What are the treatment options for breakthrough menstrual bleeding?

Treatment for Breakthrough Menstrual Bleeding

NSAIDs for 5-7 days during bleeding episodes are the first-line treatment for breakthrough menstrual bleeding, regardless of contraceptive method used. 1, 2

Initial Assessment

Before initiating treatment, rule out the following conditions 1, 3:

• Pregnancy - must be excluded in all reproductive-age women 3, 4
• IUD displacement (if applicable) 1
• Sexually transmitted infections 1
• Structural pathology - fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 3, 5
• Coagulopathies - particularly if heavy bleeding is present 3
• Medication effects - review anticoagulants or antiplatelet therapy 3

Treatment Algorithm by Contraceptive Method

For Copper IUD Users

• First-line: NSAIDs for 5-7 days during bleeding 1, 2
• Multiple NSAIDs have proven effective: mefenamic acid, indomethacin, flufenamic acid, diclofenac sodium 1, 2
• All demonstrated statistically significant reductions in menstrual blood loss 1
• Avoid aspirin - may paradoxically increase bleeding in women with lower baseline blood loss 1, 2, 5

For LNG-IUD Users

• First-line: NSAIDs for 5-7 days 1
• Second-line: Combined oral contraceptives OR estrogen for 10-20 days (if medically eligible) 1, 5
• Reassure patients that spotting/light bleeding during first 3-6 months is expected and generally not harmful 1, 2
• Heavy or prolonged bleeding is uncommon with LNG-IUD use 1

For Contraceptive Implant Users

• First-line: NSAIDs for 5-7 days 1
• Second-line: Combined oral contraceptives OR estrogen for 10-20 days (if medically eligible) 1, 2

For DMPA Injectable Users

• First-line: NSAIDs for 5-7 days 1
• Second-line: Combined oral contraceptives OR estrogen for 10-20 days (if medically eligible) 1

For Combined Hormonal Contraceptive Users (Extended/Continuous Regimen)

• Hormone-free interval for 3-4 consecutive days for heavy or prolonged bleeding 1
• Not recommended during first 21 days of extended/continuous use 1
• Not recommended more than once per month as contraceptive effectiveness may be reduced 1

Second-Line Hormonal Therapy

When NSAIDs fail or are contraindicated 1, 5:

• Combined oral contraceptives: 10-20 days of treatment 1, 2
• Estrogen alone: 10-20 days of treatment 1, 2
• Tranexamic acid: Reduces bleeding by 40-60% but contraindicated in women with active thromboembolic disease or history/intrinsic risk of thrombosis 1, 2, 5, 6

Long-Term Management

If breakthrough bleeding persists despite treatment 1, 3:

• Consider switching to LNG-IUD - most effective long-term option, reduces menstrual blood loss by 71-95% 2, 3, 7
• Counsel on alternative contraceptive methods 1
• Offer method change if patient finds bleeding unacceptable 1

Critical Contraindications and Warnings

NSAIDs

• Avoid in cardiovascular disease - increased risk of MI and thrombosis 2, 3

Tranexamic Acid

• Contraindicated: Active thromboembolic disease, history of thrombosis/thromboembolism, or intrinsic risk for thrombosis 1, 2, 5, 6
• Avoid in cardiovascular disease 2, 3

Combined Hormonal Contraceptives

• Carefully assess cardiovascular and thrombotic risk factors, especially in perimenopausal women 3

Common Pitfalls

• Do not use higher estrogen formulations unnecessarily - increases thromboembolic risk 4
• Bleeding in first 3-6 months of hormonal contraceptive use is normal - does not require treatment unless patient requests it 1, 2
• Do not use oral contraceptives to test for pregnancy - inappropriate indication 4
• Persistent bleeding requires re-evaluation - do not continue same treatment indefinitely without reassessing for underlying pathology 1, 5

When to Refer

If bleeding persists despite optimal medical therapy 3:

• Consider endometrial ablation as conservative surgical option 3
• Counsel on surgical alternatives if medical management fails 3