What are the next steps for a 19-year-old female patient on birth control (hormonal contraception) who has been experiencing prolonged menstrual bleeding for 1.5 months?

Management of Prolonged Bleeding in a 19-Year-Old on Birth Control

For a 19-year-old with 1.5 months of bleeding on hormonal contraception, first rule out pregnancy, STDs, medication interactions, and new uterine pathology (polyps/fibroids), then treat with NSAIDs for 5-7 days or add supplemental estrogen (combined oral contraceptives with 30-35 mcg ethinyl estradiol) for 10-20 days if NSAIDs fail. 1, 2

Initial Assessment

Before treating the bleeding, systematically exclude underlying causes:

• Rule out pregnancy first - this is the critical first step before any intervention 2
• Screen for STDs, particularly chlamydia and gonorrhea, as these commonly cause breakthrough bleeding in contraceptive users 1, 2
• Assess for medication interactions that reduce contraceptive hormone levels (antibiotics, anticonvulsants, St. John's wort) 1, 2
• Evaluate for new uterine pathology including fibroids, polyps, or cervical lesions through pelvic examination 1, 2
• Ask about cigarette smoking, which increases breakthrough bleeding risk 1, 2
• Verify contraceptive compliance - inconsistent use is a frequent cause of abnormal bleeding 1, 3

Treatment Algorithm

First-Line Treatment

• Start NSAIDs for 5-7 days during bleeding episodes (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) 1, 2
• This is appropriate for both light spotting and heavy bleeding as initial therapy 1, 2

Second-Line Treatment (If NSAIDs Fail)

• Add supplemental estrogen with combined oral contraceptives containing 30-35 mcg ethinyl estradiol for 10-20 days during bleeding episodes 1, 2, 4
• Check medical eligibility before prescribing estrogen - COCs increase VTE risk 3-4 fold (up to 4 per 10,000 woman-years) 2, 5
• Monophasic formulations with levonorgestrel or norgestimate are preferred 5

Alternative Management Strategy

If the patient is using extended or continuous combined hormonal contraception:

• Consider a 3-4 day hormone-free interval to allow withdrawal bleeding 1
• Do NOT use this approach during the first 21 days of continuous use 1, 5
• Limit to once per month maximum as more frequent breaks reduce contraceptive effectiveness 1

Critical Counseling Points

• Set realistic expectations: Unscheduled bleeding is most common in the first 3-6 months of any hormonal method and generally decreases with continued use 1, 2, 3
• At 1.5 months, this patient is still within the expected adjustment period 1, 3
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 2, 3

When to Consider Method Change

If bleeding persists despite treatment and the patient finds it unacceptable:

• Counsel on alternative contraceptive methods and offer another method if desired 1, 2
• Options include switching to a different formulation with higher estrogen content (if using low-dose pills) or changing to a different contraceptive class entirely 3, 4

Common Pitfalls to Avoid

• Don't assume bleeding at 1.5 months requires immediate method change - this is within the normal adjustment period 1, 3
• Don't prescribe estrogen without checking contraindications - assess for VTE risk factors, smoking >15 cigarettes/day if age >35, migraine with aura, or history of thrombosis 2, 5
• Don't recommend hormone-free intervals more than once monthly as this compromises contraceptive efficacy 1
• Don't forget to verify the patient is taking contraception correctly - missed pills are a common cause of breakthrough bleeding 1, 3

Follow-Up Instructions

• Instruct the patient to return if bleeding becomes unacceptable or if she wants to change methods 1, 2
• No routine follow-up visit is required if bleeding resolves with treatment 1
• Reassess at follow-up for satisfaction with method and any health status changes 1