II. Approach

  1. See Abnormal Uterine Bleeding
  2. General
    1. Pregnancy Test (bHCG) in all patients
    2. Sexually Transmitted Infection (STI) screening as indicated
    3. Cervical Cancer Screening (e.g. Pap Smear) if not up to date
  3. Hormonal Contraception related uterine bleeding
    1. Evaluate for Contraception compliance and missed doses (consider reminder apps and other tools)
    2. Evaluate for other hormonal agents
    3. Evaluate for Drug Interactions that alter Estrogen metabolism

III. Causes: Hormonal Contraception

  1. Levonorgestrel IUD (e.g. Mirena, Liletta, Kyleena, Skyla)
    1. Associated with prolonged bleeding in first 3 months
    2. Bleeding decreases in the first 12 months in 90% of patients
    3. Up to 20% will have Amenorrhea within 12 months
  2. Progesterone Implant (e.g. Nexplanon, Implanon)
    1. Frequent or prolonged bleeding occurs in 23% of patients (unlike IUD, often persists)
  3. Depo Provera (DMPA)
    1. Associated with prolonged Menses in 26% in first 3 months of use, but improves with continued use
    2. Abnormal Uterine Bleeding resolves in 85% of patients within first 12 months
  4. Oral Contraceptives
    1. See Oral Contraceptive-Related Uterine Bleeding Management
    2. Most common cause of mid-cycle bleeding
    3. Abnormal Uterine Bleeding occurs in up to 50% of patients in first 3-6 months (10% afterward)

IV. Causes: General

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