What is the management for abnormal and heavy uterine bleeding after starting a combined oral contraceptive pill (COC)?

Management of Abnormal and Heavy Uterine Bleeding After Starting Combined Oral Contraceptives

For abnormal and heavy uterine bleeding after starting a combined oral contraceptive pill (COC), first rule out underlying gynecological conditions, then consider NSAIDs for 5-7 days during bleeding episodes as first-line treatment, or hormonal treatment with additional estrogen for 10-20 days if bleeding persists. 1

Initial Assessment

• Evaluate for underlying gynecological problems such as:

  • Inconsistent pill use/compliance
  • Medication interactions
  • Cigarette smoking
  • Sexually transmitted infections
  • Pregnancy
  • Pathologic uterine conditions (polyps, fibroids) 1

• If an underlying gynecological problem is identified, treat the condition or refer for care 1

Treatment Algorithm

First 3 Months of COC Use

• Bleeding irregularities are common during the first 3-6 months of COC use and generally not harmful 1
• Provide reassurance and counseling about expected bleeding patterns 1
• Emphasize the importance of correct and consistent pill use 2

If Bleeding Persists Beyond 3 Months or Is Unacceptable

1. First-line treatment options:

   • NSAIDs for 5-7 days during days of bleeding 1, 2
   • Hormonal treatment with low-dose COCs or additional estrogen for 10-20 days if medically eligible 1

2. Alternative treatment options if first-line fails:

   • Change to a COC with higher estrogen content (increase from 20 mcg to 35 mcg daily) 3, 2
   • Switch to a different formulation containing a different progestin 2
   • For those using continuous or extended regimens, consider a hormone-free interval of 3-4 consecutive days for heavy bleeding 1
     • Note: A hormone-free interval is not recommended during the first 21 days of using continuous/extended regimens
     • Do not use hormone-free intervals more than once per month as contraceptive effectiveness may be reduced 1

Important Caveats and Considerations

• Abnormal uterine bleeding is a major cause for discontinuation of hormonal contraception, which can lead to unplanned pregnancy 2
• Hormone-free intervals should not be used during the first 21 days of extended or continuous COC use 1
• For continuous COC users with persistent bleeding, adding a 4-5 day hormone-free interval can help regulate bleeding patterns 3
• If bleeding persists despite treatment and the woman finds it unacceptable, counsel her on alternative contraceptive methods and offer another method if desired 1
• Low-dose doxycycline may be considered as an additional treatment option for persistent bleeding in COC users 3

Follow-up Recommendations

• No routine follow-up visit is required, but advise women to return if they have concerns about side effects or want to change methods 1
• At follow-up visits:
  • Assess satisfaction with the current method
  • Evaluate any changes in health status that might affect COC eligibility
  • Measure blood pressure 1
  • Consider assessing weight changes if the patient is concerned 1