Breakthrough Bleeding with Continuous Combined Oral Contraceptive Use
Yes, continuous use of combined oral contraceptives (COCs) without a placebo week commonly causes breakthrough bleeding, particularly during the first 3-6 months, though this bleeding typically decreases with continued use. 1
Expected Bleeding Pattern
Unscheduled spotting or bleeding is common during the first 3-6 months of extended or continuous combined hormonal contraceptive use. 1 This is the most frequent adverse effect of extended-cycle regimens and should be anticipated when counseling patients. 1
- The bleeding is generally not harmful and decreases with continued combined hormonal contraceptive use. 1
- Extended-cycle or continuous-use COCs are typically associated with higher initial rates of unscheduled bleeding than conventional 21-day cyclical COCs. 2
- The longer the duration of continuous hormones, the greater the number of unscheduled bleeding days initially, though the difference between 28-day and 49-day cycles is relatively small. 1
Pre-Treatment Counseling
Before initiating continuous COC use, provide counseling about potential changes in bleeding patterns during extended or continuous combined hormonal contraceptive use. 1
- Patients should understand that breakthrough bleeding is expected in the first several months and does not indicate contraceptive failure. 1
- Appropriate counseling about the possibility of unscheduled bleeding improves compliance and reduces discontinuation rates. 2
Management Algorithm When Breakthrough Bleeding Occurs
Initial Management (First 3-6 Months)
Counseling and reassurance are adequate during the first three months of continuous use. 3
- No intervention is needed unless bleeding is clinically concerning. 1
- Continue the continuous regimen without interruption during this adaptation period. 1
Persistent Bleeding Beyond 3-6 Months
If clinically indicated, consider an underlying gynecological problem, such as:
- Inconsistent use (most common cause of unscheduled bleeding) 2
- Interactions with other medications (enzyme inducers like rifampin, phenytoin, St. John's wort) 4, 2
- Cigarette smoking 1, 2
- Sexually transmitted infections 1
- Pregnancy 1, 3
- New pathologic uterine conditions (polyps or fibroids) 1
If an underlying gynecological problem is found, treat the condition or refer for care. 1
Treatment Options for Persistent Bleeding
If an underlying gynecological problem is not found and the woman wants treatment, advise the woman to discontinue combined hormonal contraceptive use (i.e., a hormone-free interval) for 3-4 consecutive days. 1
- A hormone-free interval is not recommended during the first 21 days of using the continuous or extended combined hormonal contraceptive method. 1
- A hormone-free interval is not recommended more than once per month because contraceptive effectiveness might be reduced. 1
- Instituting a 3-day hormone-free interval is significantly more effective in resolving breakthrough bleeding than continuing active pills. 5
Alternative management strategies include:
- Supplemental estrogen and/or a nonsteroidal anti-inflammatory drug (NSAID) during bleeding episodes 3
- Changing to a COC with higher estrogen content (30-35 μg ethinyl estradiol) 1, 6
- Changing to a different progestin formulation 3, 6
If unscheduled spotting or bleeding persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods, and offer another method if it is desired. 1
Important Clinical Considerations
- Patients with heavier daily flow ratings during standard 21/7-day cycles tend to have earlier occurrence of breakthrough bleeding during extended regimens, though they are not necessarily more likely to experience it overall. 5
- The 168-day extended regimen has demonstrated an acceptable bleeding profile with a high continuation rate (92%) when properly managed. 5
- Breakthrough bleeding is responsible for approximately 25% of women discontinuing oral contraceptives, making proper counseling and management critical. 7