What is the best course of treatment for a woman of reproductive age experiencing intermenstrual spotting?

Management of Intermenstrual Spotting in Reproductive-Age Women

For a woman of reproductive age with intermenstrual spotting, first rule out pregnancy, sexually transmitted infections, and structural uterine pathology (polyps, fibroids, cervical lesions), then provide reassurance if using hormonal contraceptives, or treat with NSAIDs (mefenamic acid 500 mg three times daily for 5 days) as first-line therapy if treatment is desired. 1

Initial Evaluation: What to Look For

The evaluation must systematically exclude serious causes before assuming functional bleeding:

• Pregnancy testing is mandatory – intermenstrual bleeding can indicate threatened abortion, ectopic pregnancy, or trophoblastic disease, and pregnancy must be ruled out before any treatment 2
• Screen for sexually transmitted infections – cervicitis and endometritis commonly present with irregular bleeding 1, 2
• Assess for structural pathology – cervical polyps, endometrial polyps, submucous fibroids, and cervical lesions must be excluded, particularly in women over 30 years 1, 2
• Review medications – enzyme-inducing drugs can cause breakthrough bleeding with hormonal contraceptives, and anticoagulants increase bleeding risk 1, 3
• Check for coagulation disorders – particularly in adolescents or women with heavy bleeding, von Willebrand disease is more common than typically recognized 2, 4

Pelvic examination and transvaginal ultrasound are essential when bleeding patterns change substantially or anemia is present 5. Cervical cancer screening should not be delayed in overdue patients with new-onset bleeding 1.

Management Algorithm Based on Context

If Using Progestin-Only Contraceptives (Pills, Implants, IUDs)

Unscheduled spotting is extremely common during the first 3-6 months and does not indicate contraceptive failure 1:

• First-line: Reassurance and counseling – explain this is a normal, non-harmful side effect that typically improves with continued use 6, 1
• If treatment desired during bleeding days:
  • NSAIDs: mefenamic acid 500 mg three times daily for 5 days OR celecoxib 200 mg daily for 5 days 1, 7
  • These reduce bleeding by 20-60% through prostaglandin inhibition 5, 8
• Second-line if NSAIDs fail and medically eligible:
  • Low-dose combined oral contraceptives (30-35 μg ethinyl estradiol) for 10-20 days 1, 7
  • Screen for VTE risk factors before prescribing (3-4 fold increased risk) 7

Critical pitfall: Do not assume functional bleeding without excluding pregnancy, STIs, and medication interactions first 1, 3.

If Using Combined Hormonal Contraceptives (Pills, Patch, Ring)

Breakthrough bleeding during the first 3-6 months is expected and generally not harmful 6:

• Emphasize adherence – inconsistent pill use is the most common cause of unscheduled bleeding 6
• For extended/continuous regimens with persistent bleeding:
  • A planned 3-4 day hormone-free interval improves bleeding patterns, with cessation typically occurring 11-12 days after the break 6
  • This approach is superior to continuing without interruption 6
• Doxycycline does NOT work – a randomized trial showed oral doxycycline 100 mg twice daily for 5 days provided no benefit over placebo 6

If Not Using Hormonal Contraceptives

This requires more thorough investigation for organic causes 2:

• In perimenopausal/postmenopausal women: Consider malignancy until proven otherwise 2
• In adolescents with heavy intermenstrual bleeding: Screen for coagulopathy, particularly von Willebrand disease 2, 4
• Treatment options after excluding pathology:
  • NSAIDs (reduce bleeding 20-60%): ibuprofen or mefenamic acid during bleeding days 5, 8, 9
  • Tranexamic acid 500 mg three times daily for 5 days (reduces bleeding 20-60%) 5, 9
  • Combined oral contraceptives if medically eligible 9
  • Levonorgestrel IUD for ongoing management (efficacy comparable to surgical options) 5, 9

When to Escalate or Refer

• Persistent unacceptable bleeding despite treatment: Counsel on alternative contraceptive methods and offer method switching 6, 1
• New-onset bleeding after prolonged amenorrhea: Requires immediate evaluation for pregnancy, infection, and pathologic conditions 1
• Flooding (changing pad/tampon hourly), clots ≥1 inch, or hemodynamic instability: Urgent evaluation needed 3, 4
• Failed medical therapy or suspicion of structural pathology: Consider sonohysterography or hysteroscopy for definitive diagnosis of polyps and fibroids 5

Key Counseling Points to Reduce Discontinuation

Enhanced counseling about expected bleeding patterns significantly reduces method discontinuation 6, 1, 7:

• Set realistic expectations that irregular bleeding is common in the first 3-6 months with hormonal methods 6, 1
• Reassure that bleeding irregularities are generally not harmful and do not indicate contraceptive failure 6, 1
• Explain that bleeding typically improves with persistent use 6, 1