Clinical Opinion
Contraceptive use and unscheduled bleeding
By Dr Maria Garefalakis, Medical Director, Sexual & Reproductive Health WA
Unscheduled vaginal bleeding (syn. breakthrough bleeding) occurs outside the expected withdrawal bleeding from the use of combined hormonal contraception (CHC) or the unpredictable bleeding that goes with other contraceptive methods. It is a common reason why women attend their GP.
After excluding other causes of bleeding (remember that implants can also be affected by liver enzyme inducing medications) and if there are no contraindications, a CHC can be used for a few months. She should expect a withdrawal bleed on stopping and will generally resume her earlier pattern of bleeding. If effective, an implant user may choose to continue using CHC for the duration of the implant.
Unscheduled bleeding is commonplace when a new contraceptive method is started, often settling without intervention. Such unexpected bleeding, although temporary, often leads women to discontinue their contraception. However, many women accept irregular bleeding that lessens over time but perhaps not frequent prolonged bleeding that does not settle (in particular, implant use) and obscures the woman’s menstrual ‘pattern’. Giving information about what bleeding might be expected can reduce concerns and encourage ongoing use of a contraceptive method. An excellent summary of expected bleeding with different methods (both in the first three months and in the longer term) is included in the UK Faculty of Sexual & Reproductive Healthcare Clinical Guidance: www.fsrh.org/pdfs/ unscheduledbleedingmay09.pdf Things to look for For a woman using CHC who experiences unscheduled bleeding, find out if inconsistent dosing may be a factor. If not, reassure her that her bleeding is not associated with lower CHC efficacy and risk of pregnancy. Check for liver enzyme inducing medication (including St John’s Wort) as these can reduce the effectiveness of CHC (both oral and vaginal ring), progestogen only pills and implants. Alternative causes of bleeding include pregnancy, sexually transmitted infections and other genital tract pathology. Examination and investigation is guided by the clinical history, including risk factors. What to do If unscheduled bleeding persists after three months of oral contraceptive use and other causes are excluded, the dose of ethinyloestradiol may be increased up to a maximum of 35mcg or she may consider changing to the contraceptive vaginal ring or another method. There is little evidence that changing the type or dose of progestogen or changing to biphasic/triphasic pills will improve bleeding. Using CHC continuously (without the monthly hormone-free break) avoids withdrawal bleeding and other symptoms around hormone withdrawal, a CHC use that is regarded as safe for women. However, unscheduled bleeding is very common in early cycles and this usually decreases with time. One option for management of a woman who has had at least 21 days of continuous combined hormone use and then experiences MEDICAL FORUM
Other options include a short course of NSAIDs (e.g. mefenamic acid 500mg twice a day for five days) or, if bleeding is heavy, tranexamic acid (500mg twice a day for five days). If successful, these can be repeated monthly. There is limited evidence for the use of progestogen-only pills or early removal and replacement of an implant or hormonal IUD.
Take Home Points
a bleeding episode that lasts for more than four days, is to have a four day hormone free interval and then restart. Intrauterine devices and implants have the highest rates of efficacy, satisfaction and continuation and these long-acting reversible methods and are being increasingly offered as first line options. In addition to counselling about expected bleeding, it is recommended that women feel able to return if bleeding is troublesome as management options are available (“don’t wait until you’re completely fed up”) and they should be advised that they may have the device removed any time with rapid reversal. Family Planning Alliance Australia (http:// fpallianceaus.org/larc) has developed the helpful Guidance for management of troublesome vaginal bleeding with progestogen-only long-acting reversible contraception (LARC) which is available for download www.fpv.org.au/assets/FPAAguidance-for-bleeding-on-progestogen-onlyLARC.pdf
så 7HENåPRESCRIBINGåCONTRACEPTION å advise women about the expected changes to uterine bleeding, both initially and in the longer term. så !SåUNSCHEDULEDåBLEEDINGåWITHåNEWå combined oral contraceptive use tends to settles with time, changing to another COC type in the first three months is not recommended. så 7OMENåWITHåUNSCHEDULEDåBLEEDINGå who are at risk for STIs (e.g. under 30 years old or change in sexual partner in the last 12 months) should be offered STI testing. Check out www.sti.guidelines.org.au. så ,ETåWOMENåWHOåCHOOSEåAåLONG ACTINGå reversible methods ‘LARC’ know that there are management options for troublesome vaginal bleeding.
Competing interests: As medical director at SRHWA, the author provides training for Implanon and IUD insertion and has been a past member of MSD and Bayer advisory committees. Questions? Tel 92276177 (ext 920)
Expressions of Interest Dr John Raven is retiring towards the end of 2015 creating a good opportunity for a Clinical Haematologist to open a practice in Bunbury. There is a busy and interesting work load. The district covers Harvey in the North, Augusta in the South and Wagin in the East. There are excellent pathology facilities and access to a good day-only oncology unit. Bunbury is suitable for solo or partnership practice or part-time or full-time, according to experience. There are two part-time haematologists in Mandurah and one on Saturday mornings in Busselton.
Further information available from Dr J L Raven Telephone: 9384 7860
37