What is the cause of breakthrough bleeding in an 18-year-old female started on Aviane (ethinyl estradiol and levonorgestrel)?

From the Guidelines

For an 18-year-old experiencing breakthrough bleeding on Aviane, the patient should be reassured and advised to continue use, with the option to contact their provider at any time to discuss bleeding irregularities or other side effects, as per the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.

Management of Breakthrough Bleeding

The management of bleeding irregularities while using contraception involves exploring patient goals, including continued method use or method discontinuation. If the patient wants to continue use, they should be provided with reassurance and advised that they may contact their provider at any time to discuss bleeding irregularities or other side effects 1.

Treatment Options

For patients using combined hormonal contraceptives (CHC) like Aviane, who experience spotting or light bleeding, or heavy/prolonged bleeding, treatment options may include:

• Hormone-free interval for 3–4 consecutive days, although this is not recommended during the first 21 days of extended or continuous CHC use, and not more than once per month because contraceptive effectiveness might be reduced 1.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for 5–7 days can be considered for spotting or light bleeding, or heavy/prolonged bleeding 1.

Considerations

It's essential to consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids), and treat the condition or refer for care if necessary 1.

Key Points

• Breakthrough bleeding is a common side effect, especially in the first few months of contraceptive use.
• Consistent daily pill-taking at the same time each day is crucial to maintain hormone levels and minimize bleeding irregularities.
• Smoking can exacerbate breakthrough bleeding and should be avoided.
• If bleeding is accompanied by severe pain, unusual discharge, or other concerning symptoms, prompt medical attention is necessary to rule out other causes.

From the FDA Drug Label

Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. 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.

Breakthrough bleeding is a common issue in patients taking oral contraceptives, especially during the first three months of use. To address this, non-hormonal causes should be considered and adequate diagnostic measures should be taken to rule out malignancy or pregnancy.

• Time or a change to another formulation may solve the problem.
• If pathology has been excluded, the patient can continue with the current oral contraceptive or switch to another one. 2 2

From the Research

Breakthrough Bleeding in 18-Year-Old on Avaine

• Breakthrough bleeding is a common side effect of hormonal contraceptives, including Avaine 3.
• The incidence of breakthrough bleeding may decrease over time, but it can take several months to return to baseline, especially at lower estrogen doses 4.
• Factors that can influence the risk of breakthrough bleeding include the type and dose of estrogen and progestin, as well as individual patient characteristics 4, 5.

Management of Breakthrough Bleeding

• There is no one-size-fits-all solution to managing breakthrough bleeding, and the approach may need to be tailored to each individual woman 3.
• Extended- or continuous-cycle oral contraceptives may be associated with more breakthrough bleeding and spotting, especially during the initial months of use 6, 7.
• However, these regimens may also offer benefits such as reduced frequency of menses or elimination of menses altogether, which can be beneficial for women with certain medical conditions or preferences 6, 7.

Considerations for 18-Year-Old Women

• For an 18-year-old woman experiencing breakthrough bleeding on Avaine, it may be helpful to consider alternative contraceptive regimens or adjustments to the current regimen to minimize bleeding side effects 4, 5.
• It is essential to weigh the benefits and risks of different contraceptive options and to consider individual patient preferences and medical history when making decisions about contraception 7.