How to stop breakthrough bleeding while on Lo Loestrin Fe (ethinyl estradiol and norethindrone acetate)?

Management of Breakthrough Bleeding on Lo Loestrin Fe

For breakthrough bleeding on Lo Loestrin Fe (norethindrone acetate/ethinyl estradiol), start with NSAIDs for 5-7 days during active bleeding episodes as first-line treatment, after ruling out pregnancy, sexually transmitted infections, medication interactions, and uterine pathology. 1, 2

Initial Assessment and Reassurance

Before initiating treatment, you must exclude underlying causes:

• Rule out pregnancy - particularly important if the patient has missed pills or has irregular pill-taking 3
• Screen for sexually transmitted infections 1, 2
• Review medication interactions - especially enzyme-inducing drugs like St. John's Wort, which can reduce contraceptive hormone levels by 13-15% and increase breakthrough bleeding 4
• Consider new uterine pathology - polyps or fibroids 1, 2

Provide reassurance that breakthrough bleeding is common during the first 3-6 months of combined hormonal contraceptive use and generally improves with continued use. 2 This bleeding does not indicate reduced contraceptive effectiveness. 2

Emphasize Adherence

Consistent daily pill-taking at the same time each day is critical - missed or irregular dosing significantly increases breakthrough bleeding episodes. 2 This is particularly important with Lo Loestrin Fe, which contains only 10 mcg ethinyl estradiol (one of the lowest doses available).

First-Line Treatment: NSAIDs

NSAIDs are the recommended first-line pharmacologic treatment for breakthrough bleeding on combined hormonal contraceptives. 1, 2

• Mefenamic acid 500 mg three times daily for 5-7 days during active bleeding 2
• Ibuprofen (standard dosing) for 5-7 days during active bleeding 1, 2
• Treatment should only be given during days of bleeding, not continuously 1, 2

Alternative Approach: Hormone-Free Interval (Use With Caution)

If NSAIDs fail and the patient is on an extended or continuous regimen:

• Consider a 3-4 day hormone-free interval 1, 2
• Do NOT use this approach during the first 21 days of extended/continuous use 1, 2
• Do NOT use more than once per month as contraceptive effectiveness may be reduced 1, 2

Important caveat: Lo Loestrin Fe is typically taken as a standard 28-day pack (24 active pills + 2 ferrous fumarate pills + 2 ethinyl estradiol-only pills), not as an extended regimen, so this approach has limited applicability. 3

When to Consider Method Change

If breakthrough bleeding persists beyond 3-6 months despite treatment and the patient finds it unacceptable, counsel on alternative contraceptive methods. 2 The extremely low estrogen dose in Lo Loestrin Fe (10 mcg ethinyl estradiol) may predispose to more breakthrough bleeding compared to formulations with 20-35 mcg ethinyl estradiol. 5, 6

Consider switching to:

• A combined hormonal contraceptive with higher estrogen content (20-35 mcg ethinyl estradiol) - this may improve cycle control but increases thromboembolic risk 3
• Long-acting reversible contraceptives (IUD or implant) if the patient desires to avoid estrogen-related side effects 1

Common Pitfalls to Avoid

• Do NOT use combined oral contraceptives to "induce withdrawal bleeding" as a pregnancy test 3
• Do NOT continue the method without ruling out pregnancy if two consecutive periods are missed 3
• Do NOT ignore abrupt changes in bleeding pattern - this warrants reevaluation for underlying pathology 2, 3
• Do NOT assume all breakthrough bleeding requires treatment - many patients are satisfied with reassurance alone if counseled appropriately 2

Follow-Up

• No routine follow-up visit is required unless bleeding persists beyond 3-6 months or worsens 2
• Advise patients they can contact their provider at any time to discuss bleeding irregularities or other side effects 1, 2