How should I manage persistent heavy bleeding in a 21‑year‑old woman with polycystic ovary syndrome on spironolactone and metformin, who stopped a combined oral contraceptive two months ago and is taking sertraline and buspirone for depression (PHQ‑9 18) and anxiety (GAD‑7 15)?

Management of Persistent Heavy Bleeding in a 21-Year-Old with PCOS Post-OCP Discontinuation

Restart a combined oral contraceptive (COC) containing 30–35 μg ethinyl estradiol immediately to control the bleeding, and continue it for at least 21 consecutive days before any hormone-free interval. 1

Immediate Management: Restart Hormonal Contraception

• Initiate a monophasic COC with 30–35 μg ethinyl estradiol (such as one containing levonorgestrel or norgestimate) as soon as possible, regardless of where she is in her bleeding pattern. 1, 2
• No backup contraception is needed if started within 5 days of bleeding onset; if started later, use condoms for 7 days. 1, 2
• Continue active pills for at least 21 consecutive days without a hormone-free interval to stabilize the endometrium and stop the bleeding. 1
• After the initial 21 days, transition to either standard cyclic use (21–24 days active pills followed by 4–7 day hormone-free interval) or extended continuous use (3–4 months of active pills) to prevent recurrence. 1

The rationale is straightforward: withdrawal bleeding after OCP discontinuation in PCOS patients often becomes prolonged and heavy because the underlying anovulation and unopposed estrogen exposure destabilize the endometrium. 3, 4 Restarting COCs provides immediate endometrial stabilization through progestin-mediated suppression and organized withdrawal bleeding. 1

Rule Out Underlying Pathology First

Before attributing bleeding solely to PCOS and OCP withdrawal, exclude pregnancy, sexually transmitted infections, new uterine pathology (polyps, fibroids), and medication interactions. 5, 1

• Obtain a urine pregnancy test even though she's on spironolactone and metformin (both are teratogenic). 1
• Screen for gonorrhea and chlamydia if she has been sexually active since stopping the OCP. 5
• Consider pelvic ultrasound if bleeding persists despite hormonal therapy to evaluate for structural abnormalities, though this is not first-line. 5

Adjunctive Therapy: NSAIDs for Acute Bleeding Control

Add ibuprofen 400–600 mg three times daily for 5–7 days during active bleeding episodes to reduce menstrual blood loss by 25–35% through prostaglandin inhibition. 5, 1

• NSAIDs are effective for heavy bleeding and can be used concurrently with COC initiation. 5
• This provides symptomatic relief while hormonal therapy takes effect (typically 2–3 days). 5

Address the Underlying PCOS and Continue Current Medications

Continue spironolactone and metformin as these are appropriate long-term management for PCOS and do not interfere with COC efficacy. 6, 3, 4

• Spironolactone (antiandrogen) addresses hirsutism and acne. 3, 4
• Metformin improves insulin resistance and may help restore ovulatory cycles long-term. 6, 3, 4
• The combination of metformin plus spironolactone has been shown to reduce BMI, testosterone, and improve insulin resistance more effectively than metformin alone, particularly when used for >6 months. 6
• Research indicates that 75% of PCOS patients achieve regular cycles post-OCP using spironolactone and metformin as non-hormonal options, though this takes time (average 1.9 years in one study). 7

Long-Term Contraceptive Strategy

Once bleeding is controlled, discuss long-term contraceptive options based on her preferences:

• Extended or continuous COC regimens (taking active pills for 3–4 months continuously) are particularly effective for PCOS patients to prevent endometrial hyperplasia and reduce bleeding episodes. 1, 3
• If breakthrough bleeding occurs with extended regimens, allow a 3–4 day hormone-free interval (but not during the first 21 days of use and not more than once per month). 1
• Consider a levonorgestrel-releasing IUD as an alternative if she prefers non-daily contraception; it reduces menstrual blood loss by 71–95% and provides endometrial protection. 1

Address Mental Health Comorbidities

Her PHQ-9 score of 18 (moderately severe depression) and GAD-7 of 15 (moderate anxiety) require attention, as PCOS patients have increased risk of mood disorders. 4

• Ensure her sertraline and buspirone doses are optimized and consider psychiatric referral if not already established. 4
• Counsel that hormonal contraceptives do not worsen depression and may improve quality of life by controlling bleeding and PCOS symptoms. 1, 8

Critical Safety Considerations

Before prescribing COCs, measure blood pressure (mandatory pre-initiation screening). 2, 8

• Screen for additional cardiovascular risk factors: smoking status, personal or family history of venous thromboembolism, hypertension, and glucose intolerance. 8
• COCs carry a 3–4-fold increased risk of venous thromboembolism (up to 4 per 10,000 woman-years), but absolute risk remains low in young women without additional risk factors. 1, 8
• Smoking is not a contraindication in women <35 years old, though cessation should be encouraged. 1

Follow-Up and Monitoring

No routine follow-up visit is required, but she should return if bleeding persists beyond 7 days of COC initiation, if she experiences intolerable side effects, or for blood pressure monitoring. 1, 2

• Reassure her that irregular spotting during the first 3–6 months of COC use is common and not harmful, and typically improves with continued use. 5, 1
• If heavy bleeding persists despite 10–20 days of COC therapy, consider short-term estrogen supplementation (though this is rarely needed). 5

Common Pitfalls to Avoid

• Do not delay COC initiation waiting for "the right time in her cycle"—she can start immediately given her continuous bleeding. 1, 2
• Do not prescribe progestin-only pills (mini-pills) for heavy bleeding—they are ineffective for this indication as they do not suppress ovulation or thin the endometrium adequately. 1
• Do not use depot medroxyprogesterone acetate (DMPA) as first-line therapy—while it can control bleeding, it may worsen mood symptoms and has a higher discontinuation rate. 5, 1
• Do not remove spironolactone or metformin—these are complementary to hormonal therapy and address the underlying PCOS pathophysiology. 6, 3, 4