What is the treatment for intermenstrual bleeding or mid-cycle spotting?

From the Guidelines

Ovulation bleeding or mid-cycle spotting can be managed with hormonal treatment, such as 20–30 μg ethinylestradiol combined oral contraceptives, or antifibrinolytic agents like tranexamic acid for 5 days, as recommended by the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1. When considering treatment options, it's essential to explore patient goals and preferences, including continued use of contraceptive methods or implant removal.

• Treatment goals may include managing bleeding irregularities, and
• Medical history should be taken into account when selecting a treatment option. Some key points to consider when treating ovulation bleeding or mid-cycle spotting include:
• Hormonal treatment may improve bleeding irregularities during treatment use, but bleeding is likely to recur after treatment cessation 1.
• Antifibrinolytic agents, such as tranexamic acid, can be used for 5 days to manage bleeding irregularities 1.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or mefenamic acid can be used for 5-7 days to manage discomfort associated with ovulation bleeding 1. It's crucial to consult a healthcare provider if the bleeding becomes heavy, lasts longer than 3 days, occurs multiple times per cycle, or is accompanied by severe pain, as these could indicate underlying conditions requiring medical attention.
• Underlying health conditions, such as interactions with other medications, sexually transmitted infections (STIs), pregnancy, thyroid disorders, or new pathologic uterine conditions, should be considered and treated or referred for care if necessary 1.

From the Research

Treatment Options for Ovulation Bleeding or Mid Spotting

• Non-steroidal anti-inflammatory drugs (NSAIDs) may be used to reduce heavy menstrual bleeding, but their effectiveness in treating ovulation bleeding or mid spotting is not well established 2, 3, 4.
• Studies have shown that NSAIDs can inhibit ovulation in some women, which may affect their fertility 5, 6.
• The use of NSAIDs for ovulation bleeding or mid spotting may be associated with a delay in follicular collapse, but this effect is seen in a small group of study subjects 5.
• Other treatment options for heavy menstrual bleeding, such as tranexamic acid, danazol, and the levonorgestrel-releasing intrauterine system (LNG IUS), may be more effective than NSAIDs, but their use for ovulation bleeding or mid spotting is not well established 2, 3, 4.

Mechanism of Action

• NSAIDs reduce prostaglandin levels, which are elevated in women with excessive menstrual bleeding, and may have a beneficial effect on dysmenorrhoea 2, 3, 4.
• The inhibition of cyclooxygenase 2 (COX-2) by NSAIDs may disrupt the ovulatory process, leading to ovulatory dysfunction 6.
• The molecular targets and precise role of prostaglandins in the ovulatory process are not fully understood, and further research is needed to determine the effects of NSAIDs on ovulation bleeding or mid spotting.

Efficacy and Safety

• The evidence quality for the use of NSAIDs in treating ovulation bleeding or mid spotting is limited, and most studies were underpowered 2, 3, 4.
• Adverse events associated with NSAID use, such as gastrointestinal upset and bleeding, should be considered when evaluating their use for ovulation bleeding or mid spotting 2, 3, 4.