I’m a perimenopausal woman who has been taking Nextstellis (estetrol 14.2 mg + drospirenone 3 mg) for about a year for vasomotor symptoms and mood swings, but I’m now having continuous breakthrough spotting and I’m skipping the four placebo pills—what should I do to manage the bleeding?

Management of Breakthrough Bleeding with Nextstellis During Continuous Use

Continue your current Nextstellis regimen without the placebo pills for at least 3 months total before making any changes, as breakthrough bleeding during continuous combined hormonal contraceptive use is common in the first 3-6 months and typically resolves with persistent use. 1, 2

Understanding Your Current Situation

Breakthrough bleeding when skipping placebo pills is expected and benign. The spotting you're experiencing reflects endometrial adjustment to continuous hormone exposure rather than any pathology, and this bleeding pattern is not harmful. 2 Unscheduled bleeding is most frequent during the first 3-6 months of continuous combined hormonal contraceptive regimens and diminishes as you continue the method consistently. 1, 2

The FDA label for Nextstellis confirms that unscheduled bleeding occurred in 30.3% of women at Cycle 1, decreasing to 17.4% by Cycle 12, with mean bleeding days dropping from 0.4 days at Cycle 1 to 0.2 days at Cycle 12. 3

Immediate Management Steps

First: Rule Out Other Causes

Before attributing your bleeding solely to the continuous regimen, ensure you have excluded:

• Pregnancy - Obtain a pregnancy test immediately, as pregnancy complications can manifest as mid-cycle spotting 2
• Sexually transmitted infections - Screen for STIs as they can cause irregular bleeding 2
• Medication interactions - Review for enzyme-inducing drugs (anticonvulsants, rifampin, certain antiretrovirals) that may reduce Nextstellis efficacy 2
• Structural pathology - Consider evaluation for endometrial polyps, fibroids, or cervical lesions if clinically indicated 1, 2

Second: Continue Current Regimen

The primary management approach is counseling and reassurance that bleeding irregularities will improve. 2 Since you've been on Nextstellis for about a year but only recently started skipping placebos, you need to allow 3-6 months of continuous use for your endometrium to fully adjust. 1, 2

Enhanced pre-initiation counseling about expected bleeding patterns has been shown to reduce method discontinuation, so understanding that this is temporary and expected should help you persist through this adjustment period. 2

If Bleeding Persists Beyond 3 Months

Treatment Options (in order of preference):

1. NSAIDs for 5-7 days during bleeding episodes - This is first-line pharmacologic therapy if the bleeding remains bothersome after the adjustment period 1, 2

2. Brief 3-4 day hormone-free interval - This may be considered only if NSAIDs fail and the bleeding is unacceptable to you 2

   • Critical restrictions: Do NOT use this during the first 21 days of continuous use, and do NOT repeat more than once per month, as this compromises contraceptive effectiveness 2
   • During this interval, expect an initial increase in flow, followed by abrupt decrease at days 7-8, and cessation by days 11-12 2

3. Consider alternative contraceptive methods - If bleeding persists despite the above interventions and remains unacceptable, discuss switching to long-acting reversible contraceptives or other hormonal methods 1, 2

What NOT to Do

• Do not take doxycycline - It does not improve breakthrough bleeding and should not be prescribed for this purpose 2
• Do not assume the bleeding indicates contraceptive failure - The bleeding does not mean Nextstellis isn't working 2
• Do not stop Nextstellis abruptly - Consistent daily timing reduces unscheduled spotting 2

Monitoring Plan

• Reassess bleeding pattern after 3 months of continuous use 4
• Consider endometrial thickness assessment by ultrasound if clinically indicated 4
• If bleeding continues after 3 months and is bothersome, consider adding low-dose estrogen if medically eligible, using NSAIDs for short-term treatment, or switching to a sequential regimen 4

Why Nextstellis Has Advantages for Your Situation

Research demonstrates that the estetrol-drospirenone combination in Nextstellis provides a more predictable bleeding profile compared to progestin-only options, with high rates of scheduled bleeding (82.9-87.0% per cycle) and decreasing unscheduled bleeding over time. 5, 6, 7 The addition of estetrol to drospirenone specifically provides advantages in contraceptive efficacy and a regular, predictable bleeding profile with minimal impact on hemostasis parameters. 5