What alternative birth control options are available for a 35-year-old patient experiencing frequent spotting while taking Apri (desogestrel and ethinyl estradiol) for contraception?

From the Guidelines

For a 35-year-old patient experiencing significant spotting on Apri, I recommend switching to a different combined hormonal contraceptive, such as Sprintec or Loestrin Fe, or considering a continuous or extended-cycle pill like Seasonique, as these options may provide better cycle control and reduce bleeding episodes 1. When managing bleeding irregularities, it's essential to explore patient goals and preferences, including continued method use or method discontinuation 1. According to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use, if the patient wants to continue use, reassurance and advice on contacting their provider for bleeding irregularities or other side effects can be provided 1. However, if the patient desires treatment, options such as NSAIDs, hormonal treatment, or antifibrinolytic agents may be considered, depending on the patient's preferences, treatment goals, and medical history 1. Some key points to consider when switching contraceptive methods include:

• Exploring patient goals and preferences, including continued method use or method discontinuation 1
• Providing reassurance and advice on contacting their provider for bleeding irregularities or other side effects 1
• Considering alternative contraceptive methods, such as continuous or extended-cycle pills, non-oral options like the NuvaRing, or hormonal IUDs like Mirena or Kyleena 1
• Evaluating the patient's medical history and treating any underlying health conditions that may be contributing to bleeding irregularities 1 It's also important to note that spotting is a common side effect with low-dose pills like Apri, particularly in the first 3 months of use 1. If the spotting persists beyond 3 months or is particularly bothersome, switching formulations is appropriate, and there's no need for a break between methods - the patient can start the new method immediately after finishing the current pack of Apri 1. Follow-up in 3 months to assess if the new method has resolved the spotting issue is recommended 1.

From the FDA Drug Label

Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use Non-hormonal causes should be considered and adequate diagnostic measures taken to rule out malignancy or pregnancy in the event of breakthrough bleeding, as in the case of any abnormal vaginal bleeding. If pathology has been excluded, time or a change to another formulation may solve the problem.

The patient can be switched to another formulation of oral contraceptives to try to alleviate the spotting.

• Non-hormonal causes should be considered and ruled out.
• Pathology should be excluded before making any changes.
• If the patient has been on the current formulation for more than three months, a change to another formulation may be considered. 2

From the Research

Alternatives to ApRI for Birth Control

For a 35-year-old patient experiencing spotting while on ApRI for birth control, alternative options can be considered to minimize spotting.

• Norethindrone acetate 1 mg/ethinyl estradiol 20 micro g (Loestrin 24 Fe): This 24-day oral contraceptive regimen has been shown to reduce the frequency of intracyclic bleeding/spotting while maintaining efficacy and tolerability 3.
• Combined norethindrone acetate and low-dose ethinyl estradiol therapy: This regimen has been found to provide better control of vaginal bleeding compared to combined conjugated equine estrogens and medroxyprogesterone acetate therapy 4.
• Levonorgestrel-releasing intrauterine device: Although primarily used for postmenopausal women, this device can be an alternative mode of progestin administration, which may reduce spotting after the initial 3 months 5.

Considerations for Switching

When switching to a new birth control method, it's essential to consider the patient's individual needs and medical history.

• Vaginal bleeding patterns: The new method should aim to reduce spotting and bleeding days.
• Hormonal balance: The patient's hormonal balance should be maintained to prevent adverse effects.
• Potential risks: The patient's risk factors, such as migraine with aura or thrombosis, should be considered when choosing a new method 6.