What should a female in her 30s do about brown spotting and menstrual symptoms after 20 years of taking desogestrel (etonogestrel), having not had a period and being overdue for a cervical smear test?

Management of Brown Spotting After 20 Years of Amenorrhea on Desogestrel

This patient requires immediate evaluation to rule out pregnancy, sexually transmitted infections, and pathologic uterine conditions before attributing the bleeding to contraceptive-related changes, and she urgently needs cervical cancer screening given she is 5 years overdue. 1, 2

Immediate Priority Actions

Cervical Cancer Screening (Overdue by 5 Years)

• Schedule a cervical Pap smear immediately - she is significantly overdue, with her last screening 5 years ago when annual screening is recommended after the initial 6-month follow-up 1
• The timing is particularly concerning given new-onset bleeding, which could represent cervical pathology 1
• Do not delay this screening while evaluating the bleeding 1

Rule Out Critical Conditions Before Treating Bleeding

Pregnancy testing is essential despite 20 years of desogestrel use, as the CDC specifically recommends pregnancy testing for "new onset of irregular bleeding after prolonged amenorrhea while using etonorgestrel implants or depot medroxyprogesterone acetate" - desogestrel is metabolized to etonogestrel 1, 3

Screen for sexually transmitted infections that can cause irregular bleeding patterns 1, 2

Evaluate for medication interactions - review all current medications for drugs that may affect contraceptive efficacy or cause bleeding (antibiotics, anticonvulsants, other medications) 1, 2

Assess for structural uterine pathology - at age 30s with new-onset bleeding after 20 years of amenorrhea, polyps, fibroids, or endometrial abnormalities must be excluded 1, 2

Management Algorithm for the Bleeding

If All Pathology is Ruled Out

First-line treatment during active bleeding days:

• Mefenamic acid 500 mg three times daily for 5 days, OR 1, 4
• Celecoxib 200 mg daily for 5 days 1, 4

Second-line treatment if NSAIDs fail:

• Low-dose combined oral contraceptives for 10-20 days (if medically eligible with no contraindications to estrogen), OR 1, 4
• Estrogen therapy for 10-20 days 1

Reassurance and Counseling

• Unscheduled spotting or light bleeding is common with progestin-only contraceptives and generally not harmful 1
• However, new-onset bleeding after 20 years of amenorrhea warrants thorough evaluation before reassurance 1
• Enhanced counseling about bleeding patterns reduces discontinuation rates 1, 4

If Bleeding Persists Despite Treatment

Counsel on alternative contraceptive methods and offer to switch if the bleeding remains unacceptable to the patient after appropriate treatment 1, 2, 4

Critical Pitfalls to Avoid

• Never assume functional bleeding without excluding structural pathology, especially in women over 30 where polyps and fibroids become more common 4
• Do not initiate bleeding treatment without first ruling out pregnancy, STDs, and medication interactions 1, 2, 4
• Do not prescribe combined hormonal contraceptives without verifying medical eligibility due to thromboembolism risk 4
• Do not delay cervical cancer screening - this patient is already 5 years overdue and now has new bleeding 1
• Avoid using aspirin for treatment as it may increase bleeding 2