How to manage breakthrough bleeding when switching oral contraceptives (OCs)?

From the Guidelines

If you're experiencing breakthrough bleeding when switching oral contraceptives, your healthcare provider may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days, as this is a suggested treatment option for spotting or light bleeding, as well as heavy or prolonged bleeding, according to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.

When managing breakthrough bleeding, it's essential to explore patient goals, including continued method use or method discontinuation, and provide reassurance that the patient can contact their provider at any time to discuss bleeding irregularities or other side effects 1.

• The patient's preferences, treatment goals, and medical history should be considered when selecting a treatment option.
• For combined hormonal contraceptive (CHC) users, particularly those on an extended or continuous regimen, a hormone-free interval for 3-4 consecutive days may be considered, but this is not recommended during the first 21 days of extended or continuous CHC use or more than once per month, as it may reduce contraceptive effectiveness 1.
• Other treatment options, such as hormonal treatment (e.g., low-dose COCs or estrogen) for 10-20 days, antifibrinolytic agents (e.g., tranexamic acid) for 5 days, or selective estrogen receptor modulators (SERMs), may be considered for implant users experiencing heavy or prolonged bleeding 1.
• It's also crucial to consider underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, and treat or refer for care if necessary 1.

From the FDA Drug Label

Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease Unscheduled (breakthrough or intracyclic) bleeding and spotting sometimes occur in patients on COCs, especially during the first three months of use. If bleeding persists or occurs after previously regular cycles, check for causes such as pregnancy or malignancy If pathology and pregnancy are excluded, bleeding irregularities may resolve over time or with a change to a different COC.

To manage breakthrough bleeding when switching oral contraceptives (OCs), the following steps can be taken:

• Rule out pregnancy and malignancy: Perform adequate diagnostic measures to exclude these conditions.
• Consider a change to another preparation: If breakthrough bleeding persists, switching to a different OC may help resolve the issue.
• Avoid changing to a higher estrogen content OC unless necessary: This may increase the risk of thromboembolic disease.
• Monitor and wait: Bleeding irregularities may resolve over time, especially during the first three months of use. 2 3

From the Research

Managing Breakthrough Bleeding when Switching Oral Contraceptives (OCs)

• Breakthrough bleeding (BTB) is a common side effect of hormonal contraception that can impact adherence to combined oral contraceptives (COCs) 4, 5.
• The incidence of BTB is related to the dose, potency, and ratio of the estrogen and progestin in the OC formulation 4.
• Low-estrogen-dose OCs (< or = 35 micrograms ethinyl estradiol [EE]) containing less androgenic progestins are associated with bleeding patterns as acceptable as older low-estrogen-dose formulations 4.
• BTB typically subsides within a few months, but the time needed for BTB to return to baseline depends on the EE dose and differs marginally between progestins during the initial months of use at the same EE dose 5.

Strategies for Managing BTB

• Switching to a monophasic pill similar to the relatively estrogenic formulation of the beginning of the package may improve late-package BTB, while switching to a more progestin-dominant formulation may improve early or mid-package BTB 6.
• Instituting a 3-day hormone-free interval (HFI) can be effective in resolving BTB/BTS during an extended OC regimen 7.
• The type of progestin and estrogen dose may influence bleeding patterns, with some studies suggesting that preparations containing norethindrone acetate result in more days of amenorrhea and fewer days of spotting than preparations containing levonorgestrel 8.

Factors Affecting BTB

• Smoking cigarettes promotes BTB in women who use OCs 4.
• Women with heavier daily flow ratings during the 21/7-day pre-extension cycle may have greater daily flow ratings and tend to have earlier occurrence of BTB during the extended regimen 7.
• The addition of 10 microg of ethinyl E2 to a 20 microg ethinyl E2 pill containing levonorgestrel or norethindrone acetate may not improve bleeding patterns 8.