What contraceptive is suitable for a 20-year-old with abnormal uterine bleeding (AUB)?

Combined Oral Contraceptives for Abnormal Uterine Bleeding in a 20-Year-Old

Combined oral contraceptives (COCs) are the most appropriate contraceptive choice for a 20-year-old with abnormal uterine bleeding (AUB) due to their ability to regulate bleeding patterns and provide effective contraception. 1

Benefits of COCs for Abnormal Uterine Bleeding

• COCs provide significant noncontraceptive benefits including decreased menstrual cramping, reduced blood loss, and improvement in acne 1
• Extended or continuous COC regimens are particularly appropriate for patients with abnormal uterine bleeding, anemia, and bleeding disorders 1
• COCs can establish regular bleeding patterns or amenorrhea, which is a primary goal in AUB management 2
• COCs are one of the best-studied medications ever prescribed and are completely reversible with no negative effect on long-term fertility 1

Recommended COC Regimen

• Start with a monophasic pill containing 30-35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
• Consider extended or continuous cycle regimens to optimize ovarian suppression and minimize fluctuations, which may be particularly beneficial for AUB 1
• Standard pill packs include 28 pills total, with 21-24 hormone pills and 4-7 placebo pills 1
• For severe AUB, extended cycle regimens with shorter or no hormone-free intervals may provide better bleeding control 1

Alternative Options If COCs Are Not Suitable

• Levonorgestrel intrauterine device (LNG-IUD) - highly effective for controlling bleeding with localized hormonal effect 1
• Progestin-only pills - option for patients with contraindications to estrogen 1
• Injectable contraceptives (DMPA) - can reduce or eliminate bleeding over time 1
• Contraceptive implant with supplemental treatment for bleeding irregularities 1

Management of Breakthrough Bleeding

If breakthrough bleeding occurs while using COCs:

• Rule out underlying gynecological problems, STIs, pregnancy, or pathologic uterine conditions 1
• For persistent irregular bleeding with COCs, consider:
  • Increasing estrogen content from 20 mcg to 35 mcg per day 3
  • Decreasing the hormone-free interval (from seven to four or five days) 1, 3
  • Short-term NSAID treatment (5-7 days) during days of bleeding 1

Important Considerations and Contraindications

• COCs should not be prescribed for patients with:
  • Severe uncontrolled hypertension (≥160/100 mmHg)
  • Ongoing hepatic dysfunction
  • Complicated valvular heart disease
  • Migraines with aura or focal neurologic symptoms
  • Thromboembolism or thrombophilia 1
• The baseline risk of venous thromboembolism in adolescents is up to 1 per 10,000 woman-years, and COCs increase this risk three to fourfold 1
• Missed pills reduce effectiveness - counsel on adherence strategies and what to do if pills are missed 1

Algorithm for Selecting Contraception in AUB

1. First-line: Combined oral contraceptives (30-35 μg ethinyl estradiol) if no contraindications 1
2. If estrogen is contraindicated: Consider LNG-IUD or progestin-only methods 1
3. If heavy bleeding requires immediate control: Consider extended or continuous COC regimen 1
4. If bleeding persists despite COC use:
   • Verify correct use and adherence 1
   • Consider short-term NSAID treatment 1
   • Evaluate for underlying pathology 1, 2

COCs provide both effective contraception and treatment for the underlying abnormal bleeding, making them the optimal choice for a 20-year-old with AUB 1, 4.