What are the next steps for a 31-year-old female with irregular menses, recently started on Brevicon (ethinyl estradiol and norethindrone) oral birth control, who is now experiencing prolonged bleeding?

Management of Prolonged Bleeding on Brevicon

For a 31-year-old woman experiencing prolonged bleeding after recently starting Brevicon, reassure her that this is expected during the first 3-6 months of combined oral contraceptive use, rule out pregnancy and other pathologic causes if clinically indicated, and treat with NSAIDs for 5-7 days if she desires symptom relief. 1, 2

Initial Assessment

Before treating the bleeding, systematically exclude non-functional causes:

• Pregnancy testing is mandatory – this is the most critical exclusion, especially if she has missed pills or the bleeding pattern changed abruptly 2
• Screen for sexually transmitted infections (chlamydia and gonorrhea) as these commonly cause irregular bleeding patterns 1, 3
• Assess for pathologic uterine conditions such as polyps or fibroids, particularly if this represents a new bleeding pattern 1, 2
• Review medication interactions that might interfere with estrogen metabolism, including herbal supplements and smoking 4
• Verify pill adherence – non-compliance is the most common cause of unscheduled bleeding with combined oral contraceptives 5, 4

Understanding the Bleeding Pattern

This bleeding is almost certainly benign:

• Breakthrough bleeding and spotting occur commonly during the first 3 months of combined oral contraceptive use and are generally not harmful 1, 5
• These irregularities typically improve with persistent, correct use of the method 1
• The bleeding does not indicate contraceptive failure if pills are taken correctly 1

Treatment Algorithm

If No Pathology Found and Patient Wants Treatment:

First-line: NSAIDs during bleeding days 1

• Mefenamic acid 500 mg three times daily for 5-7 days 1, 6
• Alternative options: naproxen 440-550 mg every 12 hours OR ibuprofen 600-800 mg every 6-8 hours, taken with food 6
• Treatment should be short-term (5-7 days) only during days of bleeding 1, 6

Second-line: If bleeding persists beyond 3-4 months 5, 4

• Consider supplemental estrogen for short-term treatment (10-20 days) if medically eligible 1
• Alternatively, switch to a combined oral contraceptive with higher estrogen content, though this increases thromboembolic risk 2, 5
• Another option is switching to a different progestin formulation 5, 7

Non-Pharmacological Adjuncts:

• Heat therapy applied to abdomen or back may reduce cramping pain 6
• Acupressure on Large Intestine-4 (LI4) point on dorsum of hand and Spleen-6 (SP6) point approximately 4 fingers above medial malleolus 6

Counseling Strategy

Enhanced counseling reduces discontinuation rates:

• Emphasize that bleeding irregularities during the first 3-6 months are expected and generally not harmful 1
• Stress the critical importance of consistent pill use at the same time daily to minimize breakthrough bleeding 1
• Explain that the bleeding does not compromise contraceptive efficacy if pills are taken correctly 1
• Studies demonstrate that detailed counseling about expected bleeding patterns significantly reduces method discontinuation 1

When to Change Methods

• If bleeding persists beyond 3-4 months despite treatment and the patient finds it unacceptable, counsel about alternative contraceptive methods and offer another method if desired 1
• If pathology is identified, treat the specific condition or refer for specialized care 1, 3

Critical Pitfalls to Avoid

• Do not discontinue the pill prematurely – most bleeding resolves with continued use over 3-6 months 1, 5
• Do not overlook pregnancy testing, especially if she missed pills or the bleeding pattern changed abruptly 2
• Do not assume bleeding indicates pill failure – breakthrough bleeding is common and benign when pills are taken correctly 1
• Do not switch to higher estrogen formulations unnecessarily as this increases thromboembolic risk; reserve this for persistent cases after 3-4 months 2, 5
• Do not perform unscheduled cervical cancer screening outside regular screening intervals for vaginal bleeding alone 3