Treatment of Prolonged Menses in Patients on Birth Control
For a patient on birth control experiencing prolonged menstrual bleeding, first-line treatment is NSAIDs (ibuprofen or naproxen) for 5-7 days during bleeding episodes, with short-term hormonal therapy (low-dose combined oral contraceptives containing 30-35 μg ethinyl estradiol or estrogen alone for 10-20 days) as an alternative if NSAIDs are insufficient or the patient is medically eligible. 1, 2
Initial Assessment Before Treatment
Before initiating any medication, you must rule out underlying pathology that could be causing the bleeding 1, 2:
- Pregnancy - Always exclude this first 1, 2
- Sexually transmitted infections - Particularly important in reproductive-aged women 2
- Medication interactions - Check if other drugs are interfering with contraceptive efficacy 1
- New pathologic uterine conditions - Such as polyps or fibroids 1
If any underlying gynecological problem is identified, treat that condition or refer for specialized care before addressing the bleeding symptomatically 1.
First-Line Medical Treatment
NSAIDs (Preferred Initial Option)
NSAIDs for 5-7 days during bleeding episodes are the recommended first-line treatment 1, 2:
- Use during active bleeding days only 1, 2
- Examples include ibuprofen or naproxen 1
- This approach reduces menstrual blood flow acutely 2
- Well-tolerated with minimal side effects 1
Short-Term Hormonal Therapy (If NSAIDs Insufficient)
If NSAIDs alone don't control bleeding and the patient is medically eligible, add hormonal treatment 1, 2:
- Low-dose combined oral contraceptives containing 30-35 μg ethinyl estradiol for 10-20 days 1, 2
- Alternatively, estrogen alone for 10-20 days can be used 1
- This is appropriate even if the patient is already on hormonal contraception 1
Important caveat: Before prescribing additional estrogen-containing therapy, assess for thrombotic risk factors, as combined oral contraceptives increase venous thromboembolism risk three to fourfold 2.
Special Considerations for Extended/Continuous Regimens
If the patient is using extended or continuous combined oral contraceptive regimens 2, 3:
- Consider a hormone-free interval of 3-4 consecutive days to temporarily induce bleeding and thin the endometrium 2, 3
- Do NOT use this approach during the first 21 days of the extended/continuous regimen 2, 3
- Do NOT use more than once per month 2, 3
Counseling and Reassurance
Provide reassurance that unscheduled bleeding is common during hormonal contraceptive use 1, 2:
- Spotting and irregular bleeding are particularly common in the first 3-6 months of hormonal therapy 2
- These bleeding changes are generally not harmful 1, 2
- Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1
When to Consider Alternative Contraceptive Methods
If bleeding persists despite treatment and the patient finds it unacceptable 1, 2:
- Counsel on alternative contraceptive methods 1, 2
- Offer another method if desired 1, 2
- Options might include switching to a different hormonal formulation or considering the levonorgestrel-releasing intrauterine system 4
Follow-Up
No routine follow-up visit is required 1, 2:
- Advise the patient to return if side effects develop or concerns arise 1, 2
- If follow-up occurs, assess satisfaction with the method and any health status changes 1, 2
- Monitor blood pressure at follow-up visits for patients on combined oral contraceptives 2
What NOT to Use
Avoid oral progestogens (medroxyprogesterone acetate or norethisterone) for this indication 5, 6:
- The FDA label specifically states that injectable medroxyprogesterone acetate "is not recommended in secondary amenorrhea or dysfunctional uterine bleeding" due to its prolonged action and difficulty predicting withdrawal bleeding 5
- Research shows short-cycle luteal phase progestogens are inferior to other medical therapies for reducing menstrual blood loss 6
- Long-cycle progestogens (day 5-26) are also inferior to other treatments 6