Are progesterone-only contraceptives (POCs) effective in managing abnormal uterine bleeding?

Effectiveness of Progesterone-Only Contraceptives for Abnormal Uterine Bleeding

Progesterone-only contraceptives are effective for managing abnormal uterine bleeding, with levonorgestrel-releasing intrauterine devices being particularly effective, reducing menstrual blood loss by 71-95% in cases of abnormal uterine bleeding. 1

Types of Progesterone-Only Contraceptives and Their Effectiveness

Levonorgestrel Intrauterine Devices (LNG-IUDs)

• LNG-IUDs (20 μg/day) are the most effective progesterone-only option for abnormal uterine bleeding, with efficacy comparable to endometrial ablation 1
• These devices primarily work at the endometrial level with minimal systemic absorption 1
• The 14 μg/day LNG-IUD may also be effective while providing lower hormonal absorption 1

Oral Progestin Options

• Norethindrone acetate (5-10 mg daily for 5-10 days) is FDA-approved for abnormal uterine bleeding due to hormonal imbalance 2
• Cyclic oral progestin treatment can reduce bleeding by approximately 87% 1
• For acute abnormal bleeding episodes, high-dose oral progestins may be considered for short-term management 1, 3

Injectable Progestins

• Depot medroxyprogesterone acetate (DMPA) can be effective for abnormal uterine bleeding 3
• A pilot study showed that DMPA 150 mg intramuscular injection combined with oral medroxyprogesterone acetate 20 mg every 8 hours for 3 days effectively stopped acute abnormal uterine bleeding within 5 days 3

Progestin Implants

• Subdermal implants can help manage abnormal uterine bleeding but may themselves cause irregular bleeding patterns, especially during the first year of use 1
• For bleeding irregularities with implants, NSAIDs or combined hormonal contraceptives may be used for treatment 1, 4

Management Algorithm for Abnormal Uterine Bleeding with POCs

Initial Assessment

• Rule out pregnancy, structural causes (polyps, fibroids), and malignancy before attributing bleeding to hormonal imbalance 1
• Consider the PALM-COEIN classification system to identify the cause of abnormal uterine bleeding 1

First-Line Treatment Options

• For women with ovulatory dysfunction bleeding:
  • LNG-IUD (20 μg/day) is the most effective option 1
  • Oral progestins (norethindrone acetate 5-10 mg daily for 5-10 days) for cyclic therapy 2
  • DMPA injections for longer-term management 4

Management of Breakthrough Bleeding on POCs

• For LNG-IUD users with persistent bleeding:
  • NSAIDs are first-line treatment 4
  • Short-term estradiol can be added if NSAIDs are ineffective 4
• For oral progestin users:
  • Consider switching from norethindrone to drospirenone progestin-only pills 4
  • NSAIDs during bleeding episodes may help reduce flow 5

Severe or Acute Bleeding

• High-dose injectable and oral progestin combination (DMPA 150 mg IM plus oral medroxyprogesterone acetate 20 mg every 8 hours for 3 days) can rapidly stop acute bleeding 3

Common Pitfalls and Considerations

• Bleeding irregularities are common during the first 3-6 months of POC use and often improve with continued use; proper counseling about this expectation can improve adherence 1, 5
• Enhanced counseling about expected bleeding patterns has been shown to reduce method discontinuation in clinical trials 1
• If abnormal bleeding persists beyond 3-6 months or is severe, further evaluation is warranted to rule out underlying pathology 1
• For women with cardiovascular disease (like SCAD), progestin-only methods are generally preferred over combined hormonal contraceptives, with LNG-IUDs being particularly suitable due to minimal systemic absorption 1
• If medical management fails or is contraindicated, surgical options including endometrial ablation and hysterectomy may be considered 1

Special Populations

• For women on antiplatelet therapy who develop abnormal uterine bleeding, LNG-IUDs are particularly effective and can reduce menstrual blood loss by 71-95% 1
• Women with cardiovascular disease should generally avoid NSAIDs and tranexamic acid for bleeding management due to thrombotic risks 1
• For women with persistent bleeding despite POC use who find it unacceptable, alternative contraceptive methods should be offered 1