Breakthrough bleeding with contraceptive use

N92.0/N92.1/N92.4

DESCRIPTION

Breakthrough bleeding refers to unscheduled or irregular vaginal bleeding which often presents as spotting, or prolonged or frequent bleeding in women using hormonal contraception. The pattern and duration of these unscheduled bleedings vary with the contraceptive method used.

GENERAL MEASURES

Before starting hormonal contraception, counsel women regarding possible bleeding patterns, both initially and in the longer term.

Clinical assessment:

  • Current method of contraception and duration of use.
  • Drug interactions.
  • Cervical screening history.
  • Risk of sexual transmitted infections (e.g. Chlamydia trachomatis).
  • Menstrual and break though bleeding history prior to current method being initiated.
  • Exclude pregnancy.

Hormonal contraceptives
causing, breakthrough
bleeding 		Treatment
Progestin-only injectables - COC containing 30 mcg
ethinylestradiol, oral, for 14 days.
LoEIII[25]
Progestin subdermal implants - Ethinylestradiol/levonorgestrel, oral,
30/150 mcg, daily for 20 days.
Progestin
intrauterine devices 		Refer – See: Levonorgesterel Intra-uterine Device (LNG-IUD)
Combined oral contraceptive pill
» Unscheduled bleeding with
COC usually settles with time.
» Changing to another COC in
the first 3 months is not
recommended. 		- Change COC to a COC containing
the lowest dose of ethinylestradiol,
oral, daily.
If bleeding persists:
- Change COC to a COC containing
35 mcg ethinylestradiol, oral, daily.
LoE:IV

LoEIII[25]

LoEIII

See: Levonorgesterel Intra-uterine Device (LNG-IUD)

REFERRAL

  • Pelvic pain.
  • Pelvic mass.
  • Heavy bleeding.
  • Abnormal cervix on speculum examination (e.g. polyps).
  • Bleeding not controlled by treatment above.