Management of Jadelle-Related Irregular Menstrual Bleeding
For this 22-year-old with irregular bleeding on Jadelle, initiate treatment with NSAIDs (mefenamic acid 500 mg three times daily for 5 days or celecoxib 200 mg daily for 5 days) during bleeding episodes, and if this fails after 2-3 cycles or bleeding remains unacceptable, add short-term low-dose combined oral contraceptives for 10-20 days. 1, 2, 3
Initial Diagnostic Workup
Before initiating treatment, complete the planned investigations to exclude underlying pathology:
- Pregnancy test - essential to rule out pregnancy including ectopic pregnancy, as contraceptive failure can occur 3, 4
- STI screening - chronic pelvic inflammatory disease can cause irregular bleeding 2
- Full blood count - assess for anemia given the prolonged bleeding pattern (3-4 weeks per month for 2 months) 2
- Blood pressure check - monitor for hypertension risk with hormonal contraception 5
The absence of abdominal pain, dysmenorrhea, and vaginal discharge makes structural pathology less likely, but these investigations are still warranted given the change from her previously normalized bleeding pattern. 2
First-Line Pharmacological Treatment
NSAIDs are the evidence-based first-line treatment for implant-related irregular bleeding:
- Mefenamic acid 500 mg three times daily for 5 days has demonstrated significant bleeding cessation within 7 days compared to placebo in levonorgestrel implant users 1
- Celecoxib 200 mg daily for 5 days is an alternative with similar efficacy 1
- Start treatment at full dose from the beginning of bleeding episodes - do not underdose 2
- Use for 5-7 days during bleeding days 2, 3
The mechanism involves reducing prostaglandin-mediated endometrial breakdown that occurs with progestin-only contraception. 1
Second-Line Treatment if NSAIDs Fail
If bleeding remains unacceptable after 2-3 treatment cycles with NSAIDs:
- Short-term low-dose combined oral contraceptives for 10-20 days if medically eligible 1, 3
- Alternatively, short-term estrogen therapy for 10-20 days 3
- Monophasic COCs with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are appropriate 2
This approach provides temporary endometrial stabilization without requiring implant removal. 1, 3
Counseling and Reassurance
Critical counseling points:
- Irregular bleeding with Jadelle is generally not harmful and does not indicate medical pathology 1, 6
- Approximately 18% of women experience prolonged bleeding with levonorgestrel implants, making her experience common 1
- The return of irregular bleeding after normalization (which occurred in her second year) is a recognized pattern 7
- Prolonged bleeding is the most common reason for removal in the first 6 months to 1 year of use, but treatment options exist before considering removal 7, 8
When to Consider Alternative Contraception
If bleeding persists despite appropriate treatment and remains unacceptable to the patient, counsel on alternative contraceptive methods rather than continuing ineffective management. 2, 6, 3
Continuation rates with Jadelle are generally high when women are satisfied with bleeding patterns, but menstrual disruption accounts for more than half of removals within the first year. 7, 8
Common Pitfalls to Avoid
- Do not dismiss irregular bleeding as "just a side effect" without offering treatment options - evidence-based pharmacological interventions exist 1, 2
- Do not immediately remove the implant - try medical management first as most women respond to NSAIDs or short-term hormonal therapy 1, 3
- Do not use aspirin - it has not shown significant benefit for implant-related bleeding 1
- Do not underdose NSAIDs - full therapeutic doses are required for efficacy 2
Addressing Her Specific Symptoms
Her occasional dizziness warrants attention given her bleeding pattern - the FBC will assess for anemia which could explain this symptom. 2 The mood changes she reports are commonly associated with progestin-only contraception and should be monitored, though they do not typically require intervention unless severe. 5