Oral Contraceptive-Related Uterine Bleeding Management

Aka: Oral Contraceptive-Related Uterine Bleeding Management

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II. Epidemiology

  1. Abnormal Uterine Bleeding is a common cause of discontinuation of Hormonal Contraception

III. Differential Diagnosis

  1. See Medication Causes of Abnormal Uterine Bleeding
  2. See Abnormal Uterine Bleeding Causes

IV. Management: Overall approach to OCP associated Abnormal Uterine Bleeding (AUB)

  1. Consider Abnormal Uterine Bleeding evaluation
  2. Anticipate uterine bleeding in first 3 months
    1. Offer anticipatory guidance
  3. Evaluate for missed OCP doses (most common AUB cause after first 3 months)
    1. Pregnancy Test
    2. Counsel on compliance
  4. Tobacco Cessation
    1. Smoking may decrease OCP absorption and increase bleeding risk
  5. Consider adjuncts to Oral Contraceptive
    1. Ibuprofen 800 mg PO tid for 1-2 weeks
    2. Supplemental Estrogen for 1-2 weeks
      1. Premarin 0.625 to 1.25 qd
      2. Ethinyl Estradiol 20 ug qd
      3. Estradiol (Estrace) 0.5 to 1 mg qd
  6. Consider alternative Oral Contraceptives
    1. Change Progesterone type as listed below
      1. Switch from Levonorgestrel to Norethindrone containing Oral Contraceptives
    2. If on Seasonal Contraception, stop for 4-5 days when breakthrough bleeding occurs
    3. Monophasic OCP and triphasic OCP are associated with similar bleeding rates
    4. Ethinyl Estradiol 30 mcg is preferred dose
      1. Increasing Ethinyl Estradiol to 50 mcg does not appear effective at reducing bleeding
      2. Avoid low Ethinyl Estradiol doses (10-20 mcg) due to increased bleeding risk
      3. Moreau (2007) Obstet Gynecol 109(6):1277-85 [PubMed]
  7. Consider alternatives to Oral Contraceptive, with lower rates of AUB
    1. Contraceptive Patch (e.g. Ortho Evra)
    2. Vaginal Contraceptive Ring (e.g. NuvaRing)

V. Management: Spotting

  1. Take pill at same time each day
  2. Evaluate if unresolved after 3 cycles of observation
    1. Missed doses
    2. Drug Interaction
    3. Abnormal Uterine Bleeding

VI. Management: Early Cycle Breakthrough Bleeding (Days 1-9) or all month

  1. Progestin characteristics
    1. Higher Estrogenic Activity
  2. Consider increasing Estrogen to 50 mcg Monophasic
    1. Ovcon 50
    2. Ortho-Novum 1/50
    3. Demulen 1/50
  3. Temporarily add Estrogen prn breakthrough bleeding
    1. Ethinyl Estradiol 0.02 mg PO qd for 7 days prn

VII. Management: Late Cycle Breakthrough Bleeding (Days 10-21)

  1. OCP Characteristics
    1. Higher Progestin Activity
    2. Higher Endometrial Activity
  2. Examples
    1. Loestrin 1.5/30
    2. Loestrin 1/20
    3. Demulen 1/35

VIII. Management: Menorrhagia or Dysmenorrhea

  1. OCP Characteristics
    1. Higher Progestin Activity
    2. Lower Estrogenic Activity
  2. Examples
    1. Loestrin 1.5/30

IX. Management: Amenorrhea or Menses too light

  1. Check Pregnancy Test!
  2. OCP Characteristics
    1. Lower Progestin Activity
    2. Higher Estrogenic Activity
    3. Higher Endometrial Activity
  3. Examples
    1. Loestrin 1.5/30
    2. Loestrin 1/20
    3. Demulen 1/35
  4. Consider additional Estrogen initially
    1. Premarin 0.625 mg qd for 7 days
    2. Start at beginning of next cycle

X. References

  1. Dickey (1998) Managing Contraceptive Pill Patients
  2. Cerel-Suhl (1999) Am Fam Physician 60(7):2073 [PubMed]
  3. Schrager (2024) Am Fam Physician 109(2): 161-6 [PubMed]
  4. Speroff (1993) Obstet Gynecol 81:1034-47 [PubMed]
  5. Schrager (2002) Am Fam Physician 65(10):2073-80 [PubMed]

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