged bleeding:
  • NSAIDs for 5-7 days of treatment 1

Injectable (DMPA) Users

• For heavy or prolonged bleeding:
  • NSAIDs for 5-7 days of treatment
  • Consider hormonal treatment with COCs or estrogen (10-20 days) if medically eligible 1

IUD Users

• For Cu-IUD users: NSAIDs for 5-7 days of treatment
• For LNG-IUD users: NSAIDs for 5-7 days or hormonal treatment with COCs if medically eligible 1

Factors Affecting Breakthrough Bleeding

1. Estrogen dose: Higher ethinyl estradiol (EE) doses reduce breakthrough bleeding

   • 30 μg EE typically resolves breakthrough bleeding within 3 months
   • Lower doses (15-20 μg) take significantly longer to establish regular bleeding patterns 2

2. Duration of use: Breakthrough bleeding is significantly increased upon initiation of COC use but typically subsides over time 2

3. Progestin type: Different progestins show marginal differences in breakthrough bleeding rates at the same EE dose 2

Clinical Implications and Adherence

• Breakthrough bleeding is a common reason for discontinuation, accounting for approximately 25% of women stopping hormonal contraception 3
• For extended regimens (168-day cycle), instituting a 3-day hormone-free interval is significantly more effective in resolving breakthrough bleeding than continuing active pills 4

Important Considerations

• Always evaluate for underlying conditions when breakthrough bleeding occurs, especially in postmenopausal women using hormone replacement therapy 5
• Persistent abnormal uterine bleeding despite treatment requires further evaluation to rule out malignancy 6
• If bleeding persists or the woman finds it unacceptable despite treatment, counsel on alternative contraceptive methods 1

Remember that breakthrough bleeding typically improves with continued use of the contraceptive method, and patients should be counseled about this expected pattern to improve adherence.