unscheduled bleeding whilst women using hormonal contraception
Last edited 02/2020
Unscheduled bleeding in women using hormonal contraception [i.e. combined oral contraceptive pill (COC), transdermal patch, progestogenonly pill (POP), injectable, implant or intrauterine system (IUS)]
Clinically important bleeding patterns in women aged 15-44 year
| SCHEDULED BLEEDING | Menstruation or regular withdrawal bleeding with combined hormonal contraception (requiring sanitary protection |
OTHER BLEEDING PATTERNS
| FREQUENT BLEEDING | More than five bleeding episodes (a) within a reference period (b) |
| INFREQUENT BLEEDING | Fewer than three bleeding episodes (a) within a reference period (b) |
| PROLONGED BLEEDING | Bleeding episode (a) lasting 14 days or more |
| SPOTTING | Vaginal discharge containing blood, that may not require the use of sanitary protection |
| BREAKTHROUGH BLEEDING | Unscheduled bleeding in women using CHC |
| AMENORRHOEA | No bleeding or spotting days throughout the 90-day reference period (b) |
(a) Bleeding episode: one or more consecutive days of bleeding, bounded by bleed-free days.
(b) Reference period: a 90-day period of time during use of a hormonal contraceptive method.
management of women who present with unscheduled bleeding while using hormonal contraception is challenging. For many women unscheduled bleeding will be due to the contraceptive method itself, and the pattern and duration of bleeding and the likelihood of this settling will vary with the method used
Expected bleeding patterns after commencing hormonal contraception and in the longer term
| Contraceptive method | Bleeding patterns in women in the first 3 months | Bleeding patterns in women in the longer term |
| COMBINED HORMONAL CONTRACEPTION (pill, patch or ring) | Up to 20% of combined oral contraception users have irregular bleeding. |
Irregular bleeding usually settles No significant differences in bleeding between pill and patch use The combined vaginal ring may afford better cycle control (less unscheduled bleeding) when compared to the pill Users of estradiol COC have reported shorter, lighter bleeds and a higher rate of absent withdrawal bleeds than women using an EE-containing COC |
| PROGESTOGEN-ONLY CONTRACEPTION Progestogen-only pill |
Bleeding is unpredictable With traditional POPs, one-third of women have a change in bleeding A comparative study of DSG LNG POP reported that frequent bleeding, prolonged bleeding and infrequent bleeding were more common in DSG users than LNG users in the first reference period of 90 days |
Bleeding may not settle with time Traditional POP users can be advised that frequent and irregular bleeding are common, while prolonged bleeding and amenorrhoea are less likely As a guide, women considering DSG-only POP can be advised that after 12 months of use, over a 3-month period approximately:
|
| Progestogen-only implant | Bleeding disturbances are common. The bleeding pattern in the first 3 months is broadly predictive of future bleeding patterns for many women |
As a guide, around:
In 75% of reference periods bleeding-spotting days are fewer than or comparable to those observed during the natural cycle, but they occur at unpredictable intervals |
|
Levonorgestrel releasing intrauterine system (LNG-IUS) 52mg (Mirena) |
Frequent bleeding/spotting is common in the first few months after insertion |
There is a decrease over time in the number of bleeding and spotting days with all doses of LNG-IUS A 90% reduction in menstrual blood loss has been demonstrated over 12 months of 52 mg LNG-IUS use At 1 year, infrequent bleeding is usual with the LNG-IUS and some women will be amenorrhoeic. 24% of 52 mg LNG-IUS users are amenorrhoeic at 3 years |
| LNG-IUS 13.5 mg (Jaydess®) |
Frequent bleeding/spotting is common in the first few months after insertion |
There is a decrease over time in the number of bleeding and spotting days with all doses of LNG-IUS Users of the 13.5 mg LNG-IUS report more spotting days than bleeding days over the duration of licensed use Fewer women (13% at 3 years) will experience amenorrhoea with this dose of LNG-IUS compared to the 52 mg LNG-IUS |
| Progestogen-only injectable (IM and SC) |
Bleeding disturbances (spotting, light, heavy or prolonged bleeding) are common. Around 1 in 10 women may be amenorrhoeic in the first 3 months of use. |
Rates of amenorrhoea increase with duration of use and are similar for IM and SC DMPA. Around 50% or more are amenorrhoeic at 12 month |
CHC, combined hormonal contraception; COC, combined oral contraceptive pill; DMPA, depot medroxyprogesterone acetate; DSG, desogestrel; EE, ethinylestradiol; IM, intramuscular; LNG, levonorgestrel; LNG-IUS, levonorgestrel-releasing intrauterine system; POP, progestogen-only pill; SC, subcutaneous
Reference:
- 1) FSRH (2015). Problematic Bleeding with Hormonal Contraception.
assessment of unscheduled bleeding if taking hormonal contraception
management of unscheduled bleeding whilst on hormonal contraception