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Contraceptive Pearl: Irregular Bleeding with Hormonal Contraception

Many patients stop taking contraceptives due to an irregular bleeding pattern. Hormonal contraceptives often cause spotting, especially during the first 3-6 months. Anticipatory counseling about changes in bleeding patterns may help patients adjust to a new method. We can reassure patients that spotting is normal, and that they can stop the new method if bleeding bothers them.

Hormonal contraceptives can cause a wide range of bleeding patterns, including regular withdrawal bleeding, amenorrhea, irregular spotting, or heavy/prolonged bleeding. Patients vary widely in their ability to tolerate changes in bleeding patterns. For transgender patients, bleeding can cause significant distress. Satisfaction with contraception may improve with treatment for spotting. 

Oral contraceptive pills with an ethinyl estradiol (EE) dose above 20 mcg may lead to less irregular bleeding than pills with a lower estrogen dose. High-dose non-steroidal anti-inflammatory drugs (NSAIDs) may reduce undesired bleeding. For patients using a progestin-only method, adding a combined hormonal contraceptive, for 10-20 days, can stop an episode of bleeding. Other less-studied medical treatments for spotting include antifibrinolytic agents, selective estrogen receptor modulators (SERMs), tetracyclines, and Vitamin E.

Mechanisms of Actions for Treatment Options:

  • NSAIDs: Disturbs the endometrial angiogenic process through inhibition of cyclooxygenase, alters prostaglandins to enhance vasoconstriction in endometrial lining.
  • Estrogen (EE): Enhances mechanisms that stop bleeding (e.g. coagulation, tissue repair).
  • Combined Hormonal Contraceptives (EE +Progestin, Pill/Patch/Ring): Prevents endometrial proliferation.
  • Tetracyclines (Doxycycline): Reduces inflammatory cytokines in the endometrium and reduces endometrial tissue breakdown through inhibition of matrix metalloproteinase.
  • SERMs (Tamoxifen): Antagonizes the angiogenic effect of estrogen.
  • Antifibrinolytic Agents (Tranexamic acid): Prevents breakdown of fibrin, slows process of dissolving clots, reduces amount of bleeding.
  • Vitamin E: Prevents membrane damage caused by oxygen radicals, may also prevent endometrial angiogenic activity.

Treatment may provide short-term effects on an active bleeding episode, but studies on long-term beneficial effects are limited.


Resources:

Your Birth Control Choices Fact Sheet


Sources:

Abdel-Aleem H, d’Arcangues C, Vogelsong KM, Gaffield ML, Gülmezoglu AM. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database of Systematic Reviews. October 21 2013. 2013, Issue 10. Art. No.: CD003449. DOI: 10.1002/14651858.CD003449.pub5.

CDC U.S. Selected Practice Recommendations (US SPR) for Contraceptive Use: Appendix E: Management of Women with Bleeding Irregularities While Using Contraception. Feb 1 2017. Available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/appendixe.html.

Schrager S. Abnormal uterine bleeding associated with hormonal contraception. Am Fam Physician. 2002;65(10):2073-2080.

Villavicencio J, Allen RH. Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates. Open Access J Contracept. 2016;7:43-52. Published 2016 Mar 31. doi:10.2147/OAJC.S85565


Pharma-free

The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.